What is the recommended treatment for Mycoplasma genitalium infection?

Treatment of Mycoplasma genitalium Infection

The recommended first-line treatment for Mycoplasma genitalium infection is azithromycin 500 mg orally on day 1, followed by 250 mg daily for days 2-5. 1

Diagnostic Approach

Before initiating treatment, proper diagnosis is essential:

• Perform nucleic acid amplification test (NAAT) on first-void urine sample or urethral smear
• If available, test for macrolide resistance mutations to guide therapy
• Consider testing for other STIs (gonorrhea, chlamydia) as co-infections are common

Treatment Algorithm

First-line Treatment

• For macrolide-susceptible M. genitalium or when resistance status is unknown:
  • Azithromycin 500 mg orally on day 1, then 250 mg daily for days 2-5 1, 2
  • This extended regimen has higher cure rates (85-95% for susceptible infections) compared to single-dose therapy 2

Second-line Treatment (for macrolide-resistant infections or treatment failure)

• Moxifloxacin 400 mg orally once daily for 7-14 days 1, 2
  • 7 days for uncomplicated infections
  • 14 days for complicated infections (PID, epididymitis) 2
  • Cure rates of approximately 92% 3

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

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

Important Clinical Considerations

Resistance Patterns

• Macrolide resistance exceeds 50% in many regions 3
• Quinolone resistance (affecting moxifloxacin efficacy) is increasing 2, 3
• Resistance-guided therapy is strongly recommended when available 2

Treatment Failure and Follow-up

• Test of cure recommended 14-28 days after completing treatment 3
• Patients with persistent M. genitalium after treatment are significantly more likely to experience persistent symptoms (91% vs 17% in successfully treated patients) 4
• Single-dose azithromycin (1g) has shown unacceptable rates of persistent infection and may contribute to resistance development 4

Partner Management

• Sexual partners should be treated while maintaining patient confidentiality 1
• Patients and partners should abstain from sexual intercourse for 7 days after single-dose therapy or until completion of multi-day regimens 1

Special Populations

• Pregnancy: Azithromycin is preferred; doxycycline and moxifloxacin are contraindicated 5
• Complicated infections (PID, epididymitis): Extend moxifloxacin treatment to 14 days 2

Pitfalls to Avoid

• Do not use single-dose azithromycin (1g) despite its convenience, as this regimen has been associated with treatment failure and development of macrolide resistance 2, 4
• Do not assume treatment success without follow-up testing, as persistent infection is common and associated with ongoing symptoms 4
• Do not overlook potential co-infections with other STIs, which may require additional treatment 5
• Do not use doxycycline as monotherapy for M. genitalium due to its low cure rate (30-40%), though it may be used as part of a resistance-guided approach 2, 3

By following this evidence-based approach to M. genitalium treatment, clinicians can maximize cure rates while minimizing the development of antimicrobial resistance.