The Population-Level Effect of Screening for Mycoplasma genitalium on Antimicrobial Resistance: A Quasi-Experimental Study

Abstract

Background: No studies have evaluated the utility and risks of screening for Mycoplasma genitalium in men who have sex with men taking preexposure prophylaxis (PrEP). We made use of a quasi-experimental design to evaluate the effect of screening for M. genitalium in a demonstration PrEP cohort with 3-monthly follow-up. Methods:We compared the proportion of PrEP participants with M. genitalium clearance, the duration of persistence, proportion with incident symptoms, the incidence of fluoroquinolone and macrolide resistance, and the proportion of noncleared infections with resistance-associated mutations between 2 groups: those in whom the first episode of M. genitalium was treated and those in whom it was not treated.Results: M. genitalium was detected in 70 of 179 individuals. The first episode of infection was treated in 46 individuals. Treatment was not significantly associated with the incidence of symptomatic infections or the acquisition of genotypic resistance. Treatment was associated with a higher probability of clearance of infection but at the expense of increasing the proportion of remaining infections that were resistant. In the nontreated group, the infections that did not clear were less likely to be fluoroquinolone resistant (1/6 [16.7%]) than those that did clear (4/4 [100%]; P = 0.048). In contrast, in the treated group, there was no significant difference in the proportion of fluoroquinolone resistance between the infections that persisted and cleared.Conclusions: If screening and treatment increase the ratio of resistant to susceptible M. genitalium in a population, then this could play a role in the spread of antimicrobial resistance.V arious countries are reporting alarming increases in both bacterial sexually transmitted infection (STI) incidence and antimicrobial resistance (AMR). [1][2][3][4] Neisseria gonorrhoeae and Mycoplasma genitalium are of particular concern because they may become untreatable in the not-too-distant future. 1,3,5 One strategy proposed to counter the increased incidence and AMR in these STIs is enhanced screening of these infections in high STI prevalence populations. 1,[6][7][8] Others have argued that the available evidence suggests that this strategy has little or no effect on the prevalence of these infections and results in dangerous increases antimicrobial consumption and thus the risk of AMR emerging. 9,10 No studies that we are aware of have evaluated the utility of screening for M. genitalium in high-STI-prevalence populations. 4 We made use of a quasi-experiment design to evaluate the effect of screening for M. genitalium in a cohort of men who have sex with men (MSM) taking HIV preexposure prophylaxis (PrEP). The most recent European International Union against Sexually Transmitted Infections (IUSTI) M. genitalium guidelines published in August 2016 argue against screening asymptomatic individuals for M. genitalium. 11 Before the publication of these guidelines, a number of authors advocated for screening high-risk populations for this infection. [12][13]...

Mycoplasma genitalium and Antimicrobial Resistance Among a Cohort of West African Men Who Have Sex With Men Using Preexposure Prophylaxis (CohMSM-PrEP ANRS 12369-Expertise France Study)

“…In addition, half of the infections cleared by the next visit and almost 75% of these infections cleared without receipt of treatment. This is in line with a PrEP study performed in Belgium among MSM in which almost half of the MG infections that did not receive treatment cleared spontaneously [ 23 ].…”

“…In our study, half of the MG infections with ParC 83/87 alterations cleared the infection by the next visit. Natural clearance of MG infections with fluoroquinolone RAMs was previously described, and the authors suggested that this could be explained by fluoroquinolone RAMs conferring a fitness cost [ 23 ]. As such, clinical fluoroquinolone resistance may be overestimated in our study.…”

Management of asymptomatic sexually transmitted infections in Europe: towards a differentiated, evidence-based approach

“…The cessation of MG screening led to a 38- and 2-fold decline in fluoroquinolone and macrolide consumption respectively but no appreciable increase in symptomatic or asymptomatic MG infections over the subsequent 12 months. 45 Similarly, reducing NG/CT screening resulted in an additional 6-fold reduction in macrolide exposure without any noticeable effect on numbers of symptomatic infections. 46 …”

Association between the Use of Macrolides in Food-Producing Animals and Mycoplasma pneumoniae Macrolide Resistance: A Global Ecological Analysis

“…What is less clear is what underpins the global variations in macrolide resistance in Mycoplasma genitalium? Various studies have clearly established that exposure to macrolides is a primary driver of macrolide resistance in a number of bacterial species including the related species, Mycoplasma genitalium [2][3][4][5][6]. This has included ecological type studies that have established that population-level consumption of macrolides is positively associated with the prevalence of macrolide resistance in a number of these species [4,5,7].…”