From the Guidelines
The recommended testing for Mycoplasma genitalium infection is nucleic acid amplification testing (NAAT) of urine, urethral, vaginal, or cervical samples, and first-line treatment consists of azithromycin 500 mg p.o. on day 1, as suggested by the European Association of Urology guidelines 1.
Key Considerations
- The treatment approach for M. genitalium infection has evolved due to increasing antimicrobial resistance, with azithromycin being the preferred initial treatment option.
- In cases of macrolide resistance or treatment failure, moxifloxacin 400 mg q.d. for 7-14 days is recommended as an alternative regimen 1.
- Testing for cure should be performed 3-4 weeks after completing treatment to ensure the infection has been eradicated.
- Partners from the past 60 days should be notified and treated with the same regimen to prevent reinfection.
Treatment Approach
- The use of azithromycin as the first-line treatment is based on its efficacy in treating M. genitalium infections, as outlined in the European Association of Urology guidelines 1.
- The guidelines also suggest alternative regimens, including moxifloxacin, for cases where azithromycin is not effective or in patients with macrolide resistance.
Patient Management
- Patients should abstain from sexual activity until they and their partners have completed treatment and symptoms have resolved to prevent reinfection, as recommended by the Centers for Disease Control and Prevention 1.
- Timely treatment of sex partners is essential for decreasing the risk of reinfecting the index patient.
From the Research
Diagnosis of Mycoplasma genitalium Infection
- Mycoplasma genitalium infection can be diagnosed through nucleic acid amplification testing (NAAT) 2, 3, 4.
- NAAT diagnosis should be followed with an assay for macrolide resistance mutations to guide treatment 3, 4.
- Symptoms such as urethritis, dysuria, and discharge in men, and vaginal discharge, dysuria, or symptoms of pelvic inflammatory disease (PID) in women, are indications for diagnostic testing 2, 3.
Treatment of Mycoplasma genitalium Infection
- Azithromycin is the recommended first-line treatment for uncomplicated M. genitalium infection, with a cure rate of 85-95% in macrolide-susceptible infections 2, 3, 5.
- An extended course of azithromycin appears to have a higher cure rate, and pre-treatment with doxycycline may decrease organism load and the risk of macrolide resistance selection 3.
- Moxifloxacin can be used as second-line therapy for uncomplicated macrolide-resistant M. genitalium infection, but resistance is increasing 2, 3, 6.
- Doxycycline has a low cure rate of 30-40%, but does not increase resistance, and can be used as third-line treatment for persistent M. genitalium infection after azithromycin and moxifloxacin 2, 3.
Complicated Mycoplasma genitalium Infection
- Complicated M. genitalium infection, such as PID or epididymitis, should be treated with moxifloxacin 400 mg od for 14 days 2, 3.
- Pristinamycin 1 g four times daily for 10 days (oral) has a cure rate of around 75-90% and can be used as an alternative treatment for complicated M. genitalium infection 2, 3.
Resistance and Treatment Failure
- The increasing prevalence of macrolide resistance and fluoroquinolone resistance is a concern, and resistance-guided therapy is recommended for symptomatic patients 3, 6, 4.
- Treatment failure can occur due to resistance, and close follow-up is necessary to investigate the efficacy of treatment and detect mutations associated with resistance 6, 5.