Mycoplasma pneumoniae infections in the Post-COVID era: recent advances from pathogenesis to clinical management

M.pneumoniae is a major cause of human respiratory infection whose pathogenicity relies on adhesion proteins, secreted virulence factors, and immune evasion mechanisms. This review contextualizes these strategies within the broader phylogeny of clinically relevant Mycoplasma species while addressing the diverse extrapulmonary manifestations of M. pneumoniae. Current challenges in managing M. pneumoniae infections are multifaceted. The post-pandemic resurgence reflects a population-level immune debt resulting from prolonged non-pharmaceutical interventions, with test positivity rising sharply after restrictions were lifted and driving pneumonia outbreaks across age groups. Macrolide resistance remains persistently high in East Asia and is emerging at variable rates in other regions; routine diagnostics cannot detect resistance in real time, complicating first-line empirical therapy. Vaccine development continues to face obstacles including antigenic variation mediated by recombination between repetitive genomic sequences, the IL-17 A paradox wherein protective Th17 responses also drive vaccine-enhanced disease, and the inability of systemic vaccines to induce mucosal secretory IgA and tissue-resident memory T cells. In response, we evaluate emerging diagnostics-including metagenomic sequencing, CRISPR-Cas platforms, and host biomarkers-and discuss resistance-guided therapies involving doxycycline, quinolones, and novel agents like lefamulin and omadacycline. We further analyze vaccine development hurdles alongside the potential of mRNA-LNP platforms targeting conserved adhesin epitopes. Our findings indicate that the lag between mechanistic insight and clinical implementation remains the most pressing challenge. Future research must shift from simple mechanistic elucidation to addressing real-world clinical dilemmas, including distinguishing colonization from infection through integrated pathogen-host evaluation, exploring synergistic use of antibiotics and immunomodulators targeting the IL-17 A pathway, advancing vaccine design that circumvents IL-17 A-mediated immunopathology via conserved epitope selection and mucosal delivery, and establishing real-time surveillance networks integrating genomics and clinical phenotypes. Collectively, this work provides a practical roadmap spanning molecular pathology to clinical practice for the precise management of M. pneumoniae infections.