Mycoplasma genitalium

Clinical Manifestations

• Asympomatic in 40-75% of sexually active women and up to 70% in sexually active men
• Non-gonococcal urethritis or cervicitis, especially if resistant to standard treatment for gonorrhoea and chlamydia
  • Symptoms include increased or altered vaginal discharge (in women), dysuria and urinary urgency, urethral discharge (in men), balanoposthitis (in men), and proctitis (in men who have sex with men)
• Complications in women include pelvic inflammatory disease, infertility, and sexually-acquired reactive arthritis
• Complications in men include epididymitis and sexually-acquired reactive arthritis
• Ocular infection can cause conjunctivitis

Differential Diagnosis

• See non-gonococcal urethritis

Management

Canadian Guidelines

• Suspected cervicitis or urethritis:
  • Not previously treated with azithromycin: Azithromycin 500 mg PO on day one followed by 250 mg PO daily for days two to five
  • Previously treated with azithromycin: moxifloxacin 400 mg PO daily for 7 days
• Suspected or confirmed macrolide-resistance: moxifloxacin 400 mg PO daily for 7 days
• Suspected or confirmed pelvic inflammatory disease: moxifloxacin 400 mg PO daily for 14 days, in addition to standard treatment for PID
• Unclear if test-of-cure is required; if done, wait at least 3 weeks before sending NAAT

American Guidelines (2021)

• Macrolide-susceptible: doxycycline 100 mg p.o. twice daily for 7 days followed by azithromycin 1 g p.o. once followed by 500 mg po.o. daily for 3 more days
• Macrolide-resistant, or testing unavailable: doxycycline 100 mg p.o. twice daily for 7 days followed by moxifloxacin 400 mg p.o. daily for 7 days
• Test-of-cure not recommended for asymptomatic people
• If symptoms are persistent, treat with moxifloxacin

European Guidelines (2016)

• Macrolide-susceptible: azithromycin 500 mg p.o. on day one, followed by 250 mg daily on days 2 to 5
• Macrolide-resistant, or second-line: moxifloxacin 400 mg p.o. daily for 7 to 10 days
• Third-line:
  • Doxycycline 100 mg p.o. twice daily for 14 days (eradication in about 30%)
  • Pristinamycin 1 g p.o. four times daily for 10 days
• Complicated infection involving PID or epididymitis: moxifloxacin 400 mg p.o. daily for 14 days
• Test-of-cure is recommended as routine, collected at least 3 weeks after start of treatment

Further Reading

• Canadian STI Guidelines
• CDC Guidelines
• 2016 European guideline on Mycoplasma genitalium infections. J Eur Acad Dermatol Venereol. 2016;30:1650-1656. doi: 10.1111/jdv.13849