Sunday, October 1, 2023
| Category | Questions |
|---|---|
| New evidence | 1. What new evidence has emerged on associations between M. genitalium and reproductive tract disease syndromes? |
| 2. What is the prevalence of asymptomatic M. genitalium infection in various risk groups (e.g., general population, high-risk cisgender women, high-risk men, MSM)? | |
| 3. What is the current efficacy of currently recommended syndromic therapies for NGU, epididymitis, cervicitis, and PID against M. genitalium? Does this differ by sex or by sex of sex partners? | |
| 4. What is the current efficacy of moxifloxacin (400 mg × 7–14 d) against M. genitalium? Does this differ by sex or by sex of sex partners? | |
| 5. What is the prevalence of antimicrobial resistance-associated gene mutations among M. genitalium strains? Does this differ by sex or by sex of sex partners? | |
| 6. What antimicrobials other than azithromycin and moxifloxacin have been studied, either in vitro, or in patients with persisting M. genitalium infections and what is their efficacy? | |
| 7. What new M. genitalium diagnostic assays are on the horizon and what is the expected timeline for FDA approval of additional assays? | |
| 8. What is the time to M. genitalium nucleic acid clearance after therapy? | |
| Discussion | 1. Who should be tested for M. genitalium (e.g., general population, high-risk cisgender women, high-risk men, MSM)? |
| 2. Should the recommended empiric therapies for NGU, persistent/recurrent NGU, cervicitis, and/or PID be altered in recognition of the role played by M. genitalium? If so, how? | |
| 3. What is the preferred therapy for M. genitalium after detection by an FDA approved test? Does this differ by sex or by sex of sex partners? | |
| 4. What is the recommended approach in cases where M. genitalium infection persists after treatment with a) doxycycline, b) azithromycin, and c) moxifloxacin? | |
| 5. What is the recommended approach to partner management? Does this differ by sex or by sex of sex partner? | |
| 6. Should a test of cure be recommended after antibiotic therapy for a proven M. genitalium infection? Does this differ for symptomatic and asymptomatic persons? | |
| 7. Should antimicrobial resistance in M. genitalium be monitored in the United States? |
Table 1. Key questions for the 2021 CDC Sexually Transmitted Infections Treatment Guidelines Review for Mycoplasma genitalium*
*The summary of the primary evidence that informed the responses to these questions can be accessed in the Tables of Evidence posted on the CDC website: https://www.cdc.gov/std/treatment-guidelines/evidence.htm. CDC, Centers for Disease Control and Prevention; FDA, Food and Drug Administration; MSM, men who have sex with men; NGU, nongonococcal urethritis; PID, pelvic inflammatory disease.
This activity is intended for infectious disease clinicians, obstetricians/gynecologists/women’s health clinicians, urologists, epidemiologists, and other clinicians caring for patients with or at risk for Mycoplasma genitalium infection.
The goal of this activity is for learners to be better able to describe associations of M genitalium with reproductive, urologic, and perinatal complications; indications for M genitalium testing, and management of M genitalium infections, according to a systematic review updated with evidence published since the 2015 Centers for Disease Control and Prevention Sexually Transmitted Disease Treatment Guidelines.
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Since Mycoplasma genitalium was identified 40 years ago, much of the epidemiology has been described, diagnostic tests have been developed and approved, and recommended treatment approaches have been identified. However, the natural history remains incompletely understood, and antimicrobial resistance has rapidly increased. This review summarizes evidence published since the US Centers for Disease Control and Prevention 2015 Sexually Transmitted Diseases Treatment Guidelines. Data on sequelae remain insufficient, macrolide resistance is common, and fluoroquinolone resistance is increasing. Potential benefits of testing and treatment include resolving symptoms, interrupting transmission, and preventing sequelae. Potential harms include cost, patient anxiety, and increasing antimicrobial resistance.
Mycoplasma genitalium causes 20%–30% of male urethritis cases[1,2] and has been associated with a 2-fold increased risk for female cervicitis, preterm delivery, and pelvic inflammatory disease (PID)[3]. It has also been linked to tubal-factor infertility in sero-epidemiologic studies, even after accounting for previous chlamydial infection[4,5]. Despite these strong observational data, relatively few prospective studies of reproductive and perinatal complications of M. genitalium exist, and a separate meta-analysis of the association with PID restricted to cohort studies (n = 2) observed a smaller, nonstatistically significant association[6]. Coupled with this epidemiologic conundrum are substantial treatment challenges. Doxycycline is only 30%–40% effective[7], and the efficacy of azithromycin and moxifloxacin has declined substantially[8,9] since the Centers for Disease Control and Prevention (CDC) 2015 Sexually Transmitted Diseases Treatment Guidelines were written. The reasons for the low efficacy of doxycycline are unclear, but treatment failures after azithromycin and moxifloxacin are caused by the emergence and spread of antimicrobial resistance[10]. In a recent meta-analysis, detection of macrolide resistance mutations worldwide rose from 10% before 2010 to 51% in 2016–2017 (p<0.0001). Detection of the quinolone resistance–associated mutation most clearly linked to treatment failure (S83I) was 4.3%[10], although prevalence as high as 84% has been observed in China[11]. Among urethritis cases in the United States during 2017–2018, macrolide resistance–associated mutations were detected in 64.4% and quinolone resistance–associated mutations in 11.5%[1].
