What is the treatment for Mycoplasma genitalium causing cloudy yellowish discharge?

Treatment for Mycoplasma genitalium Causing Cloudy Yellowish Discharge

For confirmed or suspected Mycoplasma genitalium infection causing urethral or cervical discharge, treat with azithromycin 500 mg orally on day 1, followed by 250 mg daily on days 2-5 (total 1.5 g extended regimen), which achieves 93-99% cure rates while minimizing resistance development. 1, 2, 3

Diagnostic Approach Before Treatment

• Test for M. genitalium using nucleic acid amplification testing (NAAT) whenever possible, as this is the only reliable diagnostic method available 1, 2, 3
• Simultaneously test for gonorrhea and chlamydia, as co-infections are common and require different treatment approaches 1, 4
• If NAAT testing is available, perform macrolide resistance mutation testing to guide therapy selection 3
• Do not rely on culture, as M. genitalium is extremely difficult to culture and this method is not clinically useful 5

First-Line Treatment Regimen

Azithromycin extended regimen (preferred):

• 500 mg orally on day 1
• Then 250 mg orally daily on days 2-5
• This achieves 85-99% cure rates in macrolide-susceptible infections 1, 2, 3

Important caveat: The single-dose azithromycin 1 g regimen, while commonly used for chlamydia, has unacceptably high failure rates (16-30%) for M. genitalium and drives macrolide resistance development 4, 6, 7. The extended 5-day regimen is superior and should be used instead 1, 2, 3.

Alternative Treatment Options

If azithromycin cannot be used or macrolide resistance is documented:

• Moxifloxacin 400 mg orally once daily for 7 days (for uncomplicated infection) 2, 3
• This is highly effective as second-line therapy and eradicates persistent infection after azithromycin failure 6

Doxycycline 100 mg orally twice daily for 7 days:

• Has only 30-40% cure rate for M. genitalium 4, 2, 3
• Should not be used as first-line therapy for confirmed M. genitalium 2, 3
• May be considered as empiric therapy when testing is unavailable and chlamydia/gonorrhea are also suspected 8, 4

Critical Management Steps

Sexual abstinence and partner management:

• Patients must abstain from all sexual intercourse for 7 days after completing therapy 1, 4
• All sexual partners from the previous 60 days require evaluation and treatment, even if asymptomatic 1, 4
• Failure to treat partners leads to reinfection rates up to 20% 9

Concurrent STI treatment:

• If gonorrhea prevalence is high (>5%) or testing unavailable, treat presumptively for both gonorrhea and chlamydia in addition to M. genitalium therapy 8, 9
• This is critical because co-infections are common and treating M. genitalium alone when gonorrhea is present leads to treatment failure 9

Follow-Up and Test of Cure

When to perform follow-up testing:

• Patients should return for evaluation if symptoms persist or recur after treatment completion, as this indicates treatment failure requiring resistance testing and alternative therapy 1, 4
• Test of cure is not routinely recommended if symptoms resolve 4
• Repeat testing at 3-6 months is recommended due to high reinfection rates 1

Persistent symptoms after azithromycin:

• 91% of patients with persistent M. genitalium infection experience ongoing symptoms, compared to only 17% in whom the organism was eradicated 6
• If symptoms persist, assume treatment failure and switch to moxifloxacin 400 mg daily for 7-10 days 2, 3, 6

Common Pitfalls to Avoid

Do not use single-dose azithromycin 1 g for M. genitalium—this regimen is appropriate for chlamydia but has unacceptably high failure rates (16-30%) for M. genitalium and drives macrolide resistance 6, 7

Do not use doxycycline as first-line therapy when M. genitalium is confirmed or strongly suspected, as cure rates are only 30-40% 4, 2, 3

Do not wait for test results if compliance with return visit is uncertain in high-prevalence populations—treat presumptively with the extended azithromycin regimen 9

Do not assume treatment success without follow-up—the increasing prevalence of macrolide resistance (driven by widespread inappropriate use of single-dose azithromycin) is drastically decreasing cure rates 2, 7

Resistance Considerations

• Macrolide resistance is increasing globally, primarily due to widespread use of single-dose azithromycin without test of cure 2, 7
• Strong association exists between 23S rRNA gene mutations and azithromycin treatment failure 7
• Fluoroquinolone resistance is also emerging, with first cases of moxifloxacin failure due to multidrug-resistant M. genitalium recently documented 7
• The extended azithromycin regimen (1.5 g total over 5 days) minimizes resistance development compared to single-dose therapy 1, 2