Mycoplasma Genitalium Treatment
The first-line treatment for Mycoplasma genitalium is azithromycin 1g orally in a single dose, as it has better efficacy (85-95% cure rate in macrolide-susceptible infections) compared to doxycycline (30-40% cure rate). 1, 2
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 requires nucleic acid amplification testing (NAAT), ideally followed by testing for macrolide resistance if available 2
Treatment Algorithm
First-Line Treatment
- Azithromycin 1g orally in a single dose 1
- Extended azithromycin regimen (500mg on day one, then 250mg on days 2-5) appears to have higher cure rates and may be preferred to reduce risk of resistance development 3, 2
Alternative First-Line Options
- Doxycycline 100mg orally twice daily for 7 days (less effective but does not increase resistance) 1, 2
- Other alternatives include erythromycin base 500mg orally four times daily for 7 days, erythromycin ethylsuccinate 800mg orally four times daily for 7 days, levofloxacin 500mg orally once daily for 7 days, or ofloxacin 300mg orally twice daily for 7 days 1
Second-Line Treatment (for macrolide-resistant infections)
- Moxifloxacin 400mg once daily for 7-14 days 4, 2, 5
- Cure rates with moxifloxacin have decreased from 100% to 89% since 2010 due to emerging resistance 6
Third-Line Treatment Options (for persistent infections)
- Doxycycline or minocycline 100mg twice daily for 14 days (40-70% cure rate) 4, 2
- Pristinamycin 1g four times daily for 10 days (approximately 75% cure rate) 4, 2
Treatment Considerations and Caveats
Resistance Concerns
- Macrolide resistance in M. genitalium exceeds 50% in many regions 5
- Single-dose azithromycin (1g) may increase the development of macrolide resistance and should be used with caution 4, 7
- Resistance-guided therapy (testing for macrolide resistance mutations before treatment) is increasingly recommended to optimize outcomes 2, 5
- Pre-treatment with doxycycline may decrease organism load and reduce risk of macrolide resistance selection 2
Special Situations
- For complicated M. genitalium infections (PID, epididymitis): moxifloxacin 400mg once daily for 14 days 3, 2
- Multidrug-resistant infections (both macrolide and fluoroquinolone resistance) are emerging and may require pristinamycin or other specialized treatments 7
Follow-Up Recommendations
- Patients should abstain from sexual intercourse for 7 days after single-dose therapy or until completion of a multi-day regimen 1
- Sexual partners should be evaluated and treated to prevent reinfection 1, 4
- Patients should return for evaluation if symptoms persist or recur after treatment 1, 4
- Test of cure is not routinely recommended if symptoms resolve, but may be considered 3-6 months after treatment for resistant infections 1, 4