2016 European guideline on Mycoplasma genitalium infections

Abstract

Mycoplasma genitalium infection contributes to 10-35% of non-chlamydial non-gonococcal urethritis in men. In women, M. genitalium is associated with cervicitis and pelvic inflammatory disease (PID). Transmission of M. genitalium occurs through direct mucosal contact. Asymptomatic infections are frequent. In women, symptoms include vaginal discharge, dysuria or symptoms of PID -abdominal pain and dyspareunia. In men, urethritis, dysuria and discharge predominates.Besides symptoms, indication for laboratory test is a high-risk sexual behaviour. Diagnosis is achievable only through nucleic acid amplification testing (NAAT). If available, NAAT diagnosis should be followed with an assay for macrolide resistance. Therapy for M. genitalium is indicated if M. genitalium is detected or on an epidemiological basis. Doxycycline has a low cure rate of 30-40%, but does not increase resistance. Azithromycin has a cure rate of 85-95% in macrolide susceptible infections. An extended course appears to have a higher cure rate. An increasing prevalence of macrolide resistance, most likely due to widespread use of azithromycin 1 g single dose without test of cure, is drastically decreasing the cure rate. Moxifloxacin can be used as second-line therapy, but resistance is increasing. Uncomplicated M. genitalium infection should be treated with azithromycin 500 mg on day one, then 250 mg on days 2-5 (oral), or josamycin 500 mg three times daily for 10 days (oral). Second line treatment and treatment for uncomplicated macrolide resistant M. genitalium infection is moxifloxacin 400 mg od for 7-10 days (oral). For third line treatment of persistent M. genitalium infection after azithromycin and moxifloxacin doxycycline 100 mg two times daily for 14 days can be tried and may cure 30%. Pristinamycin 1 g four times daily for 10 days (oral) has a cure rate of app. 90%. Complicated M.genitalium infection (PID, epididymitis) is treated with moxifloxacin 400 mg od for 14 days.

Genetic Variation inMycoplasma genitalium

“…Some strong and consistent associations between the presence of 23S rRNA gene mutations and azithromycin treatment failure, as well as between the presence of type II topoisomerase gene mutations and fluoroquinolone treatment failure have been reported around the world [54][55][56]58].…”

“…In the past, doxycycline or tetracycline had been applied for MG-caused NCNG urethritis, albeit with poor efficiency [53,54]. Azithromycin has been the preferred treatment for this infection, and it has been used extensively for several years around the globe.…”

“…Unfortunately, certain MG pathogens have become resistant to the primary azithromycin treatment. Some fluoroquinolones have revealed to be highly active against azithromycin-resistant MG [53][54][55][56][57], yet cases of moxifloxacin treatment failures have been reported recently in Japan, Australia, and some other developed countries in Europe [55][56][57]. Because of the current lack of a specific treatment strategy for macrolideresistant and fluoroquinolone-resistant MG, multi-drugs resistant MG infections will likely become a major problem in the near future [54].…”

Molecular Background of Fluoroquinolone Resistance in Pathogenic Human Mycoplasmas

“…Ассоциированные с резистентностью к фторхинолонам мутации изучены и подробно описаны у патогенных для человека микоплазм. Это позволило в случае M. genitalium признать применимость молекулярных методов для оцен-ки резистентности патогена к терапии, что от-ражено в рекомендациях по лечению вызванных этим микроорганизмом инфекций (2016 European guideline on Mycoplasma genitali um infections [35]). …”

Urogenital Mycoplasmosis and Pregnancy

“…If case of macrolide-resistancy, moxifloxacin 400 mg once daily for 7-10 days may be considered as a treatment option, however it is contraindicated in pregnancy [25,34]. Josamycin has been shown to be in vitro effective against M. genitalium [35].…”