Mycoplasma Genitalium guide: Treatment and follow-up

On this page

• Management and treatment
• Treatment
  • Suspected M. genitalium cervicitis/urethritis
  • Confirmed or suspected macrolide-resistant M. genitalium urethritis/ cervicitis
  • Suspected or confirmed M. genitalium PID
  • Management of suspected treatment failure
• Follow-up
• Reporting and partner notification
  • National/provincial/territorial notification
  • Partner Notification
• References

Management and treatment

Because screening for M. genitalium infection is not recommended and test availability is limited in Canada, management of most infections will occur in the context of syndromic management of urethritis, cervicitis or pelvic inflammatory disease (PID).

Consider M. genitalium infection in people with persistent or recurrent cervicitis, urethritis or PID following empiric treatment when pre-treatment NAAT are negative for chlamydia and gonorrhea or follow-up test of cure (TOC) is negative.

Also consider T. vaginalis as a possible causative organism.

In most settings, azithromycin has been shown to be more effective than doxycycline in treating M. genitalium ^{Footnote 1}, ^{Footnote 2}, ^{Footnote 3}, ^{Footnote 4}.

In vitro comparisons of fluoroquinolones activity with M. genitalium shows that moxifloxacin had the highest bactericidal activity ^{Footnote 5}.

Compared to moxifloxacin, azithromycin is more widely used, less costly, has a narrower spectrum, a shorter duration of therapy and fewer side effects.

In two Canadian studies, approximately half of M. genitalium infections were found to have mutations mediating macrolide resistance ^{Footnote 6}, ^{Footnote 7}. Multi-day azithromycin treatment may be less likely to select for macrolide resistance than single dose azithromycin, but may have higher rates of side effects and is unlikely to be effective in azithromycin-resistant infections ^{Footnote 3}, ^{Footnote 6}, ^{Footnote 8}, ^{Footnote 9}, ^{Footnote 10}.

Treatment failures have been reported with azithromycin 1 g PO in a single dose ^{Footnote 3}, ^{Footnote 11}, ^{Footnote 12}, ^{Footnote 13}. Two Australian studies showed cure rates of 84% (2005-2007) and 69% (2007-2009) following treatment with azithromycin 1 g PO in a single dose. This suggests a decline in cure rate over time ^{Footnote 11}, ^{Footnote 14}. Other data show cure rates of 40% to 91% with azithromycin 1 g PO in a single dose ^{Footnote 1}, ^{Footnote 3}, ^{Footnote 9}, ^{Footnote 15}.

In patients who present with uncomplicated non-gonococcal urethritis and cervicitis, documented cure rates of M. genitalium treated with a multi-day azithromycin regimen (azithromycin 500 mg PO in a single dose on day one followed by 250 mg PO in a single dose on days two to five) range from 78% to 100% ^{Footnote 3}, ^{Footnote 4}, ^{Footnote 10}.

In the event of treatment failure with azithromycin, moxifloxacin has been shown to be effective ^{Footnote 10}, ^{Footnote 11}, ^{Footnote 16}, ^{Footnote 17}. Although cure rates as high as 100% have been reported with moxifloxacin, treatment failures have also been reported and may be related to fluoroquinolone resistance ^{Footnote 18}, ^{Footnote 19}. Canadian studies found 1.9 to 20% of cases had strains with mutations reported to mediate moxifloxacin resistance ^{Footnote 6}, ^{Footnote 7}, ^{Footnote 20}.

A seven-day treatment with moxifloxacin appears to be as effective as a 10-day treatment ^{Footnote 16}.

Pristinamycin has been used to successfully treat cases that have not responded to macrolide or moxifloxacin treatment ^{Footnote 21}. Pristinamycin is not currently available in Canada, but may be requested through Health Canada via a Special Access Request.

Treatment

The Expert Working Group for the Canadian Guidelines on Sexually Transmitted Infections reviewed the available scientific literature on M. genitalium treatment efficacy, safety and escalating antimicrobial resistance (AMR) issues when developing the following treatment recommendations.

The following treatment options are recommended in the absence of contraindication. Consult product monographs for contraindications and side effects.

Caution: Please refer to the health advisory issued by Health Canada about azithromycin and risk of cardiovascular complications and death.

Suspected M. genitalium cervicitis or urethritis

^{Footnote 3}, ^{Footnote 4}, ^{Footnote 10}

Because azithromycin 1 g PO in a single dose may select for macrolide resistance, patients who do not respond to this regimen for the treatment of cervicitis or urethritis may not benefit from retreatment with the multi-day regimen ^{Footnote 3}.

Confirmed or suspected macrolide-resistant M. genitalium urethritis or cervicitis

People with persistent urethritis or cervicitis following treatment with a multi-day regimen of azithromycin may have a macrolide-resistant strain and should be empirically treated with moxifloxacin.

Suspected or confirmed M. genitalium PID

An American study demonstrated that a cefoxitin and doxycycline regimen is not effective for M. genitalium-associated PID ^{Footnote 24}.

Management of suspected treatment failure

Consider consulting an infectious disease specialist or an experienced colleague.

Follow-up

TOC should be done for people who are persistently or recurrently symptomatic after they complete the treatment for M. genitalium or who reside in regions with a documented high prevalence of antibiotic resistance ^{Footnote 6}.

The appropriate timing of TOC by NAAT is uncertain. It is recommended to wait for at least three weeks after the completion of treatment because earlier testing may lead to detection of residual M. genitalium nucleic acid despite cure (a false positive result)^{Footnote 9}.

Reporting and partner notification

National/provincial/territorial notification

M. genitalium is not a reportable infection in Canada.

Partner Notification

Although there is insufficient evidence to provide recommendations for routine partner notification, consider treating current partners (regardless of symptoms) to prevent reinfection of the index case. Treat current sexual partners with the same therapy as the index case.

Individuals diagnosed with M. genitalium and their sexual partners should use barrier protection for any sexual activity until treatment of the individual and all current partners is complete.