Clinical Efficacy Comparison of Doxycycline versus Azithromycin Combined with Methylprednisolone in the Treatment of macrolide-unresponsive Mycoplasma pneumoniae pneumonia in children

Background The escalating prevalence of macrolide-resistant Mycoplasma pneumoniae (MRMP) in China has posed substantial challenges for pediatricians managing mycoplasma pneumoniae pneumonia (MPP). This study aimed to compare the clinical efficacy and prognostic outcomes between two treatment strategies for pediatric patients with macrolide-unresponsive mycoplasma pneumoniae pneumonia (MUMPP) following initial 72-hour intravenous azithromycin therapy: 1) continuation of intravenous azithromycin combined with methylprednisolone, versus 2) switch to oral doxycycline monotherapy. Methods We performed a retrospective analysis of children hospitalized for MPP at our institution between November 2023 and October 2024. Children with MPP who showed no clinical response to an initial 72-hour course of intravenous azithromycin were assigned to two groups: 1) intravenous azithromycin combined with methylprednisolone (AZM + methylprednisolone group), and 2) doxycycline monotherapy (DXC group). Clinical efficacy and prognosis were compared between groups using 1:1 propensity score matching (PSM) to adjust for baseline confounding, followed by calculation of statistical power for the primary outcomes. Results A total of 1,112 children with MPP were screened, of whom 493 (44.33%) met the criteria for MUMPP, and 382 were included in the final analysis. The DXC group showed a significantly higher rate of pulmonary imaging improvement at discharge compared to the AZM + methylprednisolone group (94.29%vs.77.14%, P < 0.05). No significant intergroup differences were observed in the time to fever resolution or cough relief (P > 0.05). The AZM + methylprednisolone group had a significantly longer hospital stay than the DXC group [8 (7, 9) days vs. 6 (5, 7) days, P < 0.05]. Additionally, the refractory rate was higher in the AZM + methylprednisolone group (14.29% vs. 4.29%, P < 0.05). At 3-month follow-up, the incidence of new infections or diseases was significantly higher in the AZM + methylprednisolone group (32.86% vs. 4.29%, P < 0.05), whereas no significant difference was found in the complete imaging absorption rate between groups within 3 months (98.57% vs. 94.29%,P > 0.05). Notably, no cases of tooth discoloration-related adverse reactions were observed in the DXC group. Conclusion DXC demonstrated significantly greater efficacy than AZM + methylprednisolone in resolving radiographic abnormalities at discharge among MUMPP patients. AZM + methylprednisolone combination therapy correlated with longer hospital stays, higher rates of refractory MPP, and increased post-discharge risks of new infections or diseases.