What is the recommended treatment for genital mycoplasma infections?

Treatment for Genital Mycoplasma Infections

The recommended first-line treatment for Mycoplasma genitalium infections is azithromycin 1 g orally in a single dose, as it has better efficacy against this pathogen compared to doxycycline, which only has a 30-40% cure rate. 1

Diagnostic Considerations

• Testing for M. genitalium is recommended in patients with urethritis, cervicitis, or related genital tract infections 1
• Co-testing for gonorrhea and chlamydia should be performed as co-infections are common 1
• Diagnosis is achievable only through nucleic acid amplification testing (NAAT) 2
• If available, testing for macrolide resistance should be performed to guide therapy 3

Treatment Options

First-Line Treatment

• Azithromycin 1 g orally in a single dose 1, 4
  • Cure rate of 85-95% in macrolide-susceptible infections 2
  • FDA-approved for treatment of urethritis and cervicitis due to Chlamydia trachomatis or Neisseria gonorrhoeae 4

Alternative First-Line Treatment

• Extended azithromycin regimen: 500 mg on day 1, followed by 250 mg once daily for days 2-5 (total dose 1.5 g) 2, 3
  • Higher cure rate (99%) compared to single-dose azithromycin (91%) 5
  • May reduce the risk of developing macrolide resistance 5

Second-Line Treatment Options

• Doxycycline 100 mg orally twice daily for 7 days 6, 1
  • Lower efficacy (30-40% cure rate) but does not increase resistance 2, 3
• For macrolide-resistant infections: Moxifloxacin 400 mg once daily for 7-10 days 2, 3
  • Efficacy has decreased from 100% to 89% since 2010 due to emerging resistance 7

Third-Line Treatment Options

• For persistent infection after azithromycin and moxifloxacin failure:
  • Doxycycline or minocycline 100 mg twice daily for 14 days (40-70% cure rate) 8, 3
  • Pristinamycin 1 g four times daily for 10 days (approximately 75% cure rate) 8, 3

Treatment Considerations

• For complicated M. genitalium infections (PID, epididymitis): Moxifloxacin 400 mg once daily for 14 days 2, 3
• Resistance-guided therapy is recommended when available:
  • Pre-treatment with doxycycline followed by targeted therapy based on resistance testing has shown high cure rates (>92%) 9
• Single-dose azithromycin (1g) has been associated with selection of macrolide-resistant strains 5
• Macrolide resistance has been increasing, from 0% in 2006-2007 to 18% in 2011 5

Follow-Up Recommendations

• Patients should abstain from sexual intercourse for 7 days after single-dose therapy or until completion of a multi-day regimen 6, 1
• Test of cure is not routinely recommended if symptoms resolve 1
• Patients should return for evaluation if symptoms persist or recur after treatment 1
• Sexual partners should be evaluated and treated to prevent reinfection 6, 1

Common Pitfalls and Caveats

• Using doxycycline as first-line therapy is not recommended due to low cure rates (30-40%) 1, 2
• Single-dose azithromycin may increase the risk of developing macrolide resistance; extended regimens may be preferable 5
• Fluoroquinolone resistance is increasing; moxifloxacin should be reserved for second-line treatment 7, 3
• Failure to test for and treat sexual partners may result in reinfection 6, 1