Outcomes of M. pneumoniae pneumonia with mixed infection

Background: Mycoplasma pneumoniae pneumonia (MPP) is often complicated with mixed infections that worsen the prognosis, but the outcomes in pediatric cases are unclear. The aim of this study is to investigate the association of mixed infection and outcomes in severe MPP that occurs in childhood.

Methods: This retrospective study included 184 pediatric cases of severe MPP that were managed at our hospital (between January 2014 and December 2017). The cohort was divided into the single Mycoplasma pneumoniae infection, mixed infection with a noxa other than M. pneumoniae, and mixed infection with two or more noxae other than M. pneumoniae groups. The demographic and clinical information of the patients was compared via statistical analysis.

Results: The incidence of mixed infections was high at 64.1%. Cytomegalovirus and Epstein-Barr virus were the most common causes of mixed infection. According to the findings of binary logistic regression analysis, the presence of more than one pathogen (other than M. pneumoniae) was positively associated with the score determined from Pediatric Risk of Mortality III (β = 0.760, odds ratio [OR] = 2.139, 95% confidence interval [CI] = 1.391-2.390, P = 0.001), Pediatric Critical Illness Score (β = 1.203, OR = 3.328, 95% CI = 1.723-6.731, P = 0.000), and total length of hospital stay (β = 0.730, OR = 2.075, 95% CI = 1.404-3.066, P = 0.000).

Conclusion: Viral and bacterial mixed infection in pediatric cases of severe MPP is positively associated with hospitalization period and disease severity, and ultimately, may increase the chances of severe illness and death among children.

Mycoplasma pneumonia; Severity; Mixed infection; PRISM III; PCIS; Retrospective

[1] Søndergaard MJ, Friis MB, Hansen DS, Jørgensen IM. Clinical manifestations in infants and children with Mycoplasma pneumoniae infection. PLoS One. 2018; 13: e0195288.

[2] Jiang W, Wu M, Zhou J, Wang Y, Hao C, Ji W, et al. Etiologic spectrum and occurrence of coinfections in children hospitalized with community-acquired pneumonia. BMC Infectious Diseases. 2017; 17: 787.

[3] Oumei H, Xuefeng W, Jianping L, Kunling S, Rong M, Zhenze C, et al. Etiology of community-acquired pneumoniain 1500 hospitalized children. Journal. Journal of Medical Virology. 2018; 90: 421-428.

[4] Pessoa E, Bárbara C, Viegas L, Costa A, Rosa M, Nogueira P. Factors associated with in-hospital mortality from community-acquired pneumonia in Portugal: 2000-2014. BMC Pulmonary Medicine. 2020; 20: 18.

[5] Song Q, Xu BP, Shen KL. Bacterial co-infection in hospitalized children with mycoplasma pneumoniae pneumonia. Indian Journal of Pediatrics. 2016; 53: 879-882.

[6] Han MS, Yun KW, Lee HJ, Park JY, Rhie K, Lee JK, et al. Contribution of co-detected respiratory viruses and patient age to the clinical manifestations of mycoplasma pneumoniae pneumonia in children. Pediatric Infectious Disease. 2018; 37: 531-536.

[7] Li Y, Pattan V, Syed B, Islam M, Yousif A. Splenic infarction caused by a rare coinfection of Epstein-Barr virus, cytomegalovirus, and Mycoplasma pneumoniae. Pediatric Emergency Care. 2014; 30: 636-637.

[8] Cawcutt KA, Kalil AC. Viral and bacterial co-infection in pneumonia: do we know enough to improve clinical care? Critical Care. 2017; 21: 19.

[9] Chiu CY, Chen CJ, Wong KS, Tsai MH, Chiu CH, Huang YC. Impact of bacterial and viral coinfection on mycoplasmal pneumonia in childhood community-acquired pneumonia. Journal of Microbiology, Immunology and Infection. 2015; 48: 51-56.

[10] Zhang X, Chen Z, Gu W, Shen N, Tao Y, Zhao R, et al. Viral and bacterial co-infection in hospitalised children with refractory Mycoplasma pneumoniae pneumonia. Epidemiology and Infection. 2018; 146: 1384-1388.

[11] Wang C, Song C, Wang S, Liu G. Prealbumin may predict clinical outcomes in children with severe mycoplasma pneumoniae pneumonia. Iranian Journal of Pediatrics. 2020; 30: e97680.

[12] Hsu BS, Lakhani S, Brazelton TB 3rd. Relationship between severity of illness and length of stay on costs incurred during a pediatriccriticalcare hospitalization. South Dakota Medicine. 2015; 68: 339, 341-344.

[13] Wang L, Feng Z, Shuai J, Liu J, Li G. Risk factors of 90-day rehospitalization following discharge of pediatric patients hospitalized with mycoplasma Pneumoniae pneumonia. BMC Infectious Diseases. 2019; 19: 966.

[14] Wang L, Feng Z , Zhao M , Yang S, Yan X, Guo W, et al. A comparison study between GeXP-based multiplex-PCR and serology assay for Mycoplasma pneumoniae detection in children with community acquired pneumonia. BMC Infectious Diseases. 2017; 17: 518.

[15] Colin AA, Yousef S, Forno E, Korppi M. Treatment of mycoplasma pneumoniae in pediatric lower respiratory infection. Pediatrics. 2014; 133: 1124-1125.

[16] Wiegers HMG, van Nijen L, van Woensel JBM, Bem RA, de Jong MD, Calis JCJ. Bacterial co-infection of the respiratory tract in ventilated children with bronchiolitis; a retrospective cohort study. BMC Infectious Diseases. 2019; 19: 938.

[17] Teng F, Liu X, Guo SB, Li Z, Ji WQ, Zhang F, et al. Community-acquired bacterial co-infection predicts severity and mortality in influenza-associated pneumonia admitted patients. Journal of Infection and Chemotherapy. 2019; 25: 129-136.

[18] Cantan B, Luyt CE, Martin-Loeches I. Influenza infections and emergent viral infections in intensive care unit. Seminars in Respiratory and Critical Care Medicine. 2019; 40: 488-497.

[19] Cawcutt K, Kalil AC. Pneumonia with bacterial and viral coinfection. Current Opinion in Critical Care. 2017; 23: 385-390.

[20] Steensels D, Reynders M, Descheemaeker P , Curran MD, Hites M, Etienne I, Montesinos I. Epidemiology and clinical impact of viral, atypical, and fungal respiratory pathogens in symptomatic immuno-compromised patients: a two-center study using a multi-parameter customized respiratory Taqman® array card. European Journal of Clinical Microbiology and Infectious Diseases. 2019; 38: 1507-1514.

[21] Nolan VG, Arnold SR, Bramley AM, Ampofo K, Williams DJ, Grijalva CG, et al. Etiology and impact of coinfections in children hospitalized with community-acquired pneumonia. Journal of the Infectious Diseases. 2018; 218: 179-188.

[22] Chauhan JC, Slamon NB. The impact of multiple viral respiratory infections on outcomes for critically Ill children. Pediatric Critical Care Medicine. 2017; 18: e333-e338.

[23] D’Alonzo R, Mencaroni E, Di Genova L, Laino D, Principi N,Esposito S. Pathogenesis and treatment of neurologic diseases associated with mycoplasma pneumoniaeinfection. Frontiers in Microbiology. 2018; 9: 2751.

[24] Kinnula H, Mappes J, Sundberg LR. Coinfection outcome in an opportunistic pathogen depends on the inter-strain interactions. BMC Evolutionary Biology. 2017; 17: 77.

[25] Loubet P, Voiriot G, Houhou-Fidouh N , Neuville M, Bouadma L, Lescure FX, et al. Impact of respiratory viruses in hospital-acquired pneumonia in the intensive care unit: A single-center retrospective study. Journal of Clinical Virology. 2017; 91: 52-57.

[26] Kim YJ, Lee ES , Lee YS. High mortality from viral pneumonia in patients with cancer. Infectious Diseases(London). 2019; 51: 502-509.

[27 Eşki A, Öztürk GK, Gülen F, Çiçek C, Demir E. Risk factors for influenza virus related severe lower respiratory tract infection in children. Pediatric Infectious Disease Journal. 2019; 38: 1090-1095.

[28] Rehder KJ, Wilson EA, Zimmerman KO, Cunningham CK, Turner DA. Detection of multiple respiratory viruses associated with mortality and severity of illness in children. Pediatric Critical Care Medicine. 2015; 16: e201-6.

[29] Sayed HA, Ali AM, Elzembely MM. Can pediatric risk of mortality Score (PRISM III) be used effectively in initial evaluation and follow-up of critically Ill cancer patients admitted to pediatric oncology intensive care unit(POICU)? A prospective study, in a tertiary cancer center in Egypt. Journal Pediatric Hematology and Oncology. 2018; 40: 382-386.

[30] Ho K, Wang X, Chen L.Reasons for parental withdrawal of care in a pediatric intensive care unit in P. R. China. PLoS One. 2018; 13: e0199419.