What is the recommended treatment for mycoplasma genitalium?

Treatment for Mycoplasma Genitalium

Azithromycin 1g orally in a single dose is the recommended first-line treatment for Mycoplasma genitalium infections, as infections with M. genitalium respond better to azithromycin than to doxycycline. 1

Treatment Algorithm

First-line Treatment:

• Azithromycin 1g orally in a single dose 1

Alternative Regimens (if azithromycin cannot be used):

• Doxycycline 100mg orally twice a day for 7 days
• Erythromycin base 500mg orally four times a day for 7 days
• Erythromycin ethylsuccinate 800mg orally four times a day for 7 days
• Levofloxacin 500mg orally once daily for 7 days
• Ofloxacin 300mg orally twice a day for 7 days 1

For Persistent Infection (Treatment Failure):

If symptoms persist after initial treatment, consider:

1. Moxifloxacin 400mg orally once daily for 7 days 1

Important Considerations

Increasing Antimicrobial Resistance

Recent evidence shows significant macrolide resistance rates (up to 55.5%) in M. genitalium infections 2. The 2021 European guideline suggests that resistance testing should guide therapy when available 3.

Test of Cure

• Patients should be instructed to return for evaluation if symptoms persist or recur after completion of therapy 1
• Test of cure is not routinely recommended unless symptoms persist, therapeutic compliance is in question, or reinfection is suspected 1

Partner Management

• All sex partners within the preceding 60 days should be referred for evaluation, testing, and treatment 1
• Patients should abstain from sexual intercourse for 7 days after single-dose therapy or until completion of a 7-day regimen 1
• To minimize risk of reinfection, patients should abstain from sexual intercourse until all sex partners are treated 1

Emerging Treatment Approaches

For regions with high macrolide resistance, resistance-guided therapy is becoming more common:

• Pre-treatment with doxycycline (100mg twice daily for 7 days) followed by:
  • For macrolide-susceptible infections: Extended azithromycin (2.5g total: 1g day 1, then 500mg daily for 3 days)
  • For macrolide-resistant infections: Moxifloxacin 400mg daily for 7 days 4, 5

This approach has shown cure rates of 95.4% for macrolide-susceptible infections and 92.0% for macrolide-resistant infections 4.

Common Pitfalls and Caveats

1. Underestimating resistance: Standard azithromycin 1g single dose may have unacceptable failure rates (up to 16%) due to increasing macrolide resistance 6

2. Inadequate follow-up: Persistent symptoms strongly correlate with treatment failure. 91% of patients with persistent M. genitalium infection experience ongoing symptoms compared to only 17% of successfully treated patients 6

3. Ignoring partners: Failure to treat partners is a common cause of reinfection and apparent treatment failure

4. Fluoroquinolone resistance: ParC mutations (especially S83I) are associated with moxifloxacin treatment failure in up to 62.5% of cases 5

For optimal outcomes in terms of morbidity and mortality, clinicians should consider local resistance patterns when selecting treatment and ensure adequate follow-up for patients with persistent symptoms.