Mycoplasma genitalium: test positivity in syndromic presentations and clinicians’ adherence with treatment guidelines at Sydney Sexual Health Centre

Mycoplasma genitalium ( M.genitalium) is associated with urethritis, cervicitis, pelvic inflammatory disease, proctitis and epididymitis. Its treatment is complicated by antimicrobial resistance. To assess clinicians’ adherence to M.genitalium diagnostic testing recommendations for syndromic presentations, as well as resistance-guided management of M.genitalium at Sydney Sexual Health Centre, we reviewed patients presenting between August and December 2018. 349/372 (94%) syndromic presentations were tested for M.genitalium with 16% M.genitalium test positivity and 81% macrolide resistance. 16/27 (59%) macrolide-sensitive infections and 65/77 (84%) macrolide-resistant infections received resistance-guided treatment. Tests of cure (TOCs) were unnecessarily ordered for 82% macrolide-sensitive cases, while 88% macrolide-resistant cases were correctly ordered TOCs. Co-existing STIs at the time of macrolide-sensitive ( p = 0.30) or macrolide-resistant M.genitalium ( p = 0.94) diagnosis did not significantly affect adherence to treatment guidelines. This study confirms the expected prevalence of M.genitalium and macrolide resistance in syndromic presentations while our real-world data highlight the decision-making challenges involved with managing M.genitalium, offering insights for further research.

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Antimicrobial resistance in Mycoplasma genitalium sampled from the British general population

Sexually Transmitted Infections ◽

10.1136/sextrans-2019-054129 ◽

2020 ◽

Vol 96 (6) ◽

pp. 464-468 ◽

Cited By ~ 3

Author(s):

Rachel Pitt ◽

Magnus Unemo ◽

Pam Sonnenberg ◽

Sarah Alexander ◽

Simon Beddows ◽

...

Keyword(s):

Antimicrobial Resistance ◽

General Population ◽

Sexual Health ◽

Treatment Guidelines ◽

Mycoplasma Genitalium ◽

Macrolide Resistance ◽

Sample Survey ◽

23S Rrna ◽

Health Clinic ◽

Rrna Gene

BackgroundMycoplasma genitalium is a common sexually transmitted infection. Treatment guidelines focus on those with symptoms and sexual contacts, generally with regimens including doxycycline and/or azithromycin as first-line and moxifloxacin as second-line treatment. We investigated the prevalence of antimicrobial resistance (AMR)-conferring mutations in M. genitalium among the sexually-active British general population.MethodsThe third national survey of sexual attitudes and lifestyles (Natsal-3) is a probability sample survey of 15 162 men and women aged 16–74 years in Britain conducted during 2010–12. Urine test results for M. genitalium were available for 4507 participants aged 16–44 years reporting >1 lifetime sexual partner. In this study, we sequenced regions of the 23S rRNA and parC genes to detect known genotypic determinants for resistance to macrolides and fluoroquinolones respectively.Results94% (66/70) of specimens were re-confirmed as M. genitalium positive, with successful sequencing in 85% (56/66) for 23S rRNA and 92% (61/66) for parC genes. Mutations in 23S rRNA gene (position A2058/A2059) were detected in 16.1% (95%CI: 8.6% to 27.8%) and in parC (encoding ParC D87N/D87Y) in 3.3% (0.9%–11.2%). Macrolide resistance was more likely in participants reporting STI diagnoses (past 5 years) (44.4% (18.9%–73.3%) vs 10.6% (4.6%–22.6%); p=0.029) or sexual health clinic attendance (past year) (43.8% (23.1%–66.8%) vs 5.0% (1.4%–16.5%); p=0.001). All 11 participants with AMR-conferring mutations had attended sexual health clinics (past 5 years), but none reported recent symptoms.ConclusionsThis study highlights challenges in M. genitalium management and control. Macrolide resistance was present in one in six specimens from the general population in 2010–2012, but no participants with AMR M. genitalium reported symptoms. Given anticipated increases in diagnostic testing, new strategies including novel antimicrobials, AMR-guided therapy, and surveillance of AMR and treatment failure are recommended.

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Resistance-guided treatment of Mycoplasma genitalium infection at a UK sexual health centre

International Journal of STD & AIDS ◽

10.1177/0956462420987764 ◽

2021 ◽

pp. 095646242098776

Author(s):

Ruairi JH Conway ◽

Seamus Cook ◽

Cassandra Malone ◽

Simon Bone ◽

Mohammed Osman Hassan-Ibrahim ◽

...

Keyword(s):

Single Dose ◽

Confidence Interval ◽

Sexual Health ◽

Treatment Failure ◽

Inflammatory Disease ◽

Health Centre ◽

Mycoplasma Genitalium ◽

Macrolide Resistance ◽

Fluoroquinolone Resistance ◽

Treatment Failure Rate

We evaluated the ResistancePlus® MG assay in providing macrolide resistance-guided treatment (RGT) for Mycoplasma genitalium infection at a UK sexual health centre. M. genitalium–positive samples from men with urethritis and women with pelvic inflammatory disease (PID) were tested for macrolide resistance–mediating mutations (MRMMs). MRMM-positive infections were given moxifloxacin 400 mg; otherwise 2 g azithromycin (1 g single dose and then 500 mg OD) was given. Among 57 M. genitalium–positive patients (32 men and 25 women), MRMMs were detected in 41/57 (72% [95% confidence interval (95% CI) 58–83%). Thirty-two of 43 patients given RGT attended for test of cure. Treatment failure rate was significantly lower at 1/32 (3%) than 10/37 (27%) before RGT ( n = 37 [men = 23 and women = 17]; p = 0.008). Treatment failure was lower in male urethritis (0/15 vs. 7/21 p = 0.027) but not in female PID. There was a trend of a shorter time to negative test of cure (TOC) in male urethritis (55.1 [95% 43.7–66.4] vs. 85.1 [95% CI CI 64.1–106.0] days, p = 0.077) but not in female PID. Macrolide resistance is higher than previous UK reports and higher than expected. RGT reduces overall treatment failure and is particularly beneficial in M. genitalium urethritis. Fluoroquinolone resistance will continue to rise with increasing fluoroquinolone use, and RGT is critical to direct appropriate azithromycin use and prevent overuse of moxifloxacin.

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Prevalence of rectal Mycoplasma genitalium and macrolide resistance in men who have sex with men attending Sydney Sexual Health Centre

Sexual Health ◽

10.1071/sh18221 ◽

2020 ◽

Vol 17 (2) ◽

pp. 114

Author(s):

Isabella Bradley ◽

Rick Varma ◽

Vickie Knight ◽

Dimitra Iliakis ◽

Leon McNally ◽

...

Keyword(s):

Multivariate Analysis ◽

Sexual Health ◽

Rectal Swab ◽

Health Centre ◽

Mycoplasma Genitalium ◽

Macrolide Resistance ◽

Cross Sectional ◽

Screening Guidelines ◽

Sexually Transmissible Infections ◽

Sex With Men

Background Sexually transmissible infections (STIs) have been increasing in men who have sex with men (MSM) in recent years; however, few studies have investigated the prevalence or antimicrobial resistance in rectal Mycoplasma genitalium in this group. This study aimed to determine the prevalence and predictors of rectal M. genitalium in MSM attending an urban sexual health service in Sydney, Australia, namely the Sydney Sexual Health Centre (SSHC), as well as estimate the rate of macrolide resistance. Methods: A prospective cross-sectional analysis was conducted of rectally asymptomatic MSM having a rectal swab collected as part of their routine care. Participants self-collected a rectal swab to be tested for M. genitalium and completed a 14-item questionnaire that provided information on behavioural risk factors. The prevalence of rectal M. genitalium was determined and multivariate analysis was performed to assess the associations for this infection. Positive specimens then underwent testing for macrolide-resistant mutations (MRMs) using the ResistancePlus MG assay (SpeeDx, Eveleigh, NSW, Australia). Results: In all, 742 patients were consecutively enrolled in the study. The median age was 31 years (interquartile range 27–39 years), with 43.0% born in Australia. Overall, 19.0% of men were bisexual, 22.9% were taking pre-exposure prophylaxis (PrEP) and 4.3% were HIV positive. The prevalence of rectal M. genitalium was 7.0% (95% confidence interval (CI) 5.3–9.1) overall and 11.8% in those taking PrEP. On multivariate analysis, PrEP use was significantly associated with having rectal M. genitalium (odds ratio 2.01; 95% CI 1.09–3.73; P = 0.01). MRMs were detected in 75.0% (36/48; 95% CI 60.4–86.4%) of infections. Conclusion: Rates of rectal M. genitalium infection were high among asymptomatic MSM attending SSHC and MRMs were detected in 75% of infections. PrEP use was found to be significantly associated with rectal M. genitalium infection. These data contribute to the evidence base for screening guidelines in MSM.

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The clinical indications for testing women for Mycoplasma genitalium

Sexually Transmitted Infections ◽

10.1136/sextrans-2020-054818 ◽

2021 ◽

pp. sextrans-2020-054818

Author(s):

Rosie L Latimer ◽

Lenka A Vodstrcil ◽

Erica L Plummer ◽

Michelle Doyle ◽

Gerald L Murray ◽

...

Keyword(s):

Sexual Health ◽

Trichomonas Vaginalis ◽

Health Centre ◽

Mycoplasma Genitalium ◽

Cross Sectional Study ◽

Macrolide Resistance ◽

Cross Sectional ◽

Routine Testing ◽

Sexual Health Service ◽

Asymptomatic Women

BackgroundWhile the contribution of Mycoplasma genitalium (MG) to symptoms in men is well described, less is known about its association with common genital symptoms in women. We aimed to determine the prevalence of MG and macrolide resistance, and its association with common genital symptoms in women attending a sexual health service, to inform indications for testing and clinical practice.MethodsWe undertook a cross-sectional study of symptomatic and asymptomatic women attending Melbourne Sexual Health Centre (MSHC), between April 2017 and April 2019. Women were tested for MG and macrolide resistance, Chlamydia trachomatis (CT), Neisseria gonorrhoeae, Trichomonas vaginalis, bacterial vaginosis and vulvovaginal candidiasis. Women completed a questionnaire on symptoms, and symptomatic women underwent examination. The prevalence of MG (and macrolide resistance) and other genital infections was calculated with 95% CIs, and associations between these outcomes and specific genital symptoms were examined using logistic regression.ResultsOf 1318 women, 83 (6%, 95% CI: 5% to 8%) had MG, of which 39 (48%, 95% CI: 36% to 59%) had macrolide-resistant MG; 103 (8%, 95% CI: 6% to 9%) women had CT. MG prevalence was similar in asymptomatic (10 of 195; 5%) and symptomatic (73 of 1108; 7%) women, p=0.506. MG was associated with mucopurulent cervicitis on examination (adjusted OR=4.38, 95% CI: 1.69 to 11.33, p=0.002), but was not associated with other specific genital symptoms or signs.ConclusionsMG was as common as CT among women attending MSHC. MG was not associated with genital symptoms, but like CT, was significantly associated with cervicitis. These data provide evidence that routine testing for MG in women with common genital symptoms is not indicated. The presence of macrolide resistance in 48% of women supports use of resistance-guided therapy.

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Levels ofMycoplasma genitaliumAntimicrobial Resistance Differ by Both Region and Gender in the State of Queensland, Australia: Implications for Treatment Guidelines

Journal of Clinical Microbiology ◽

10.1128/jcm.01555-18 ◽

2019 ◽

Vol 57 (3) ◽

Cited By ~ 15

Author(s):

E. L. Sweeney ◽

E. Trembizki ◽

C. Bletchly ◽

C. S. Bradshaw ◽

A. Menon ◽

...

Keyword(s):

Antibiotic Resistance ◽

Treatment Guidelines ◽

Mycoplasma Genitalium ◽

Macrolide Resistance ◽

Quinolone Resistance ◽

Resistance Mutations ◽

Transmitted Infection ◽

Content Type ◽

Sexually Transmitted ◽

And Gender

ABSTRACTMycoplasma genitaliumis frequently associated with urogenital and rectal infections, with the number of cases of macrolide-resistant and quinolone-resistantM. genitaliuminfection continuing to increase. In this study, we examined the levels of resistance to these two common antibiotic treatments in geographically distinct locations in Queensland, Australia. Samples were screened for macrolide resistance-associated mutations using a commercially available kit (ResistancePlus MG; SpeeDx), and quinolone resistance-associated mutations were identified by PCR and DNA sequencing. Comparisons between antibiotic resistance mutations and location/gender were performed. The levels ofM. genitaliummacrolide resistance were high across both locations (62%). Quinolone resistance mutations were found in ∼10% of all samples, with a number of samples harboring mutations conferring resistance to both macrolides and quinolones. Quinolone resistance was higher in southeast Queensland than in north Queensland, and this was consistent in both males and females (P = 0.007). TheM. genitaliumisolates in rectal swab samples from males harbored high levels of macrolide (75.9%) and quinolone (19%) resistance, with 15.5% harboring resistance to both classes of antibiotics. Overall, the lowest observed level of resistance was to quinolones in females from north Queensland (1.6%). These data highlight the high levels of antibiotic resistance inM. genitaliumisolates within Queensland and the challenges faced by sexually transmitted infection clinicians in managing these infections. The data do, however, show that the levels of antibiotic resistance may differ between populations within the same state, which has implications for clinical management and treatment guidelines. These findings also support the need for ongoing antibiotic resistance surveillance and tailored treatment.

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Detection of markers predictive of macrolide and fluoroquinolone resistance in Mycoplasma genitalium from patients attending sexual health services in England

Sexually Transmitted Infections ◽

10.1136/sextrans-2017-053164 ◽

2017 ◽

Vol 94 (1) ◽

pp. 9-13 ◽

Cited By ~ 21

Author(s):

Rachel Pitt ◽

Helen Fifer ◽

Neil Woodford ◽

Sarah Alexander

Keyword(s):

Diagnostic Testing ◽

Mycoplasma Genitalium ◽

Macrolide Resistance ◽

Fluoroquinolone Resistance ◽

Resistance Testing ◽

Rrna Gene ◽

Reference Laboratory ◽

Wild Type ◽

Sequencing Data ◽

The Uk

ObjectivesResistance to both macrolides and fluoroquinolones has been reported in Mycoplasma genitalium; however, due to limited diagnostics, studies are often small and confined to specific geographical areas. This study sought to determine the rate of predicted resistance in M. genitalium-positive specimens referred for diagnostic testing.MethodsSeventy-four M. genitalium-positive specimens, referred to the national reference laboratory (2010-2013) from 19 centres across England, were blinded and anonymised. Specimens were examined for markers predictive of resistance to macrolides and fluoroquinolones using PCR followed by sequence analysis of 23S rRNA gene, or gyrA and parC, respectively.Results23S rRNA gene PCR sequencing revealed that 82.4% (61/74) of specimens harboured a single nucleotide polymorphism (SNP) associated with macrolide resistance. Differences were observed between the rates of predicted macrolide resistance in male (95.1% (58/61)) and female (23.1% (3/13)) patients (P = <0.001). By contrast, all specimens for which sequencing data were available (73/74) yielded wild-type gyrA sequences; and 58/61 (95.1%) had wild-type parC genes. Three specimens (3/61 4.9%) had SNPs in the parC gene associated with fluoroquinolone treatment failure, and all three also had predicted resistance to macrolides.ConclusionsEighty-two per cent and 4.9% of M. genitalium specimens had SNPs associated with macrolide and fluoroquinolone resistance, respectively. Due to lack of widespread availability of testing for M. genitalium in the UK, this study sample was likely to be sourced from patients who may have already failed first-line macrolide therapy. Nevertheless, this study highlights the need for both greater access to M. genitalium diagnostics and genetic antimicrobial resistance testing.

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Mycoplasma genitalium Antimicrobial Resistance in Community and Sexual Health Clinic Patients, Auckland, New Zealand

Emerging Infectious Diseases ◽

10.3201/eid2602.190533 ◽

2020 ◽

Vol 26 (2) ◽

pp. 332-335

Author(s):

Anna Vesty ◽

Gary McAuliffe ◽

Sally Roberts ◽

Gillian Henderson ◽

Indira Basu

Keyword(s):

New Zealand ◽

Antimicrobial Resistance ◽

Sexual Health ◽

Mycoplasma Genitalium ◽

Health Clinic

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Resistance-Guided Antimicrobial Therapy Using Doxycycline–Moxifloxacin and Doxycycline–2.5 g Azithromycin for the Treatment of Mycoplasma genitalium Infection: Efficacy and Tolerability

Clinical Infectious Diseases ◽

10.1093/cid/ciz1031 ◽

2019 ◽

Vol 71 (6) ◽

pp. 1461-1468 ◽

Cited By ~ 9

Author(s):

Duygu Durukan ◽

Tim R H Read ◽

Gerald Murray ◽

Michelle Doyle ◽

Eric P F Chow ◽

...

Keyword(s):

De Novo ◽

Health Centre ◽

Mycoplasma Genitalium ◽

Evidence Base ◽

Macrolide Resistance ◽

Transmitted Infection ◽

Sexually Transmitted ◽

European Guidelines ◽

Sex With Men ◽

Guided Therapy

Abstract Background Macrolide resistance in Mycoplasma genitalium (MG) exceeds 50% in many regions, and quinolone resistance is increasing. We recently reported that resistance-guided therapy (RGT) using doxycycline followed by sitafloxacin or 2.5 g azithromycin cured 92% and 95% of macrolide-resistant and macrolide-susceptible infections, respectively. We present data on RGT using doxycycline–moxifloxacin, the regimen recommended in international guidelines, and extend data on the efficacy of doxycycline–2.5 g azithromycin and de novo macrolide resistance. Methods Patients attending Melbourne Sexual Health Centre between 2017 and 2018 with sexually transmitted infection syndromes were treated with doxycycline for 7 days and recalled if MG-positive. Macrolide-susceptible cases received 2.5 g azithromycin (1 g, then 500 mg daily for 3 days), and resistant cases moxifloxacin (400 mg daily, 7 days). Test of cure was recommended 14–28 days post-antimicrobials. Results There were 383 patients (81 females/106 heterosexual males/196 men who have sex with men) included. Microbial cure following doxycycline–azithromycin was 95.4% (95% confidence interval [CI], 89.7–98.0) and doxycycline–moxifloxacin was 92.0% (95% CI, 88.1–94.6). De novo macrolide resistance was detected in 4.6% of cases. Combining doxycycline–azithromycin data with our prior RGT study (n = 186) yielded a pooled cure of 95.7% (95% CI, 91.6–97.8). ParC mutations were present in 22% of macrolide-resistant cases. Conclusions These findings support the inclusion of moxifloxacin in resistance-guided strategies and extend the evidence for 2.5 g azithromycin and presumptive use of doxycycline. These data provide an evidence base for current UK, Australian, and European guidelines for the treatment of MG.

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