What is the recommended treatment for genital mycoplasma infections?

Treatment of Genital Mycoplasma Infections

For Mycoplasma genitalium infections, the recommended first-line treatment is azithromycin 500 mg on day one, followed by 250 mg on days 2-5 (extended regimen) for macrolide-susceptible infections, with moxifloxacin 400 mg once daily for 7 days reserved as second-line therapy for macrolide-resistant infections. 1, 2

Diagnostic Approach

• Testing for M. genitalium is primarily recommended for symptomatic individuals
• When available, testing should include investigation for macrolide resistance mutations to guide therapy 1
• Nucleic acid amplification tests (NAATs) are the only reliable diagnostic method 3, 2

Treatment Algorithm for Mycoplasma genitalium

First-line Treatment (Macrolide-susceptible or Unknown Resistance)

• Azithromycin extended regimen: 500 mg orally on day 1, then 250 mg daily on days 2-5 1, 3, 2
  • Cure rates of 95-99% for macrolide-susceptible infections 4
  • Extended regimen is preferred over single 1g dose to reduce risk of resistance development

Second-line Treatment (Macrolide-resistant infections)

• Moxifloxacin: 400 mg orally once daily for 7 days 1, 2
  • Cure rate approximately 92% 5
  • Should be reserved for confirmed macrolide-resistant infections to prevent further resistance development

Third-line Options (For persistent infections after above treatments)

• Doxycycline: 100 mg orally twice daily for 14 days (40-70% cure rate) 2
• Pristinamycin: 1 g orally four times daily for 10 days (75-90% cure rate) 3, 2

Special Considerations

Complicated Infections (PID, epididymitis)

• Moxifloxacin: 400 mg orally once daily for 14 days 3, 2

Pregnancy

• Azithromycin is generally considered safe in pregnancy
• Moxifloxacin is contraindicated in pregnancy

Follow-up Recommendations

• Test of cure recommended 2-4 weeks after completing treatment 5
• Patients should abstain from sexual intercourse until:
  • 7 days after single-dose therapy, or
  • Until completion of multi-day regimens AND resolution of symptoms 1
  • All sexual partners have been treated 6

Clinical Pearls and Pitfalls

Key Considerations

• Avoid single-dose azithromycin (1g) despite FDA approval for chlamydia, as this regimen has been associated with development of macrolide resistance in M. genitalium 4, 7
• Doxycycline monotherapy has poor efficacy (30-40% cure rate) but may be used as pre-treatment to reduce bacterial load before azithromycin 2
• Increasing prevalence of macrolide resistance (up to 50% in some regions) necessitates resistance testing when available 5

Partner Management

• Sexual partners should be evaluated and treated to prevent reinfection 1
• Partners of patients with M. genitalium should receive the same treatment regimen as the index case

The evidence strongly supports using extended-course azithromycin rather than single-dose therapy to maximize cure rates and minimize resistance development. Resistance-guided therapy based on molecular testing for macrolide resistance mutations represents the optimal approach when available 5.