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.