Treatment for Mycoplasma Genitalium
Azithromycin 1 g orally in a single dose is the recommended first-line treatment for Mycoplasma genitalium infections, as it has better efficacy against this pathogen compared to doxycycline. 1
Diagnostic Considerations
- Testing for M. genitalium should be performed in patients with urethritis, cervicitis, or related genital tract infections 1
- Nucleic acid amplification tests (NAATs) are the only reliable diagnostic method for detecting M. genitalium 2
- Testing for both gonorrhea and chlamydia should also be performed in patients with suspected M. genitalium infection, as co-infections are common 1
First-Line Treatment Options
- Azithromycin 1 g orally in a single dose is the preferred first-line treatment 1
- Infections with M. genitalium respond better to azithromycin than to doxycycline (which has only 30-40% cure rate) 1, 2
- Single-dose regimens have the advantage of improved compliance and allow for directly observed treatment 1
Alternative Treatment Options
If azithromycin cannot be used, alternative regimens include:
- Doxycycline 100 mg orally twice daily for 7 days (though less effective) 1
- Erythromycin base 500 mg orally four times daily for 7 days 1
- Erythromycin ethylsuccinate 800 mg orally four times daily for 7 days 1
- Levofloxacin 500 mg orally once daily for 7 days 1
- Ofloxacin 300 mg orally twice daily for 7 days 1
Treatment for Persistent or Resistant Infections
- For persistent infections after azithromycin treatment, moxifloxacin 400 mg daily for 7 days is recommended as second-line therapy 3, 2
- Moxifloxacin has been shown to be effective in eradicating persistent M. genitalium infections not responding to azithromycin 3
- For patients with macrolide-resistant M. genitalium, an extended azithromycin regimen (500 mg on day 1, then 250 mg on days 2-5) may be more effective than the single 1 g dose 2, 4
Follow-Up Recommendations
- Patients should be instructed to return for evaluation if symptoms persist or recur after completion of therapy 1
- Test of cure is not routinely recommended if symptoms resolve 1
- Patients should abstain from sexual intercourse for 7 days after single-dose therapy or until completion of a 7-day regimen 1
- Partners should be evaluated and treated to prevent reinfection 1
Special Considerations
- Increasing rates of macrolide resistance (>50% in some regions) are a growing concern 2, 5
- Resistance testing for macrolide mutations, when available, can guide therapy selection 2, 6
- Patients with persistent symptoms despite treatment are more likely to have resistant infections 3
- Combination therapy with doxycycline followed by azithromycin or moxifloxacin (based on resistance testing) has shown improved efficacy in recent studies 4, 6
Treatment Pitfalls to Avoid
- Inadequate treatment can lead to persistent infection and complications 3
- Using doxycycline alone has poor efficacy (30-40% cure rate) for M. genitalium 2, 5
- Failing to test for and treat partners can lead to reinfection 1
- Not considering antimicrobial resistance when initial treatment fails 3, 5
- Not addressing persistent symptoms, which may indicate treatment failure requiring alternative therapy 3