What is the treatment for Mycoplasma genitalium infection?

From the Guidelines

The treatment for Mycoplasma genitalium is Azithromycin 500 mg orally on day 1, with an alternative regimen of Moxifloxacin 400 mg orally once daily for 7-14 days in cases of macrolide resistance. According to the European Association of Urology guidelines on urological infections, published in 2024 1, Azithromycin is the recommended first-line treatment for Mycoplasma genitalium. The guidelines suggest a dosage of 500 mg orally on day 1. However, in cases where macrolide resistance is suspected, Moxifloxacin 400 mg orally once daily for 7-14 days is recommended as an alternative regimen.

Some key points to consider when treating Mycoplasma genitalium include:

• The importance of completing the full treatment course to ensure the infection is fully cleared
• The need to test for cure 3-4 weeks after completing treatment to ensure the infection has been eradicated
• The importance of treating sexual partners simultaneously to prevent reinfection
• The need to be aware of local resistance patterns and adjust treatment accordingly, as antibiotic resistance is a growing concern with this infection, as noted in the guidelines 1.

It's also important to note that Mycoplasma genitalium can be difficult to eradicate due to its lack of a cell wall, which makes it naturally resistant to many common antibiotics like penicillins and cephalosporins. Therefore, treatment should be guided by the most recent and highest quality evidence, such as the European Association of Urology guidelines 1.

From the Research

Treatment Options for Mycoplasma genitalium

• The current guidelines recommend 1 g of azithromycin as the first-line treatment for patients diagnosed with M. genitalium infection 2.
• Moxifloxacin is used as a second-line drug due to its remarkable efficacy, but increased use has caused the emergence of cases of moxifloxacin treatment failure 2, 3.
• Azithromycin 1 g single dose has a recovery rate of 79%, and is as effective as an extended five-days' course of azithromycin 4.
• Extended azithromycin (500 mg on day 1 followed by 250 mg o.d. for 4 days) has an eradication rate of 99% 5.
• Doxycycline is inefficient in eradicating M. genitalium, with an eradication rate of 43% 5.

Resistance Issues

• Macrolide resistance-associated mutations correlate with microbiological and clinical treatment failure 3.
• Fluoroquinolone resistance-associated mutations correlate with microbiological moxifloxacin treatment failure 3.
• Macrolide resistance developed in 7/7 examined patients who tested positive after azithromycin 1 g, but in none of those treated with extended azithromycin 5.
• The emergence of multidrug-resistant (MDR) M. genitalium strains is an alarming sign for its treatment and the associated public health impact 6.

Alternative Treatment Options

• Moxifloxacin 400 mg o.d. for seven days as either second-, third- or fourth-line treatment after azithromycin or ofloxacin failure cured 100% of patients 4.
• Newer drugs like pristinamycin, solithromycin, sitafloxacin, and others have shown hope for clinical cure, but need further clinical trials to optimize therapeutic dosing schedules and formulate appropriate treatment regimens 6.