Treatment of Asymptomatic Mycoplasma genitalium
No, you should not treat asymptomatic Mycoplasma genitalium infection unless the patient is a sexual contact of someone with documented M. genitalium infection. 1
Testing Indications for M. genitalium
Testing for M. genitalium should be limited to specific clinical scenarios to avoid inappropriate antibiotic use and resistance development:
Test in These Situations:
- Persistent or recurrent urethritis in men after treatment for gonorrhea/chlamydia 1
- Mucopurulent cervicitis that persists after standard treatment 1
- Proctitis 1
- Pelvic inflammatory disease (consider testing) 1
- Sexual contacts of patients with documented M. genitalium infection 1
Do NOT Test in These Situations:
- Asymptomatic patients without known M. genitalium exposure 1
- Asymptomatic pregnant patients without known exposure 1
- Routine STI screening in asymptomatic individuals 1, 2
Rationale for Not Treating Asymptomatic Infection
The CDC explicitly recommends against testing asymptomatic patients who lack a history of M. genitalium exposure, which inherently means no treatment is indicated 1. The 2021 European guideline emphasizes that symptoms are the main indication for diagnostic testing, and due to increasing antimicrobial resistance concerns, indications for testing and treatment have been narrowed to primarily involve symptomatic patients 2.
Critical Context About M. genitalium
Asymptomatic infections are frequent in both men and women 2. M. genitalium is associated with:
- 10-35% of non-chlamydial non-gonococcal urethritis in men 2
- Cervicitis and pelvic inflammatory disease in 10-25% of women 2
- Potential complications including epididymitis, infertility, pregnancy complications, and HIV transmission 1
The Antimicrobial Resistance Problem
This is the key reason for restricting treatment to symptomatic patients:
- Doxycycline cure rate is only 30-40% 2
- Azithromycin cure rate is 85-95% in macrolide-susceptible infections, but resistance is increasing 2
- Moxifloxacin resistance is increasing 2
- Macrolide-resistant M. genitalium prevalence is rising due to suboptimal treatment practices 3
- Cases of multidrug-resistant M. genitalium with both macrolide and fluoroquinolone resistance have been documented 3
Inappropriate treatment of asymptomatic infections will likely lead to untreatable infections in the future 3.
Common Pitfalls to Avoid
- Do not perform routine M. genitalium screening in asymptomatic patients, as this leads to unnecessary antibiotic exposure and resistance development 1, 2
- Do not treat empirically without testing, as resistance-guided therapy is recommended but resistance testing is not widely available in the United States 1
- Do not confuse M. genitalium with chlamydia or gonorrhea screening recommendations—while asymptomatic chlamydia screening is recommended in young women, this does NOT apply to M. genitalium 1
Exception: Sexual Contacts
The only asymptomatic patients who should be tested and treated are sexual contacts of individuals with documented M. genitalium infection 1. In this scenario, testing is recommended, and if positive, treatment should be initiated even without symptoms.