East Asia as a sentinel: risk-stratified corticosteroid therapy for paediatric macrolide-resistant <i>Mycoplasma pneumoniae</i> pneumonia

Background Mycoplasma pneumoniae is a major cause of paediatric community-acquired pneumonia. The prevalence of macrolide-resistant M. pneumoniae (MRMP) has exceeded 80% in East Asia, posing significant challenges to clinical management. Increasing evidence suggests that disease progression is driven not only by direct microbial injury but also by host-mediated hyperinflammatory responses. Methods This structured narrative review was conducted using PubMed and Embase databases to identify relevant studies published between 2000 and 2025. Clinical studies, biomarker analyses and regional guidelines, particularly from East Asia, were reviewed to examine the indications, timing and risk-stratified use of systemic corticosteroids in refractory and severe M. pneumoniae pneumonia. Results Available evidence suggests that management of MRMP often involves both second-line antimicrobial therapy and consideration of adjunctive immunomodulation. Among available biomarkers, lactate dehydrogenase (LDH) has been most frequently reported in association with refractory disease. Elevated LDH levels (commonly around 400 IU·L −1 ), particularly when dynamically rising, have been associated with increased risk of disease progression, although thresholds vary across studies. Reported treatment strategies include conventional-dose methylprednisolone (1–2 mg·kg −1 ·day −1 ) in refractory cases and higher-dose regimens (10–30 mg·kg −1 ·day −1 ) in severe hyperinflammatory presentations, with careful clinical assessment. Conclusion Corticosteroids may represent a potential adjunctive strategy rather than a last-resort intervention in selected patients. A risk-stratified approach integrating clinical severity, radiologic progression and biomarker profiles may help guide individualised treatment decisions, although the overall evidence remains heterogeneous and further studies are needed.