Mycoplasma genitalium treatment guidelines

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What you should know about Mycoplasma genitalium. How to get diagnosed? How can I know if I have MG? Is Mgen treatable?

Mycoplasma genitalium treatment guidelines

Mycoplasma genitalium treatment guidelines

Mycoplasma genitalium (MG) is a sexually transmitted bacterium that is difficult to culture. Detection relies on the use of PCR assays. MG causes urethritis in men. In women, MG can cause cervicitis and pelvic inflammatory disease. MG can also cause rectal infection.

 

There are risks of complications when STIs are left untreated. You should regularly get tested if you engage in sexual activity to minimize the risk of long-term effects from complications. PULSE Clinic offers a variety of tests and treatments to help you get the care you need and find the right treatment that fits you. Contact us at info.bkk@pulse-clinic.com for more information or chat with us at any of the following platforms:

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Causes and Transmission of Mycoplasma Genitalium

MG is caused by the bacterium Mycoplasma genitalium. It can be transmitted through unprotected sex with someone who has MG, including oral sex, penetration, or even from touching the area of infection, as it can be passed through fluids. Sharing sex toys with someone who has MG can also put you at risk of infection.

 

What Are the Symptoms of Mycoplasma Genitalium?

Most of the time, MG goes unnoticed as it usually doesn’t cause symptoms. In cases where symptoms do appear, they often overlap with other STDs like chlamydia, making MG difficult to notice. Some signs you might observe include:

If you have these symptoms, it is suggested that you get tested as soon as possible. Mycoplasma genitalium requires extra care in treatment. Due to its characteristics, you need to ensure that antibiotics can completely eradicate the bacteria, or it can remain in your system for a long time. If left untreated, MG could spread to other areas of the body and cause permanent damage, including infertility if the infection spreads to the reproductive organs.

As mycoplasma genitalium usually goes unnoticed due to it showing no symptoms, this results in MG not getting tested. You can still give your sexual partners mycoplasma genitalium despite being asymptomatic, and leaving it in your system for too long could lead to complications that cause permanent damage to your body.

Our PCR28 comprehensive STD test includes mycoplasma genitalium test to help you make sure you’re free from any sexually-transmitted infections that could be hidden in your system. This test offers you an option for anyone who wants an all-in-one test that can help identify up to 28 pathogens that cause STDs. Contact us for more information about the test and make an appointment today!

 

Who Is at Risk of Mycoplasma Genitalium?

Mycoplasma genitalium can be transmitted as easily as chlamydia. Anyone who is sexually active is at risk of catching MG. This includes everyone who engages in vaginal sex, anal sex, and non-penetrative sex, regardless of sex and gender.

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Clinical presentation

Mycoplasma genitalium can cause urethritis, cervicitis, pelvic inflammatory disease, and rectal infection. Rectal infection is commonly asymptomatic. Asymptomatic rectal infection in men who have sex with men (MSM) is common. Studies are conflicting around the association between MG and proctitis. MG is associated with preterm delivery and spontaneous abortion and is a possible cause of tubal factor infertility. MG is uncommonly associated with sero-reactive arthritis.

 

Clinical indications for testing

  • Acute, persistent and recurrent non-gonococcal urethritis
  • Cervicitis
  • Pelvic inflammatory disease
  • Post-coital bleeding
  • Sexual contacts of MG. MSM require urine and anorectal swabs. Throat swabs are unnecessary as pharyngeal infection is rare (1%).
  • Consider testing prior to termination of pregnancy
  • Consider testing in proctitis
  • Consider testing in epididymo-orchitis
  • Consider testing in balanoposthitis
  • Consider testing in sero-reactive arthritis

Screening asymptomatic individuals, other than sexual contacts of MG positive index patient, for MG is currently not recommended.

 

Diagnosis

 

Males

Test

Site/ specimen

Comments

NAAT

Nucleic acid amplification test

  • First pass urine (FPU)
  • Urethral swab
  • Anorectal swab
  • Most labs offer NAAT testing for MG, and some NAATs also detect mutations conferring resistance to azithromycin to assist in individualising therapy.
  • A FPU specimen is more sensitive than a urethral swab.
  • Throat swabs are unnecessary as pharyngeal infection is rare

 

Females

Test

Site/ specimen

Comments

NAAT

  • Vaginal swab
  • Cervical swab
  • FPU
  • A vaginal swab is the most sensitive specimen followed by cervical swab then urine
  • Women who present with cervicitis, PID or post coital bleeding should be tested for MG. 

 

Management

 

Index patient

Condition

Recommended

Comments

Asymptomatic MG

  • For MG known or suspected to be macrolide-susceptible:
    • Doxycycline 100mg PO, twice daily for 7 days,followed immediately by Azithromycin 1g PO, stat, then 500mg daily for another 3 days (2.5g total)
  • For MG known or suspected to be macrolide resistant:
    • Doxycycline 100mg PO, twice daily for 7 days, followed immediately by Moxifloxacin 400mg PO daily for 7 days
  • Macrolide resistance mutations are detected in approximately 80% of MSM and 50% of heterosexual men and women infected with MG at Melbourne Sexual Health Centre (MSHC).
  • Infections susceptible to azithromycin develop detectable de novo resistance in 12% of cases treated with azithromycin.
  • To improve treatment efficacy and reduce selection of resistance MSHC developed a sequenced resistance-guided treatment strategy based on the macrolide-resistance profile of M. genitalium.
  • Moxifloxacin is not approved by the Therapeutic Goods Administration (TGA) for this infection and may cause significant side-effects including diarrhoea or tendonitis. We recommend discussing this with patients and assessing for contraindications and drug interactions. Pharmacies typically charge over $70 for five tablets. There are limited efficacy data and no data for treatment courses of less than 7 days.
  • MG already treated with azithromycin on the same day as they were tested may be cured but confirm this with a test of cure 2-3 weeks later. If treatment fails, resistance is likely, particularly if reinfection is unlikely. Clinicians with no access to resistance testing can assume resistance in azithromycin treatment failures.

MG-associated pelvic inflammatory disease

Moxifloxacin 400mg [PO] daily for 14 days

Refer to PID treatment guidelines

MG in pregnancy

Azithromycin 1g PO, stat, then 500mg daily for another 3 days (2.5g total)

OR

Pristinamycin 1g PO, 4 times a day for 10 days

 

Resistant MG which has failed moxifloxacin

1) Minocycline 100 mg PO twice daily for 14 days

OR

2) Pristinamycin 1g PO, 3 times a day for 10 days combined with

Doxycycline 100 mg PO, twice daily for 10 days

OR

3) Sitafloxacin 100 mg PO, twice daily for 7 days combined with

Doxycycline 100 mg PO, twice daily for 7 days

  • Resistance to moxifloxacin was detected in 15-20% of infections in Melbourne in 2016-18 and so moxifloxacin treatment-failures are not uncommon.
  • Minocycline cures 70% of macrolide-resistant infections. Minocycline is available on private script and is therefore a practical option for patients with macrolide-resistant MG who have failed moxifloxacin in the community.
  • Pristinamycin has been used at MSHC at a dose of 1g three times daily combined with doxycycline 100mg bd for 10 days and cures 75% of macrolide-resistant infections. Pristinamycin is available through hospital pharmacies, using the Special Access Scheme of the TGA and can be used in pregnancy. For patients with macrolide-resistant MG in whom doxycycline is contraindicated, prescribe pristinamycin 1g four times daily for ten days.
  • Sitafloxacin in combination with doxycycline has proven effective at MSHC and cures >90% of patients in a published series of patients with highly resistant MG. Access to this medication is limited and requires TGA approval (completion of a Category B TGA form). This option is limited to specialised services so consult with a sexual health physician if no other options are available. A test of cure 2- 3 weeks after completing therapy is essential.


To avoid the selection of macrolide resistance, STI syndromes such as urethritis, cervicitis, PID and proctitis should be treated with one week of doxycycline 100mg bd, instead of azithromycin. Patients with these syndromes should be tested for MG and recalled if positive. Other MG-infected patients should also pre-treated with doxycycline. Doxycycline lowers the bacterial load, increasing the likelihood of cure with a second antibiotic.

 

Follow up

Test of cure is important in managing MG because of the risk of persisting, asymptomatic, resistant infection. Test of cure should be performed 2-3 weeks after completing all antimicrobial therapy.

If symptoms have persisted or rebounded to similar intensity, treatment failure due to resistance is likely, but reinfection is also possible, so assess for risk of reinfection.

 

Contact tracing & partner management

Testing and treating infected partners is recommended, particularly in a continuing relationship.

Sexual partners should be pre-treated with doxycycline. Doxycycline lowers the bacterial load, increasing the likelihood of cure with a second antibiotic.

Given the high prevalence of macrolide resistance and need for moxifloxacin in cases with resistance, discuss with patients both the benefits of treatment and the risk of uncommon but serious side effects.

Infection rates in contacts are 40–50% in women and MSM (mostly rectal infection) and 30% in heterosexual men.

 

Related treatment guidelines

 

References

  1. Latimer RL, Shilling HS, Vodstrcil LA, Machalek DA, Fairley CK, Chow EPF, Read TR, Bradshaw CS. Prevalence of Mycoplasma genitalium by anatomical site in men who have sex with men: a systematic review and meta-analysis. Sex Transm Infect. 2020 Apr 27: sextrans-2019-054310. doi: 10.1136/sextrans-2019-054310. Online ahead of print.
  2. Read TRH, Murray GL, Danielewski JA, Fairley CK, Doyle M, Worthington K, Su J, Mokany E, Tan LT, Lee D, Vodstrcil LA, Chow EPF, Garland SM, Chen MY, Bradshaw CS. Symptoms, Sites, and Significance of Mycoplasma genitalium in Men Who Have Sex with Men. Emerg Infect Dis. 2019 Apr;25(4):719-727.
  3. Durukan D, Read TRH, Murray G, Doyle M, Chow EPF, Vodstrcil LA, Fairley CK, Aguirre I, Mokany E, Tan LY, Chen MY, Bradshaw CS. Resistance-guided antimicrobial therapy using doxycycline-moxifloxacin and doxycycline-2.5g azithromycin for the treatment of Mycoplasma genitalium infection: efficacy and tolerability. Clin Infect Dis. 2019 Oct 20:ciz1031. doi: 10.1093/cid/ciz1031. Online ahead of print.
  4. Read TRH, Fairley CK, Murray GL, Jensen JS, Danielewski J, Worthington K, Doyle M, Mokany E, Tan L, Chow EPF, Garland SM, Bradshaw CS Outcomes of Resistance-guided Sequential Treatment of Mycoplasma genitalium Infections: A Prospective Evaluation. Clin Infect Dis. 2019 Feb 1;68(4):554-560. doi: 10.1093/cid/ciy477
  5. Jensen JS, Bradshaw CS. Management of Mycoplasma genitalium infections - can we hit a moving target? BMC infectious diseases 2015;15:343. doi: 10.1186/s12879-015-1041-6
  6. Slifirski JB, Vodstrcil LA, Fairley CK, Ong JJ, Chow EPF, Chen MY, Read TRH, Bradshaw CS Mycoplasma genitalium Infection in Adults Reporting Sexual Contact with Infected Partners, Australia, 2008-2016. Emerg Infect Dis. 2017 Nov;23(11):1826-1833.
  7. Murray GL, Bradshaw CS, Bissessor M, et al. Increasing Macrolide and Fluoroquinolone Resistance in Mycoplasma genitalium. Emerg Infect Dis 2017;23:809-12.
  8. Doyle M, Vodstrcil LA, Plummer EL, Aguirre I, Fairley CK, Bradshaw CS. Nonquinolone Options for the Treatment of Mycoplasma genitalium in the Era of Increased Resistance. Open Forum Infect Dis. 2020 Jul 13;7(8)
  9. Read TRH, Jensen JS, Fairley CK, Grant M, Danielewski JA, Su J, Murray GL, Chow EPF, Worthington K, Garland SM, Tabrizi SN, Bradshaw CS.. Use of Pristinamycin for Macrolide-Resistant Mycoplasma genitalium Infection. Emerg Infect Dis. 2018 Feb;24(2):328-335.
  10. Durukan D, Doyle M, Murray G, Bodiyabadu K, Vodstrcil L, Chow EPF, Jensen JS, Fairley CK, Aguirre I, Bradshaw CS. Doxycycline and Sitafloxacin Combination Therapy for Treating Highly Resistant Mycoplasma genitalium. Emerg Infect Dis. 2020 Aug;26(8):1870-1874.

 

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