What is the recommended treatment for Mycoplasma infections in men?

Treatment of Mycoplasma Infections in Men

For Mycoplasma genitalium infections in men, azithromycin 1g orally as a single dose is the recommended first-line treatment due to its superior efficacy compared to doxycycline. 1

Diagnostic Approach

• All patients with suspected urethritis should be tested for gonorrhea and chlamydia, with specific testing for Mycoplasma genitalium when available 1
• Objective evidence of urethral inflammation should be obtained when possible (leukocyte esterase test or microscopic examination showing ≥10 WBC per high-power field) 1
• Nucleic acid amplification testing (NAAT) is the only reliable method for diagnosing M. genitalium infections 2
• When available, testing for macrolide resistance mutations should be performed to guide therapy 2

First-Line Treatment for Mycoplasma genitalium

• Azithromycin 1g orally in a single dose is the recommended first-line treatment 1
• Azithromycin has a cure rate of 85-95% in macrolide-susceptible M. genitalium infections 2
• In a randomized comparison, azithromycin was significantly more effective than doxycycline for M. genitalium urethritis (87% vs 45% cure rate) 3

Alternative Treatment Options

• Doxycycline 100mg orally twice daily for 7 days can be used as an alternative but has lower efficacy (30-40% cure rate) 1, 4, 2
• For macrolide-resistant infections or treatment failures:
  • Moxifloxacin 400mg orally once daily for 7 days is recommended as second-line therapy 2, 5
  • Extended azithromycin regimen (500mg on day 1, then 250mg on days 2-5) may be more effective than single-dose therapy 2

Treatment Approach Based on Resistance Testing

When macrolide resistance testing is available:

• For macrolide-susceptible infections: Azithromycin 1g single dose or extended regimen 2, 5
• For macrolide-resistant infections: Moxifloxacin 400mg daily for 7 days 2, 5
• For multidrug-resistant infections (both macrolide and fluoroquinolone resistance): Consider pristinamycin or consultation with infectious disease specialist 6

Emerging Resistance Concerns

• Macrolide resistance in M. genitalium is increasing globally, with rates exceeding 50% in some regions 2, 5
• Fluoroquinolone resistance is also emerging, with moxifloxacin efficacy declining from 100% to 89% since 2010 7
• Resistance-guided therapy using preliminary doxycycline (to reduce bacterial load) followed by targeted therapy based on resistance testing has shown promising results (>92% cure rates) 5

Follow-Up Recommendations

• Patients should be instructed to return for evaluation if symptoms persist or recur after treatment 1
• 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
• Testing for other STIs including syphilis and HIV should be considered 1

Important Caveats

• Azithromycin is not effective for E. coli UTIs but is appropriate for M. genitalium infections 8
• Increasing antimicrobial resistance necessitates careful selection of therapy and consideration of resistance testing when available 2, 5, 6
• Treatment failures should prompt resistance testing and consideration of alternative regimens 2, 6