Indications for bronchoalveolar lavage and therapeutic strategies in children with severe Mycoplasma pneumoniae pneumonia: a retrospective study

Controversy persists regarding the management of severe Mycoplasma pneumoniae pneumonia (SMPP) in children, including the indications for bronchoalveolar lavage (BAL) and whether doxycycline (DOX) should be first-line for children under 8 years of age. This study aimed to compare clinical outcomes across treatment regimens and to develop and evaluate a prediction model for identifying children requiring BAL. This retrospective cohort study included 294 pediatric SMPP patients. Clinical outcomes were compared between patients receiving BAL, methylprednisolone sodium succinate (MSS), or DOX, with inverse probability of treatment weighting (IPTW) applied. A prediction model for BAL was developed by multivariable logistic regression, internally validated by bootstrap resampling, and evaluated by decision curve analysis (DCA). An exploratory subgroup analysis compared azithromycin (AZM) plus MSS versus switching from AZM to DOX without MSS in children under 8 years. BAL (n = 159, 54.1%) was associated with a significantly shorter time to cough relief and a higher rate of significant improvement on pulmonary imaging (p < 0.05). Pulmonary imaging findings, C-reactive protein (CRP), fibrinogen (FIB), and interleukin-6 (IL-6) were independent predictors of BAL; the combined model achieved a bootstrap-corrected area under the curve (AUC) of 0.754 (95% CI: 0.728–0.847), and DCA showed greater net benefit than single indicators across a wide threshold range. MSS was associated with faster clinical improvement but a higher fever recurrence rate (p < 0.05). Exploratory subgroup analysis in children under 8 years of age with SMPP, no significant differences were observed between the AZM+MSS group and the group that switched from AZM to DOX without MSS (p > 0.05). The prediction model incorporating CRP, FIB, IL-6, and pulmonary imaging findings was internally validated only and should therefore be regarded as an exploratory tool to assist. In children under 8 years of age with SMPP, combining macrolides with corticosteroids may be considered as a potential therapeutic strategy, whereas for children aged 8 and older or in cases where the first-line treatment has failed, tetracyclines remain the best option. Not applicable.