The aim is to look at the rate of macrolide resistance in a group of children admitted with mycoplasma pneumonia at a local hospital and to compare and analyze clinical features of macrolide-resistant Mycoplasma pneumoniae (MRMP) and macrolide-sensitive Mycoplasma pneumoniae (MSMP) to facilitate early recognition of likely resistance and to guide the choice of appropriate antibiotics for treatment. Paediatric patients with pneumonia with a real time mycoplasma PCR positive result were analyzed. Mutations associated with macrolide resistance were identified by direct DNA sequencing of the domain V of the 23S rRNA gene and patient. MRMP was identified in 43% of the patients tested within March 2013 to August 2013. No single clinical characteristic or laboratory markers were reliable in differentiating between MSMP and MRMP. A clinical parameter of non-defervescence at 72 hours was identified as a good clinical indicator for likely macrolide resistance. 96% of MSMP patients achieved defervescence by 72 hours. There were 5 patients that developed pleural effusion and 80% of them belonged to the MRMP group. All of the 15 patients treated with doxycycline, were able to achieve rapid defervescence within 24 hours. The overall length of stay was longer in the MRMP group. Macrolide resistance in Hong Kong appears to be lower than previous published data. With limited laboratory support to identity resistance, clinical parameters help facilitate and support the decision for alternative treatment options such as doxycycline to prevent complications and prolong length of stay in a common and treatable condition in the paediatric population.