What is the recommended treatment for Mycoplasma genitalium infection?

Treatment of Mycoplasma genitalium Infection

For Mycoplasma genitalium infections, the recommended first-line treatment is azithromycin 500 mg on day one, followed by 250 mg on days 2-5, which has a cure rate of 95-99% for macrolide-susceptible infections. 1

Treatment Algorithm

First-line Treatment

• For macrolide-susceptible M. genitalium or when resistance testing is unavailable:
  • Azithromycin 500 mg on day one, followed by 250 mg on days 2-5 (oral) 1, 2
  • This extended course appears to have a higher cure rate than the single-dose regimen 3

Second-line Treatment

• For macrolide-resistant infections or treatment failures:
  • Moxifloxacin 400 mg once daily for 7 days 1, 2
  • Cure rate approximately 92% 1

Third-line Treatment

• For persistent infection after azithromycin and moxifloxacin:
  • Doxycycline 100 mg twice daily for 14 days (may cure 30-70%) 3, 2
  • Pristinamycin 1 g four times daily for 10 days (cure rate ~75-90%) 3, 2

Resistance Considerations

The treatment landscape for M. genitalium has become increasingly complex due to rising antimicrobial resistance:

• Macrolide resistance:

  • Increasing prevalence, likely due to widespread use of azithromycin 1 g single dose 3
  • Macrolide resistance increased from 0% in 2006-2007 to 18% in 2011 4
  • Studies show 100% development of macrolide resistance in patients who fail treatment with azithromycin 1 g single dose 4

• Doxycycline efficacy:

  • Low cure rate of 30-40% 3, 2
  • MICs for doxycycline do not correlate with treatment outcomes 5

• Moxifloxacin concerns:

  • Should be reserved for confirmed infections that have failed first-line therapy 1
  • Resistance is increasing 2
  • Potential adverse effects include tendinopathy and QT prolongation 1

Management of Sexual Partners

• Sexual partners should receive the same treatment regimen as the index case 1
• Partners should be evaluated and treated to prevent reinfection 1

Follow-up and Test of Cure

• A test of cure is recommended 2-4 weeks after completing treatment 1
• Patients should abstain from sexual intercourse until:
  • 7 days after single-dose therapy or until completion of multi-day regimens
  • Resolution of symptoms
  • All sexual partners have been treated 1

Important Clinical Considerations

• Diagnostic testing should include investigation for macrolide resistance mutations to guide therapy 1, 2
• Testing is primarily recommended for symptomatic individuals due to increasing antimicrobial resistance 1
• The extended azithromycin regimen is preferred over the single 1 g dose due to lower risk of developing resistance 4
• Pre-treatment with doxycycline may decrease organism load and reduce risk of macrolide resistance selection 2
• For complicated infections (PID, epididymitis), moxifloxacin 400 mg daily for 14 days is recommended 2