Treatment of asymptomatic Mycoplasma genitalium infection

Treatment of asymptomatic Mycoplasma genitalium infection is recommended for ongoing sexual partners of patients with confirmed symptomatic infection.

Treatment of pregnant patients with asymptomatic M. genitalium infection can be considered because there is a possible association between infection and preterm deliveryFrenzer, 2022Soni, 2019. Data are limited for association with other adverse pregnancy and perinatal outcomesFrenzer, 2022. Seek expert advice for individualised assessment of risk factors and patient advice regarding lack of data on the harm–benefit profile of antibiotic therapySoni, 2019.

For the management of other patients with asymptomatic M. genitalium infection (eg patients with persistent infection), seek expert advice. Treatment involves balancing the potential harms of antimicrobial use (eg adverse effects, potential for antimicrobial resistance in the patient and community) against the likelihood of harm to the patient if left untreated; there are limited data to guide the best approach.

If a decision is made to treat asymptomatic M. genitalium infection, if available, request molecular testing for macrolide resistance mutations before starting therapy.

Treatment for M. genitalium infection is with doxycycline followed by either azithromycin or moxifloxacin. Monotherapy with doxycycline has poor efficacy against M. genitalium, with microbiological cure rates of approximately 30%Manhart, 2022. The aim of pretreatment with doxycycline is to reduce bacterial load and increase the likelihood of cure by the second antibioticRead, 2019Workowski, 2021.

Resistance to macrolides (eg azithromycin) among M. genitalium in Australia is more than 60% and the rate of resistance to quinolones (eg moxifloxacin) is approximately 10 to 15%Machalek, 2020Ong, 2023. Macrolide and fluroquinolone resistance is more common in gay, bisexual and other men who have sex with men, and transgender womenMachalek, 2020.

For asymptomatic M. genitalium infection that is known or suspected to be susceptible to macrolides, useDurukan, Doyle, , 2020Durukan, Read, , 2020Ong, 2023Read, 2019Read, 2018Workowski, 2021:

For asymptomatic M. genitalium infection where macrolide resistance is confirmed or suspected (eg in gay, bisexual and other men who have sex with men, and transgender women), useDurukan, Doyle, , 2020Durukan, Read, , 2020Ong, 2023Read, 2019Read, 2018Workowski, 2021:

Advise patients to abstain from condomless sex until treatment is completed (ie 14 days after treatment starts), or a test-of-cure result is negativeOng, 2023.

Perform a test of cure inOng, 2023Workowski, 2021:

• pregnant patients
• all females¹ because of an association with pelvic inflammatory disease (PID) and infertility
• patients with persistent symptoms of a syndrome associated with M. genitalium
• patients at risk of reinfection because of ongoing sexual partner who has not been treated.

If required, a test of cure should be performed at least 14 days after treatment is completedDurukan, Read, , 2020Ong, 2023Vodstrcil, 2022.

For persistent infection in patients treated with the combination of doxycycline and azithromycin, use the moxifloxacin regimen above. If infection persists after completion of the moxifloxacin regimen, seek expert advice – treatment options include pristinamycin, minocycline and sitafloxacinClarke, 2023Doyle, 2020Durukan, Doyle, , 2020Manhart, 2022Ong, 2023Read, 2018.