China’s ‘walking’ pneumonia shows the dangers of drug resistance


The harm caused by antibiotic drug resistance was clear to see in China’s packed pediatric hospitals.
An outbreak of walking pneumonia, normally a mild infection, struck millions of children in the second half of 2023, creating Covid flashbacks and raising fears about another novel pathogen. But doctors say another real danger is the rise of superbugs, crafted by drug resistance that’s been building for years and rendering life-saving antibiotics less effective.
The threat became tangible for Rachel Qiao when her one-and-half-year-old daughter came down with a fever, cough and runny nose during the thick of Beijing’s sweltering summer.Initially, rising bacterial infections caused by mycoplasma pneumoniae didn’t trigger worry, as other countries had similar experiences with different germs after they eased pandemic-control measures.
The doctor prescribed the antibiotic azithromycin and offered a warning: some kids weren’t responding to treatment. The toddler developed lesions in her lungs and continued to deteriorate even after she was switched to an intravenous dosage, given a stronger antibiotic and treated with other drugs to target the inflammation that developed around her heart.
“I melted down,” said Qiao said. “I was constantly stupefied by how much worse this thing could go.”
Her daughter was among the first hit in China’s mycoplasma pneumoniae surge. Many experienced similar journeys: antibiotics failed to control the infection, leaving them with severe pneumonia and forcing doctors to prescribe more potent drugs.
Winter worry
While authorities now say there is a “fluctuating downtrend” in respiratory ailments, parents remain anxious as colder weather sets in. Waiting times in the country’s top pediatric medical centers last month stretched to more than seven hours and some parents brought in their own hooks to hang infusion bags full of medicine on hallway walls as hospitals ran out of space.
The dramatic scenes and fraught social media postings led many people — inside and outside the country — to speculate on what was happening in China. The World Health Organization asked Beijing to explain at the end of November, and requested details on circulating respiratory pathogens.
China denied the emergence of a novel germ. Authorities blamed mycoplasma pnuemoniae for most of the infections as of mid-November. Their presentation, however, was unusual. The bacteria is thought to cause only sporadic outbreaks and rarely triggers hospitalization.
The US Centers for Disease Control and Prevention said it was closely monitoring the situation in China and several European countries, even as American cases began to emerge.
In China, treating children with mycoplasma pneumoniae infections can be difficult. Nearly 80% of cases are resistant to macrolides, a class of drug that includes Pfizer Inc.’s Zithromax given to Qiao’s daughter, according to a study published in JAMA Network Open in 2022. The proportion of drug-resistant cases were less than 10% in Europe, America and Southeast Asia.
Yet azithromycin remains among the most used antibiotics in China and is the default treatment for mycoplasma pneumoniae. Alternatives carry side effects such as teeth discoloration and bone abnormalities for younger children, leaving doctors with few good options.
Several experts blame overuse in mild infections for the high level of resistance. In many cases the drugs remain easy to get, with doctors prescribing them upon request or in anticipation of illness.
“If the antibiotic no longer works, the illness will stretch out longer,” said Zuo-Feng Zhang, chair of epidemiology at the Fielding School of Public Health at the University of California, Los Angeles. That increases the risk of spread and the outsized outbreaks that are occurring, he said.
Global threat
The situation in China highlights the global challenge. The WHO warned for years that overuse of antibiotics made some of the most common bacteria less responsive to existing drugs, calling it a silent epidemic.
Resistance “threatens to send us back to a time when minor infections were untreatable,” WHO director-general Tedros Adhanom Ghebreyesus said in a November video that marked the World Antimicrobial Resistance Awareness Week.
It’s already deadly. Antibiotic resistance contributed to nearly 5 million deaths worldwide in 2019, according to the WHO. Drug-resistant illnesses are projected to lead to an estimated $1 trillion in health-care costs and as much as $3.4 trillion in economic losses by 2050, according to the World Bank.
While health authorities in China have sought to reduce misuse and educate the public, common misconceptions persist. For example, many people consider antibiotics standard for colds, despite the fact that colds are caused by viruses that don’t respond to the drugs.
“That type of use on a large scale can lead to increases in resistance, which means it’s more difficult to treat the people that really need the antibiotics,” said Ben Cowling, chair of epidemiology at the University of Hong Kong’s School of Public Health.
Routine IVs
Intravenously infused antibiotics aren’t uncommon in China for children with bacterial infections, either. While they can help patients recover faster, in many cases the infection may have resolved on its own, albeit at a slower pace, doctors said.
“It’s not a terrible decision to do it, but it’s also something that may not be essential,” Cowling said.
But many parents in China don’t want to wait.
“Very few kids here in the US have had antibiotics from IV drips by the time they hit adolescence, but which kid in China hasn’t?” asked UCLA’s Zhang. “That’s a thing the hospital will do even for minor ailments.”
They don’t always work. Rachel Qiao’s daughter is still getting frequent chest scans and inhaled steroids. While her shortness of breath has eased and the lesions on her lungs are shrinking, they aren’t gone. Doctors are hopeful she’ll fully recover.
“We have to take various measures to curb antibiotic drug resistance,” Yin Yudong, an infectious disease doctor at Beijing Chaoyang Hospital, the nation’s top respiratory disease center, told local media Beijing News in November. “Otherwise, we risk having no treatments for children.”


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