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. 2022 May;36(5):641-650.
doi: 10.1111/jdv.17972. Epub 2022 Feb 19.

2021 European guideline on the management of Mycoplasma genitalium infections

J S Jensen  1 , M Cusini  2 , M Gomberg  3 , H Moi  4 , J Wilson  5 , M Unemo  6
Affiliations

2021 European guideline on the management of Mycoplasma genitalium infections

J S Jensen et al. J Eur Acad Dermatol Venereol. 2022 May.

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) in 10-25%. Transmission of M. genitalium occurs through direct mucosal contact.

Clinical features and diagnostic tests: Asymptomatic infections are frequent. In men, urethritis, dysuria and discharge predominate. In women, symptoms include vaginal discharge, dysuria or symptoms of PID - abdominal pain and dyspareunia. Symptoms are the main indication for diagnostic testing. Diagnosis is achievable only through nucleic acid amplification testing and must include investigation for macrolide resistance mutations.

Therapy: Therapy for M .genitalium is indicated if M. genitalium is detected. Doxycycline has a cure rate of 30-40%, but resistance is not increasing. Azithromycin has a cure rate of 85-95% in macrolide-susceptible infections. An extended course of azithromycin appears to have a higher cure rate, and pre-treatment with doxycycline may decrease organism load and the risk of macrolide resistance selection. Moxifloxacin can be used as second-line therapy but resistance is increasing.

Recommended treatment: Uncomplicated M. genitalium infection without macrolide resistance mutations or resistance testing: Azithromycin 500 mg on day one, then 250 mg on days 2-5 (oral). Second-line treatment and treatment for uncomplicated macrolide-resistant M. genitalium infection: Moxifloxacin 400 mg od for 7 days (oral). Third-line treatment for persistent M. genitalium infection after azithromycin and moxifloxacin: Doxycycline or minocycline 100 mg bid for 14 days (oral) may cure 40-70%. Pristinamycin 1 g qid for 10 days (oral) has a cure rate of around 75%. Complicated M. genitalium infection (PID, epididymitis): Moxifloxacin 400 mg od for 14 days. MAIN CHANGES FROM THE 2016 EUROPEAN M.

Genitalium guideline: Due to increasing antimicrobial resistance and warnings against moxifloxacin use, indications for testing and treatment have been narrowed to primarily involve symptomatic patients. The importance of macrolide resistance-guided therapy is emphasised.

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References

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    1. Tully JG, Taylor-Robinson D, Cole RM, Rose DL. A newly discovered mycoplasma in the human urogenital tract. Lancet 1981; 1: 1288-1291.
    1. Taylor-Robinson D, Jensen JS. Mycoplasma genitalium: from Chrysalis to multicolored butterfly. Clin Microbiol Rev 2011; 24: 498-514.
    1. Andersen B, Sokolowski I, Ostergaard L, Kjølseth Møller J, Olesen F, Jensen JS. Mycoplasma genitalium: prevalence and behavioural risk factors in the general population. Sex Transm Infect 2007; 83: 237-241.
    1. Oakeshott P, Aghaizu A, Hay P et al. Is Mycoplasma genitalium in women the "New Chlamydia?" A community-based prospective cohort study. Clin Infect Dis 2010; 51: 1160-1166.

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