From the Guidelines
Azithromycin 500mg on day 1, followed by 250mg daily for days 2-4, is the recommended first-line treatment for Mycoplasma genitalium, with moxifloxacin 400mg once daily for 7-14 days as a second-line option in cases of macrolide resistance. The European Association of Urology guidelines suggest this treatment regimen, as outlined in Table 13 of their 2024 guidelines 1. Key points to consider when treating M. genitalium include:
- Azithromycin is the primary treatment option, but resistance is a growing concern
- Moxifloxacin is an effective second-line treatment for macrolide-resistant cases
- Treatment success should be confirmed with a test of cure 3-4 weeks after completing antibiotics
- Sexual partners should also be treated to prevent reinfection
- Patients should abstain from sexual activity until treatment is complete and symptoms have resolved The lack of a cell wall in M. genitalium makes it naturally resistant to certain antibiotics, such as penicillins and cephalosporins, which target cell wall synthesis 1. In cases where azithromycin is not effective, moxifloxacin is a suitable alternative, with a recommended dosage of 400mg once daily for 7-14 days 1. It is essential to note that M. genitalium has developed increasing resistance to antibiotics, particularly azithromycin, which is why extended regimens and second-line options are often necessary 1.
From the Research
Effective Treatments for Mycoplasma genitalium
- The primary treatment for uncomplicated M. genitalium infection is azithromycin, with a cure rate of 85-95% in macrolide-susceptible infections 2, 3.
- 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 2.
- Moxifloxacin can be used as second-line therapy, but resistance is increasing 2, 3, 4.
- For uncomplicated M. genitalium infection without macrolide resistance mutations or resistance testing, the recommended treatment is azithromycin 500 mg on day one, then 250 mg on days 2-5 (oral) 2.
- Second-line treatment and treatment for uncomplicated macrolide-resistant M. genitalium infection is moxifloxacin 400 mg od for 7 days (oral) 2.
- Third-line treatment for persistent M. genitalium infection after azithromycin and moxifloxacin may include doxycycline or minocycline 100 mg bid for 14 days (oral), which may cure 40-70% of cases 2, or pristinamycin 1 g qid for 10 days (oral), which has a cure rate of around 75% 2.
- Complicated M. genitalium infection (PID, epididymitis) can be treated with moxifloxacin 400 mg od for 14 days 2, 3.
- Combination therapy with doxycycline and sitafloxacin has been shown to be effective in treating highly resistant M. genitalium, with a cure rate of 11/12 infections that had failed prior regimens with moxifloxacin and pristinamycin 5.