Mycoplasma Genitalium

Organism
  • Established cause of STI
  • 2nd to Chlamydia trachomatis in prevanlence
  • No cell wall → all betalactams are intrinsically resistant
    • Few available anti microbial classes: macrolides, quinolones, stropogramins, tetracyclines
 
Antimicrobian resistance
  • Global concern
  • Collateral effect of chlamydia management
  • Mediated by mutations
    • A2058G and A2059G (E coli numbering) > 90%
 
Diagnostics
  • PCR based tests. May be combined with resistance to macro lide resistance.
  • Most are Low quality. Currently, the best are 3 FDA/CE-IVD approved high-throughput M. Genilalium NAATs: Hologic Altima, Roche Cobas, Abbott Alinity
    • Roche Liat (newer in 2025, better, will be available, but no macrolide resistance results)
  • Detection of macrolide resistance mutations should be performed in all positive samples to guide treatment (several guidelines) to shorten duration of infectious news and limit use of moxifloxacin
    • Numerous approaches with laboratory developed and commercially available assays (SpeeDx, Pathofinder, SeeGene) to look for macrolide sensitivity
    • If a test is not available, ask the patient if they got a macrolide antibiotic in the last year
  • Diagnostics manufacturers uncritically include commensalism as urea plasmas and M. Hominids in STI pannels
 
Tratamento
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  • The only well evaluated antibiotic is moxifloxacin 10 days
    • Quinolone resistance is raising (specially in China)
    • Testing for quinolone resistance are not predictive of treatment failures (MIC variable, detection of mutation doesn’t mean tretmanet failure), so is not recommended
  • Pristinamucin 1g 4-10 days
    • Safe in pregnancy
    • Consider combining with doxycycline (non pregnant)
  • Minocycline 100mg x2 2-14 days, 70% cure
    • Combine with metronidazole 400mg x2
  • Sitafloxacin 100mg x2 7 days (70% cure)
  • Pleuromutilins
    • Lefamulin (50% cure), company went bankrupt
  • Gyrase/topoisomerase inhibitors
  • Nitroimidazoles
    • Metronidazole and tinidazole (slightly more effective than metronidazole)
    • Some effect in combination effect
  • Other Tetracyclines
    • Omacycline and eracycline appeared (?)
    • Evaracycline only available in and expensive
  • Amphenicols
    • Chloramphenicol
    • Thiamphenicol is a safer alternative
      • Has been used for STIs
      • Much better PK/PD properties than CHL
  • M3P (minocucline, metronidazole, methenamine, pristinamycin) 14-28 days
    • Aggressive cocktail but patients tolerate quite well