What is the recommended treatment for Mycoplasma genitalium infections?

Treatment of Mycoplasma genitalium 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, which has a cure rate of 95-99% for macrolide-susceptible infections. 1

Treatment Algorithm

First-line Treatment

• Macrolide-susceptible M. genitalium infections:
  • Azithromycin 500 mg on day one, followed by 250 mg on days 2-5 (oral) 1, 2
  • Alternative: Azithromycin 1 g orally in a single dose (though extended regimen is preferred due to higher cure rates) 1

Second-line Treatment (for macrolide-resistant infections)

• Moxifloxacin 400 mg once daily for 7-10 days (oral) 1, 2, 3
  • Note: Moxifloxacin cure rate is approximately 92%, but resistance is increasing 4, 3

Third-line Treatment (for persistent infections after azithromycin and moxifloxacin)

• Doxycycline 100 mg twice daily for 14 days (may cure 30-40%) 2, 3
• Pristinamycin 1 g four times daily for 10 days (cure rate ~75-90%) 2, 3

For Complicated Infections (PID, epididymitis)

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

Resistance Considerations

Antimicrobial resistance is a significant concern with M. genitalium:

• Macrolide resistance rates exceed 50% in many regions 5, 6
• Fluoroquinolone resistance is increasing, with cases of moxifloxacin treatment failure documented 6
• Testing for macrolide resistance mutations should guide therapy when available 1, 3
• Resistance-guided therapy (RGT) has shown high cure rates (>92%) 5

Important Clinical Considerations

• Patients should abstain from sexual intercourse until:

  • 7 days after single-dose therapy
  • Until completion of multi-day regimens
  • Until resolution of symptoms
  • Until all sexual partners have been treated 1

• Test of cure is recommended 2-4 weeks after completing treatment 1

• Sexual partners should receive the same treatment regimen as the index case to prevent reinfection 1

• Doxycycline monotherapy has a low cure rate (30-40%) but does not increase resistance and may be used as pre-treatment to decrease organism load before azithromycin 3, 5

Pitfalls to Avoid

1. Using azithromycin 1g single dose as first-line without resistance testing may lead to treatment failure and increased resistance 3, 6

2. Prescribing moxifloxacin prophylactically or as first-line therapy can accelerate fluoroquinolone resistance development 1

3. Failing to test for cure after treatment can miss persistent infections

4. Not treating sexual partners increases risk of reinfection

5. Using doxycycline alone as primary treatment is likely to fail (30-40% cure rate) 2, 3

The evidence strongly supports using extended azithromycin regimens for macrolide-susceptible infections and reserving moxifloxacin for confirmed macrolide-resistant cases to preserve its effectiveness as a second-line agent.