Mycoplasma genitalium

• Asymptomatic Screening: Not currently recommended due to lack of knowledge about natural history, rising antimicrobial resistance, and complexities in accessing effective treatments.
• Clinical Implications:
  • Established cause of
    • urethritis
    • cervicitis
    • PID
    • associated with preterm delivery.
  • Potential role in tubal factor infertility and proctitis, though evidence is not strong.
• Antimicrobial Resistance:
  • Rising globally, particularly in the region.
  • Azithromycin resistance >60% in Australia, >80% in MSM.
  • Fluoroquinolone resistance approaching 20% in urban areas, affecting moxifloxacin efficacy.
  • Resistance-guided therapy improves first-line cure rates from 60% to >90%.

Risk Factors:

• General:
  • Unprotected sexual activity.
  • Multiple sexual partners.
  • Prior sexually transmitted infections (STIs).
  • Association with HIV.
• Specific Groups:
  • Men who have sex with men (MSM) (1%–26% rectal infection prevalence).
  • Women with cervicitis or PID.

Clinical Presentation

• Symptoms:
  • Often asymptomatic.
  • Symptoms similar to chlamydia: dysuria, urethral discharge, urethral discomfort, signs of PID and cervicitis.
  • Specific symptoms like post-coital vaginal bleeding and pelvic pain not independently associated.
• Complications:
  • PID, spontaneous abortion
  • preterm delivery
  • post-abortal PID.
  • Possible role in sexually acquired proctitis and reactive arthritis.
  • Potential role in tubal factor infertility.

Diagnosis

• Site/Specimen and Tests:
  • First Pass Urine (FPU): NAAT (less sensitive than vaginal swab).
  • Anorectal Swab: NAAT (for patients with anorectal symptoms).
  • Vaginal Swab: NAAT (most sensitive specimen, can be clinician or self-collected).
  • Endocervical Swab: NAAT (slightly less sensitive than vaginal swabs).
• Specimen Collection Guidance:
  • Clinician or self-collected.
  • Throat swabs not recommended as pharyngeal infection is uncommon.
  • NAAT tests with macrolide resistance detection improve antimicrobial stewardship.
• Clinical Indications for Testing:
  • Men with recurrent non-gonococcal urethritis (NGU)
  • Women with recurrent Cervicitis, PID, post-coital bleeding.
  • Ongoing sexual contacts of M. genitalium infection.

Management

• General Recommendations:
  • Macrolide-Resistance Testing: Recommended if available.
  • Assume macrolide resistance in persistent cases after azithromycin failure or in MSM.
  • No condomless sex until tested for cure (14-21 days after treatment).
• Principal Treatment Options:
  • Macrolide Susceptible:
    • Doxycycline 100 mg twice a day for 7 days, followed by Azithromycin 1 g immediately then 500 mg daily for 3 days.
  • Macrolide Resistant:
    • Doxycycline 100 mg twice a day for 7 days, followed by Moxifloxacin 400 mg daily for 7 days.
  • PID Due to M. genitalium:
    • Moxifloxacin 400 mg daily for 14 days (evaluate response to initial empiric therapy before switching).
• Special Treatment Situations:
  • If moxifloxacin fails or cannot be used, consider pristinamycin, minocycline, or combination therapy with doxycycline and sitafloxacin.
  • Pregnancy:
    • Azithromycin for macrolide-susceptible cases.
    • Consult specialist for macrolide-resistant cases, potential use of pristinamycin.
  • Allergy to Treatment:
    • Use alternative based on guidelines (pristinamycin or minocycline for macrolide-resistant cases).

Contact Tracing

• Recommendation:
  • Ongoing sexual partners should be offered testing.
  • Refer to Australasian Contact Tracing Guideline – Mycoplasma genitalium.

Follow-Up

• Review:
  • Confirm patient adherence and symptom resolution.
  • Confirm contact tracing and provide support.
  • Educate on safe practices (condom use, contraception, HIV PrEP/PEP, etc.).
  • Test of Cure:
    • NAAT 14-21 days after treatment completion.
    • Consider ongoing symptoms and risk of reinfection in deciding further testing and treatment.