Mycoplasma genitalium

M. genitalium is a mollicute class bacteria. It is of several types of mycoplasma in the human genital tract, not all are pathogens.

Characteristics include:

• one of the smallest bacteria
• extremely slow growing
• lacks a peptidoglycan cell wall (beta-lactams and other antibiotics targeting the cell wall will be ineffective)

Urethritis

Symptoms: dysuria, urethral discharge, meatal irritation.

There is strong evidence for M. genitalium as a cause of acute and chronic urethritis in men. It is thought that up to a third of non-chlamydial, non-gonococcal urethritis may be due to M. genitalium.

Cervicitis, Endometritis and PID

Symptoms: inter-menstrual bleeding, post-coital bleeding, pelvic pain, pain with sex, vaginal discharge.

A significant association also exists for cervicitis and endometritis and increasing studies and meta-analysis support a role in pelvic inflammatory disease (PID). As with chlamydia, it is thought that there will likely be a higher proportion of asymptomatic presence in women, but testing of asymptomatic women or men is not recommended. 

Proctitis

In MSM with  symptomatic proctitis, M. genitalium is more common in HIV positive than negative men.

Testing for Mycoplasma genitalium should be:

• Considered as a first line test in HIV positive MSM with symptomatic proctitis 
• Recommended as a second-line test in MSM with symptomatic proctitis if baseline tests negative for chlamydia, gonorrhoea and herpes. 
  
  

Epididymitis, sexually acquired reactive arthritis (SARA), acute conjunctivitis and tubal factor infertility

Given the association with the above conditions and other STIs, most notably chlamydia, it is plausible that there could be a causal association withM. genitalium. Cases of epididymitis, SARA, and conjunctivitis associated with M. genitalium have been described in the literature. In addition, seroprevalence studies are suggestive of a possible link with Mycoplasma genitalium and infertility. However, the data to date is considered inconclusive and more study is required for all of the above conditions. 

STI Atlas (external site)

Testing for M. genitalium is performed by NAAT technology.  Standard microscopy and culture will not detect this infection.

Testing recommendations

Asymptomatic individuals

• Do not test, unless contact of known infection, then test as per symptomatic individuals

Symptomatic individuals

• M. genitalium testing is indicated in cases where a man or woman presents with symptoms consistent with urethritis, cervicitis, PID, endometritis or proctitis.

• Endocervical swab (no transport medium)]

Proctitis 

• Rectal NAAT (no transport medium)

Ensure appropriate testing for other STIs such as chlamydia and gonorrhoea is performed, as well as screening for syphilis and BBVs.

Macrolide resistance is an increasing issue in Australia and is likely to be present in at least half of infections in Australian cities. Therefore a test of cure should be performed at three weeks.

First line therapy 

Doxycyline is used to lower the bacterial load, increasing the chance of cure with a subsequent antibiotic.

• Doxycyline 100mg (orally), twice daily for 7 days

FOLLOWED BY

• Azithromycin 1g (orally) as a single dose, then 500mg daily for 3 days (total 2.5g)

Due to the development of resistance and a very limited  number of second and third-line therapy options, it is recommended to refer or discuss cases with a sexual health physician prior to consideration of further therapy.

• Doxycyline 100mg (orally), twice daily for 7 days

FOLLOWED BY

• Moxifloxacin 400mg daily for 7 days 

• Moxifloxacin 400mg daily for 14 days

Patients should be educated regarding:

• We are still learning about this bacterium and the effects, including long-term complications it may or may not have on the body
• M. Genitalium can be difficult to treat, therefore follow-up testing is important to ensure it has been cured
• There are only a limited number of treatment options due to treatment resistance. Reinfection, by having sex with unsuccessfully treated or untreated partners may  increase the likelihood of development of treatment resistance.

Patients should be advised no sexual contact for 7 days after completion of treatment, and no unprotected sex until after successfully proven treatment, by test of cure at 3 weeks. Patients should also be advised to avoid sexual contact with partners from the last 6 months until 7 days after they have been tested and treated.

• Partners should be tested and treated with an appropriately sensitive antibiotic choice, if required. Partners should be advised no sexual contact for 7 days after completion of treatment, and no unprotected sex until after successfully proven treatment, by test of cure at 3 weeks. They should also be advised to avoid sexual contact with partners from the last 6 months until 7 days after they have been tested and treated.
• If the patient has proven treatment resistance, then the partners should likewise be treated with an appropriate next-line treatment option. There is little benefit in treating partners exposed to a macrolide resistant infection with Azithromycin.
• It is recommended that all ongoing partners are tested specifically for M. genitalium.
• Ensure patient provides written name of infection to give to their partners to then pass on to health care provider in order to facilitate appropriate testing. Patients and their partners may not realise that M. genitalium will not be found on routine STI screening and has to be specifically requested.

• Test of cure should be performed 3 weeks after therapy is complete. 
• Reasonable steps should be made to review patients three months after exposure as this provides an opportunity to test for reinfection and repeat blood tests for syphilis, HIV and HBV
• Encourage patients not to have unprotected sexual intercourse until they and all their partners have negative tests
• Ensure testing for other STIs such as chlamydia and gonorrhoea was performed, as well as appropriate screening for syphilis and BBVs
• Also follow-up treatment compliance, partner notification, and abstinence / condom use
• If Mycoplasma genitalium is persistent despite appropriate treatment, seek advice from a sexual health physician or refer for review.
  
  

There is a lack of sufficient data to draw conclusions of the effect of M. genitalium on pregnancy. Prevalence rates have been lower in studies where pregnant populations have been examined. Early studies have suggested there may be an association with preterm birth and early pregnancy loss, but more evidence is required. Similarly, more evidence is required to determine a possible link to infertility.

Treatment with a 1g dose of Azithromycin has been deemed acceptable in pregnancy for the treatment of Chlamydia and could be used for this indication. For further information see Australian categorisation system for prescribing medicines in pregnancy (external site).

There is no clear data to suggest the best period to contact trace and 6 months had been used as the default standard.

At this time, M. genitalium is not a notifiable infection.