What is the diagnosis and treatment for Mycoplasma (a type of bacteria) urethritis (inflammation of the urethra)?

From the Guidelines

Mycoplasma urethritis should be treated with Azithromycin 500 mg p.o. on day 1, as the first-line treatment, according to the most recent guidelines from the European Association of Urology 1. The diagnosis of Mycoplasma urethritis is typically confirmed through nucleic acid amplification testing (NAAT) of urine or urethral swab samples. Some key points to consider in the treatment of Mycoplasma urethritis include:

• The use of Azithromycin as the first-line treatment, due to its effectiveness against Mycoplasma genitalium 1.
• The potential for macrolide resistance, in which case Moxifloxacin 400 mg q.d. 7–14 d can be used as an alternative 1.
• The importance of patient education on abstaining from sexual activity for at least 7 days after starting treatment and until symptoms resolve.
• The need to notify and treat partners from the past 60 days.
• The typical symptoms of Mycoplasma urethritis, which include urethral discharge, dysuria, and urethral itching or discomfort, although some patients may be asymptomatic.
• The recommendation for follow-up testing 3-4 weeks after treatment completion to ensure cure, especially given rising antibiotic resistance rates 1.

From the Research

Diagnosis of Mycoplasma Urethritis

• The diagnosis of urethritis is confirmed by demonstrating an excess of polymorpho-nuclear leucocytes (PMNLs) in a stained smear 2.
• Nucleic acid amplification tests (NAAT) for Neisseria gonorrhoeae, C. trachomatis, and for M. genitalium should be performed to confirm the diagnosis 2.
• If viral or protozoan etiology is suspected, NAAT for HSV, adenovirus, and T. vaginalis should be performed, if available 2.

Treatment of Mycoplasma Urethritis

• Treatment options include doxycycline 100 mg x 2 for one week or azithromycin 1 gram single dose or 1.5 gram distributed in five days 2.
• However, azithromycin as first-line treatment without test of cure for M. genitalium and subsequent moxifloxacin treatment of macrolide-resistant strains will select and increase the macrolide-resistant strains in the population 2, 3.
• If positive for M. genitalium, test of cure samples should be collected no earlier than three weeks after start of treatment, and if positive in test of cure, moxifloxacin 400 mg 7-14 days is indicated 2.
• Current partner(s) should be tested and treated with the same regimen, and they should abstain from intercourse until both have completed treatment 2.
• The efficacy of azithromycin for the treatment of genital Mycoplasma genitalium has decreased to approach 60% 4.
• Fluoroquinolones such as moxifloxacin, gatifloxacin, and sitafloxacin remain highly active against most macrolide-resistant M. genitalium 3.
• Pristinamycin and solithromycin may be of clinical benefit for multidrug-resistant infections 3.

Resistance and Treatment Failure

• Azithromycin treatment failure was first reported in Australia and has subsequently been documented in several continents 3.
• Recent reports indicate an upward trend in the prevalence of macrolide-resistant M. genitalium infections (transmitted resistance), and cases of induced resistance following azithromycin therapy have also been documented 3.
• A strong and consistent association exists between the presence of 23S rRNA gene mutations and azithromycin treatment failure 3.
• The first clinical cases of moxifloxacin treatment failure, due to bacteria with coexistent macrolide-associated and fluoroquinolone-associated resistance mutations, were recently published by Australian investigators 3.