Mycoplasma genitalium

• Mycoplasma genitalium is a well-recognised cause of urethritis
• M. genitalium is also associated with pelvic inflammatory disease (PID) and cervicitis, however no data have been published that assess the benefits of testing women with PID for M. genitalium, and the importance of directing treatment against this organism is unknown. To a lesser extent, M. genitalium has been associated with proctitis, as well as preterm delivery and miscarriage
• Co-infection with other sexually transmitted infections (STIs) is common
• Asymptomatic infection is common and current evidence suggests that the majority of people with M. genitalium infection do not develop disease. Spontaneous resolution of M. genitalium can occur
• M. genitalium rapidly develops resistance to antibiotics. First- and second-line treatments include azithromycin and moxifloxacin
• Resistance to azithromycin is very common in Aotearoa New Zealand, and a treatment course of azithromycin can also induce resistance in a previously sensitive organism
• Moxifloxacin resistance is not uncommon
• Due to the paucity of treatment options for M. genitalium, and high rates of resistance, test of cure should be performed to limit onward transmission of a multi-resistant organism. M. genitalium infection may be temporarily suppressed with treatment before recurring, therefore test of cure should be performed 4 weeks after treatment is completed
• Screening asymptomatic people for M. genitalium (other than ongoing sexual partners of index cases) is currently not recommended due to insufficient knowledge of its natural history, and increasing complexity around access to and availability of effective treatments in the context of rising antimicrobial resistance.

Further studies continue to elucidate the role of M. genitalium in disease causation, complications and sequelae

• Screening asymptomatic people for M. genitalium (other than ongoing sexual partners of index cases) is currently not recommended due to insufficient knowledge of its natural history, and increasing complexity around access to and availability of effective treatments in the context of rising antimicrobial resistance
• M. genitalium is usually considered a second-line STI test in Aotearoa New Zealand, for those with persisting urethritis symptoms where infection with chlamydia and gonorrhoea has been excluded, and standard empirical treatment has failed. Clinical details on laboratory request forms are essential. Indications for testing include:
  • Regular contacts of people who test positive for M. genitalium 
  • People with persistent or recurrent penile urethritis
• There may be other situations where testing for M. genitalium is appropriate in the community, however these must be discussed with a sexual health physician or microbiologist

Note: If testing a contact of a person with M. genitalium infection, the suggested testing interval is 2 weeks from time of last unprotected sexual intercourse, however data to support this recommendation are very limited

Symptomatic people should be examined

M. genitalium is usually considered a second-line STI test in Aotearoa New Zealand for those with persisting urethritis symptoms where infection with chlamydia and gonorrhoea has been excluded, and standard empirical treatment has failed. Clinical details on laboratory request forms are essential

Current sexual partners of those testing positive for M. genitalium should be tested as part of a standard sexual health check

• Macrolide resistance testing is usually performed on positive samples and this will guide choice of therapy
• Throat swabs are not recommended as pharyngeal infection is uncommon and clinical relevance is uncertain

• Discussion with a sexual health physician is strongly recommended
• Macrolide resistance testing is usually performed on positive samples and this will guide choice of therapy
• Without access to resistance testing, it is reasonable to assume macrolide resistance is present and azithromycin should not be prescribed
• Pre-treatment with doxycycline is recommended to increase the likelihood of cure with a subsequent antibiotic. If symptomatic, a 1-2 week course of doxycycline may be started while awaiting M. genitalium result

Treatment options

Note: Moxifloxacin requires a special authority application by a sexual health specialist, or by any relevant practitioner on recommendation by a sexual health specialist. It is contraindicated in pregnancy or breastfeeding. It can cause diarrhoea, and may uncommonly be associated with tendinopathy, neurological and cardiac events

• Test of cure is recommended, even if patient is asymptomatic
• If test of cure remains positive, discuss with sexual health physician

Special Situations

• Advise patient to abstain from sex or use condoms until both patient and partner(s) have had negative tests of cure
• If a patient has an intrauterine device (IUD), leave it in place and treat as recommended. Seek specialist advice as needed

• Risk of transmission per act of unprotected intercourse is unknown, however 38-63% likelihood of long-term sexual partners acquiring the infection
• Contact tracing is important to prevent re-infection and reduce transmission
• Sexual contacts of M. genitalium in an ongoing relationship with the index case should be offered testing
• Most patients choose to tell contacts themselves; giving written information can be helpful
• Notifying all contacts may not be possible e.g. if there is insufficient information or a threat of violence

Management of sexual contacts

• Contacts should have a full sexual health check, including screening for M. genitalium. Empiric treatment is not recommended
• The suggested testing interval is 2 weeks from time of last unprotected sexual intercourse, however data to support this recommendation are very limited
• Only contacts who test positive require treatment
• Advise patient to abstain from sex or use condoms until both patient and partner(s) have had negative tests
• If contacts test positive for an STI refer to specific guideline
• Patient-delivered partner therapy is not legal in Aotearoa New Zealand

Referral to or discussion with a sexual health specialist is recommended for:

• All people testing positive for M. genitalium
• Screening and treatment of sexual contacts if clinician wishes
• Allergy or contraindication to standard treatment options
• People requiring special authority for moxifloxacin
• Treatment failure with moxifloxacin

• 100% of patients diagnosed with M. genitalium have a test of cure