Follow-Up After Mycoplasma genitalium Treatment
The most critical next step is to assess symptom resolution and ensure all sexual partners from the preceding 60 days have been treated, as reinfection rates are extremely high without proper partner management. 1, 2
Immediate Assessment at Follow-Up Visit
Symptom Evaluation
- Ask specifically about persistence or recurrence of urethral discharge, dysuria, vaginal discharge, or pelvic pain. 2, 3
- Persistent symptoms after treatment strongly suggest treatment failure (91% of patients with persistent M. genitalium have ongoing symptoms versus only 17% of those successfully treated). 4
- If symptoms persist or recur, this indicates likely treatment failure requiring resistance-guided therapy. 2, 3
Partner Treatment Verification
- Confirm that all sexual partners within the preceding 60 days were evaluated and treated simultaneously with the same M. genitalium regimen. 1, 2
- Verify both patient and partners abstained from sexual intercourse until 7 days after completing therapy. 1, 2
- Untreated or inadequately treated partners are the primary cause of persistent infection (reinfection accounts for most post-treatment infections). 5, 2
Test-of-Cure Considerations
Routine test-of-cure is NOT recommended for asymptomatic patients who completed appropriate therapy. 2
However, consider test-of-cure if:
- Symptoms persist or recur after treatment 2
- Partner treatment compliance is uncertain 1
- Patient received azithromycin monotherapy (which has unacceptable 16% failure rates) 4
If testing is performed, wait at least 3 weeks after treatment completion to avoid false-positive results from dead organisms. 5
Management of Treatment Failure
If symptoms persist or M. genitalium is detected at follow-up:
First-Line Treatment Failure
- Prescribe moxifloxacin 400 mg orally once daily for 7 days (uncomplicated) or 14 days (complicated infections including PID/epididymitis). 2, 3
- Moxifloxacin achieves 100% eradication in azithromycin-resistant cases. 4
- Macrolide resistance testing should guide therapy when available, though standardized tests are not commercially available in many settings. 2, 3
Second-Line Treatment Failure
If moxifloxacin fails:
- Doxycycline or minocycline 100 mg orally twice daily for 14 days may cure 40-70% 3
- Pristinamycin 1 g four times daily for 10 days achieves approximately 75% cure rate 3
Reinfection Prevention Strategy
Schedule repeat testing at 3-6 months even if asymptomatic, as reinfection rates are extremely high. 1, 2
This is distinct from test-of-cure and addresses the reality that:
- Most post-treatment infections result from reinfection, not treatment failure 5
- Repeat infections confer elevated risk for PID and complications compared to initial infection 5
- Recently infected individuals are high priority for retesting 5
Additional STI Screening
Ensure concurrent testing for other STIs has been completed: 1
- N. gonorrhoeae and C. trachomatis by NAAT (co-infections are common) 1
- Syphilis serology 1
- HIV testing with counseling 1
Critical Counseling Points
- Reinforce that sexual activity must cease until both patient and all partners complete treatment and remain asymptomatic for 7 days. 1, 2
- Explain that M. genitalium is an emerging STI of public health concern requiring partner notification. 2
- Emphasize the importance of returning immediately if symptoms recur, as this indicates treatment failure requiring alternative therapy. 2
Common Pitfalls to Avoid
- Do not perform test-of-cure earlier than 3 weeks post-treatment (false-positives from dead organisms are common). 5
- Do not assume treatment success based on symptom resolution alone (schedule 3-6 month reinfection screening regardless). 1, 2
- Do not neglect partner treatment verification (this is the primary cause of persistent/recurrent infection). 1, 2
- Do not use azithromycin 1g single dose (this has unacceptable 16% failure rates; extended azithromycin regimens achieve 85-95% cure in macrolide-susceptible infections). 3, 4