2015 UK National Guideline on the management of non-gonococcal urethritis

Abstract

We present the updated British Association for Sexual Health and HIV guideline for the management of non-gonococcal urethritis in men. This document includes a review of the current literature on its aetiology, diagnosis and management. In particular it highlights the emerging evidence that azithromycin 1 g may result in the development of antimicrobial resistance in Mycoplasma genitalium and that neither azithromycin 1 g nor doxycycline 100 mg twice daily for seven days achieves a cure rate of >90% for this micro-organism. Evidence-based diagnostic and management strategies for men presenting with symptoms suggestive of urethritis, those confirmed to have non-gonococcal urethritis and those with persistent symptoms following first-line treatment are detailed.

Detection of markers predictive of macrolide and fluoroquinolone resistance in Mycoplasma genitalium from patients attending sexual health services in England

“…In the absence of widely available M. genitalium tests, the UK treatment guidelines22 recommend that clinics treat male patients with non-gonococcal urethritis with a single dose of 1 g azithromycin or 1 week of doxycycline as first-line therapy. Some patients may receive a second course of therapy, for example, a further course of azithromycin, doxycycline or moxifloxacin, before specimens are referred to the national reference laboratory for M. genitalium testing and, in practice, the majority of specimens referred to the reference service are sourced from those patients who remain symptomatic post-treatment.…”

“…To aid patient management where M. genitalium infection was suspected, the national reference laboratory at Public Health England (PHE), London implemented an assay for the molecular detection of the organism. In the absence of M. genitalium testing, men with non-gonococcal urethritis (NGU) are usually treated syndromically, with a focus on treating presumptive Chlamydia trachomatis , with either one dose of azithromycin 1 g or doxycycline 100 mg twice daily for 7 days 22. Specimens sent to the reference service are most likely received from those patients who have failed treatment.…”

“…Treatment with tetracyclines is not recommended due to high rates of clinical failure,24 and so macrolides and fluoroquinolones are currently recommended as first-line and second-line therapy, respectively 22. However, as with other bacterial STIs, resistance to these antimicrobials is of growing concern.…”

Which azithromycin regimen should be used for treating Mycoplasma genitalium? A meta-analysis

“…There was no information on risk of developing macrolide drug resistance with either azithromycin 1 g or 1.5 g extended regimen in wild-type infections when compiling the 2015 UK NGU management guidelines 18. Expert opinion was divided about discontinuing azithromycin 1 g as first-line treatment in favour of doxycycline 100 mg twice daily for 7 days and/or changing to the azithromycin extended 5-day regimen for first-line treatment.…”

Mycoplasma genitalium: a new kid on the block

“…Treatment should be with an extended course of a macrolide, eg azithromycin, as this will have a higher chance of successful cure with a smaller chance of provoking resistance than a single dose. 3 If a patient has a proven case of M. genitalium, their treatment history and risk of resistant strain needs to be considered. Have they already been treated with a single dose of macrolide?…”