Failure of syndromic management due to drug-resistant <i>Mycoplasma genitalium</i> infection in South Africa: a case report

Maduna, Liteboho; Laumen, Jolein; Radebe, Oscar; Kock, Marleen M.; Peters, Remco P. H.

doi:10.1177/0956462418820745

Cited by 9 publications

(5 citation statements)

References 11 publications

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“…Consequently, continuous surveillance is warranted to detect potential emergence of resistance at this early stage, as the emergence of resistance could undermine syndromic management for STIs in our region. 24 However, at this stage, azithromycin can still be considered an appropriate drug to cover M. genitalium infection in the syndromic regimen prescribed to individuals presenting with dysuria or discharge in South Africa. 9 Our work is among the first molecular epidemiological studies of M. genitalium strains using an established dual method of SNP and STR analysis.…”

Section: Discussionmentioning

confidence: 99%

Molecular epidemiological analysis of Mycoplasma genitalium shows low prevalence of azithromycin resistance and a well-established epidemic in South Africa

et al. 2020

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ObjectivesMacrolide resistance in Mycoplasma genitalium is emerging globally. There is paucity of data from sub-Saharan Africa where syndromic management is used to treat sexually transmitted infections (STIs). We conducted a molecular epidemiological study to determine the prevalence of azithromycin resistance and epidemic diversity of M. genitalium infections in South Africa.MethodsWe analysed 90 M. genitalium-positive specimens that had been collected consecutively from men and women (50% symptomatic) from geographically diverse communities across the northern part of South Africa between 2015 and 2019. Melting curve analysis followed by targeted sequencing of the 23S rRNA gene was performed to detect azithromycin resistance. Molecular typing was done through single nucleotide polymorphism (SNP) analysis of the MG191 gene and short tandem repeats (STR) assessment of the MG309 gene. An overview of all published M. genitalium sequence types was generated and novel sequence types identified in this study were allocated numbers accordingly.ResultsAzithromycin resistance was detected in 1/90 M. genitalium-positive specimens (1.1%; 95% CI 0% to 3.3%) as conferred by A2071G mutation; this strain also harboured a C234T mutation in the parC gene with wild type gyrA gene. SNP typing and STR assessment was successful in 38/90 specimens (42%) and showed a genetically diverse epidemic, without geographic clustering, with eight novel sequence types identified.ConclusionThis is the first study that determines resistance in M. genitalium infection since introduction of azithromycin in the syndromic management regimen for STIs in South Africa in 2015. Despite a well-established epidemic, azithromycin-resistant M. genitalium infection is still uncommon in the public healthcare sector. However, it has the potential to undermine the effectiveness of syndromic management. Introduction of molecular diagnostics and continuous surveillance are warranted for early detection emergence of resistance.

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Section: Discussionmentioning

confidence: 99%

Molecular epidemiological analysis of Mycoplasma genitalium shows low prevalence of azithromycin resistance and a well-established epidemic in South Africa

et al. 2020

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“…A high frequency of macrolide resistance-associated mutations was detected in M. genitalium strains; this is in stark contrast to data from the public sector, where a low prevalence of macrolide resistance-associated mutations has been reported in several studies. [5,6,15] The observed high rate of macrolide resistance in the private healthcare sector could be due to selection bias, i.e. patients with urethritis not responding to empirical treatment may be more likely to have a diagnostic test.…”

Section: Researchmentioning

confidence: 99%

“…The national STI sentinel surveillance is conducted only in public sector facilities, and research studies have focused on that sector as well. [4][5][6][7] Research on the occurrence of AMR in STIs in the private healthcare sector therefore remains limited. [8,9] There are substantial differences between the private and public healthcare sectors with regard to patients' healthcareseeking behaviour, antimicrobial drug prescribing practice, and socioeconomic status of the patient population.…”

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confidence: 99%

Antimicrobial resistance in Neisseria gonorrhoeae and Mycoplasma genitalium isolates from the private healthcare sector in South Africa: A pilot study

Maduna

Peters

Kingsburgh³

et al. 2021

S Afr Med J

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The increasing prevalence of antimicrobial resistance (AMR) in the sexually transmitted infections (STIs) Neisseria gonorrhoeae and Mycoplasma genitalium is a major concern worldwide. [1] In South Africa (SA), STIs are treated syndromically based on the patient's presenting symptoms and using a combination of broadspectrum empirical antibiotics. The standard regimen for urethral and vaginal discharge syndrome is ceftriaxone and azithromycin with or without metronidazole. [2] An important limitation of the syndromic management approach is that there are limited data on the occurrence of AMR in N. gonorrhoeae and M. genitalium, owing to the lack of routine laboratory diagnostics.The healthcare system in SA is two-tiered: the public healthcare sector provides free healthcare and serves the majority of the population (>80%), while private healthcare is accessed by the minority (15 -17%) and is largely paid for through private health insurance. [3] Both sectors use syndromic treatment for STI management. [2] However, most of the AMR data have been reported from the public healthcare sector. The national STI sentinel surveillance is conducted only in public sector facilities, and research studies have focused on that sector as well. [4][5][6][7] Research on the occurrence of AMR in STIs in the private healthcare sector therefore remains limited. [8,9] There are substantial differences between the private and public healthcare sectors with regard to patients' healthcareseeking behaviour, antimicrobial drug prescribing practice, and socioeconomic status of the patient population. [10] These factors could all impact on the occurrence of antimicrobial-resistant STIs and result in different epidemiological profiles in the two sectors. ObjectivesTo conduct a pilot study to determine the frequency of AMR of N. gonorrhoeae and M. genitalium in patients accessing SA's private healthcare sector. MethodsIn this cross-sectional study, N. gonorrhoeae-positive cultures and M. genitalium DNA samples with linked anonymous clinical This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

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“…This alteration has been previously described, however, clinical resistance has not yet been determined. [26,27,29]…”

Section: Discussionmentioning

confidence: 99%

An alarming high prevalence of resistance associated mutations to macrolides and fluoroquinolones in Mycoplasma genitalium in Belgium: Results from samples collected between 2015-2018

Baetselier

Kenyon

Berghe

et al. 2020

Preprint

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Objectives: The number of reported cases of multi-resistant Mycoplasma genitalium (Mg) is increasing globally. The aim of this study was to estimate the prevalence of macrolide and possible fluoroquinolone resistance associated mutations (RAMs) of Mg in Belgium. Methods: The study was performed retrospectively on two sets of Mg positive samples collected in Belgium between 2015-2018. The first set of samples originated from routine surveillance activities and the second set came from a cohort of men who have sex with men (MSM) using pre-exposure prophylaxis to prevent HIV transmission. Detection of RAMs to macrolides and fluoroquinolones was performed on all samples using DNA sequencing of the 23S ribosomal RNA gene, the gyrA gene and the parC gene. Results: Seventy-six percent of the Mg samples contained a mutation conferring resistance to macrolides or fluoroquinolones (parC position 83/87). RAMs were more frequently found among men compared to women for fluoroquinolones (28.7% vs 9.1%) and macrolides (82.9% vs 27.3%). More than 90% of the Mg infections among MSM possessed a RAM to macrolides (90.7%). In addition, 23.4% of the samples harboured both macrolides and fluoroquinolone RAMs; 3.0% in women and 30.7% in MSM. Being MSM was associated with macrolide RAMs (Odds ratio: 15.1), fluoroquinolone RAMs (Odds ratio: 3.4) and having a possible multi-resistant Mg infection (Odds ratio: 8.2). Conclusion: The study shows an alarmingly high prevalence of Mg with RAMs to macrolides and fluoroquinolones in Belgium. These results highlight the need to improve antimicrobial stewardship in Belgium in order to avoid the emergence of untreatable Mg.

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Failure of syndromic management due to drug-resistant Mycoplasma genitalium infection in South Africa: a case report

Cited by 9 publications

References 11 publications

Molecular epidemiological analysis of Mycoplasma genitalium shows low prevalence of azithromycin resistance and a well-established epidemic in South Africa

Molecular epidemiological analysis of Mycoplasma genitalium shows low prevalence of azithromycin resistance and a well-established epidemic in South Africa

Antimicrobial resistance in Neisseria gonorrhoeae and Mycoplasma genitalium isolates from the private healthcare sector in South Africa: A pilot study

An alarming high prevalence of resistance associated mutations to macrolides and fluoroquinolones in Mycoplasma genitalium in Belgium: Results from samples collected between 2015-2018

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