Treatment for Mycoplasma Genitalium
For uncomplicated Mycoplasma genitalium infections, the first-line treatment is azithromycin 500 mg on day one, followed by 250 mg on days 2-5. 1
Treatment Algorithm
First-line Treatment
- For macrolide-susceptible M. genitalium infections:
Second-line Treatment (for macrolide-resistant infections)
- Moxifloxacin 400 mg once daily for 7 days 1, 2
- Note: Moxifloxacin should be reserved for confirmed M. genitalium infections that have failed first-line therapy due to increasing resistance rates 1
Third-line Treatment (for persistent infections after azithromycin and moxifloxacin)
- Doxycycline 100 mg twice daily for 14 days (cure rate 40-70%) 2
- Pristinamycin 1 g four times daily for 10 days (cure rate ~75%) 2
Diagnostic Considerations
- Testing for M. genitalium requires nucleic acid amplification testing (NAAT) 2
- When available, testing should include investigation for macrolide resistance mutations to guide therapy 1, 2
- Testing is primarily recommended for symptomatic individuals 1
Treatment Efficacy
- Extended azithromycin regimen has shown higher cure rates (95-99%) compared to single-dose azithromycin for macrolide-susceptible infections 2, 4
- Doxycycline alone has a low cure rate of only 30-40% for M. genitalium 2, 4
- Moxifloxacin has a cure rate of approximately 92% for macrolide-resistant infections, but efficacy is significantly reduced (37.5%) in the presence of parC S83I mutations 5, 6
Antimicrobial Resistance Considerations
- Macrolide resistance in M. genitalium is increasing globally, with rates exceeding 50% in many regions 6
- Quinolone resistance is also increasing, particularly mutations in the parC gene (S83I) 5, 2
- Single-dose azithromycin (1g) has been associated with selection of macrolide-resistant strains and should be avoided when possible 4
Follow-up Recommendations
- Test of cure is recommended 14-28 days after completing treatment 5, 6
- Patients should abstain from sexual intercourse until completion of treatment and resolution of symptoms 3
- Sexual partners should be evaluated and treated to prevent reinfection 3
Special Considerations
- For complicated M. genitalium infections (PID, epididymitis):
- Moxifloxacin 400 mg once daily for 14 days 2
- Resistance-guided therapy based on macrolide resistance testing is strongly recommended when available to optimize treatment outcomes 2
The treatment landscape for M. genitalium is challenging due to increasing antimicrobial resistance. Extended azithromycin regimens are preferred over single-dose therapy to reduce the risk of developing resistance, and treatment should be guided by resistance testing whenever possible.