Section 5-1: Canadian Guidelines on Sexually Transmitted Infections – Management and treatment of specific infections – Mycoplasma Genitalium Infections

Mycoplasma Genitalium Infections

Mycoplasma genitalium (M. genitalium) is an emerging sexually transmitted pathogen. Given the lack of routine diagnostic testing for M. genitalium in Canada, the management of most M. genitalium infections will occur in the context of syndromic management of urethritis, cervicitis and pelvic inflammatory disease (PID).

Etiology

  • Mycoplasmas are small facultative anaerobic bacteria (0.2-0.3 μm) without a cell wall.Footnote 1,Footnote 2 They are pleiomorphic and cannot be Gram stained or identified by light microscopy.
  • Genital mycoplasmas belong to the Mollicutes class in the family Mycoplasmataceae, which includes two genera: Mycoplasma and Ureaplasma.Footnote 1,Footnote 2
    • There are currently seven Mycoplasma species identified in the genital tract, of which M. genitalium is emerging as an important cause of genital tract disease. M. hominis is among a number of bacteria found in women with bacterial vaginosis and pelvic inflammatory disease, but it is not known whether it can cause these two conditions.Footnote 1
    • Ureaplasmas are ubiquitous micro-organisms which can be isolated from the genital tract of 30-40% of healthy sexually active young men. The exact role of ureaplasmas in non-gonococcal urethritis (NGU) is controversial, due to the conflicting observations in clinical studies.

Due to limited data on the role of ureaplasma and M. hominis in genital tract infections, the focus of this chapter is M. genitalium exclusively.

Epidemiology

  • Internationally, the prevalence of M. genitalium (using molecular diagnostic tests) is estimated to range from 1-4% among men and 1-6% among women; in those at elevated risk for sexually transmitted infections (STI), the prevalence is as high as 38%.Footnote 3
    • The National Longitudinal Study of Adolescent Health from the U.S., which included adults between the ages of 18-27, reported that the prevalence of M. genitalium was 1%.Footnote 4
    • The National Survey of Sexual Attitudes and Lifestyles (NATSAL) survey, a UK study of sexually experienced men and women, found that 1.2% of men and 1.3% of women between the ages of 16-44 years were positive for M. genitalium; of these the majority were asymptomatic (94% and 56% for men and women respectively).Footnote 5
  • In addition to associations between M. genitalium infection and non-chlamydial/non-gonococcal urethritis, associations have been reported between M. genitalium infection and C. trachomatis/N. gonorrhoeae in some settings but not all.Footnote 6 -Footnote 12
  • A large systematic review and meta-analysis found that individuals with M. genitalium infection were twice as likely to be HIV-infected; however, the reasons for this are not clear.Footnote 13
  • In a multi-site Canadian study that used remnant samples collected in women for detection of C. trachomatis and N. gonorrhoeae, M. genitalium was detected in 53/396 (13.4%) women infected with C. trachomatis and in 22/406 (5.4%) women not infected with C. trachomatis.Footnote 14
    • In addition, a Toronto study, which screened 1193 attendees at a sexual health clinic, reported that 4.5% of males and 3.2% of females tested positive for M. genitalium; 50% of males and 40% of females were symptomatic.Footnote 15
    • An Alberta study of attendees at two STI clinics reported a M. genitalium prevalence of 5.3% in males and 7.2% in females. Correlates of female infection included younger age, Indigenous/other ethnicity and C. trachomatis and N. gonorrhoeae co-infection.Footnote 16

Risk factors

Reported risk factors for M. genitalium include:

Transmission

  • M. genitalium is sexually transmissible.
    • Studies demonstrate concordant infection between partners.Footnote 18 -Footnote 20
    • Some evidence shows indistinguishable strain types between partners.Footnote 21
    • M. genitalium is rarely detected in sexually inexperienced individuals.
  • Consistent condom use may reduce an individual’s risk of M. genitalium infection.Footnote 20

Symptoms, signs and sequelae

Females

  • Often asymptomatic. Symptoms may include vaginal discharge, dysuria, inter-menstrual or post-coital bleeding.Footnote 9
  • Available data suggest an association between M. genitalium and cervicitis and a causal association with endometritis/PID.Footnote 3,Footnote 6,Footnote 23 -Footnote 28
  • Some evidence suggests that PID cases associated with M. genitalium may be similar to chlamydia in terms of severity of symptoms and signs.Footnote 29
  • A 2015 meta-analysis suggests a significant association between M. genitalium and preterm birth, spontaneous abortion and female infertility.Footnote 23
  • Insufficient evidence exists to determine whether there is an association with ectopic pregnancy.Footnote 3,Footnote 30

Males

  • M. genitalium has been widely implicated as an etiologic agent of acute and persistent or recurrent urethritis.Footnote 3,Footnote 23,Footnote 31 -Footnote 33
    • A Swedish sexually transmitted diseases (STD) clinic study found that 73% of M. genitalium-positive males had symptomatic urethritis (e.g., urethral discharge, dysuria) in comparison to 40% of men infected with C. trachomatis.Footnote 34
    • This is consistent with findings from another STD clinic study.Footnote 28
  • Insufficient evidence exists to determine whether M. genitalium causes epididymitis or proctitis.Footnote 35
  • Available evidence does not support M. genitalium infection as a cause of male infertility.Footnote 36

Diagnostic testing

  • Laboratory testing capacity with nucleic acid amplification test (NAAT) may vary across the country.
    • Consult with your laboratory regarding local availability of M. genitalium testing, specimen collection and transportation requirements.
  • Cervical, vaginal, and urethral or meatal swabs, urine, and endometrial biopsies are acceptable specimens.Footnote 37,Footnote 38
  • M. genitalium positive specimens can be forwarded to the National Microbiology Laboratory (NML) for molecular detection of mutations associated with macrolide and moxifloxacin resistance.Footnote 39,Footnote 40
    • Refer to the NML Guide to Services for specific information on specimen collection and transportation requirements.

Indications for testing

  • Routine screening for M. genitalium is not recommended.
  • Testing for M. genitalium is recommended only:
    • in the presence of persistent or recurrent urethritis, cervicitis, or PID despite empiric treatment when initial tests for gonorrhea and chlamydia are negative.
  • No data are available to guide recommendations for testing in pregnant women and neonates.

Considerations for other STIs: screening and immunization

If clinically indicated, consider:

Management and treatment

The following treatment recommendations have been developed based on limited Canadian data on the prevalence of M. genitalium and on the limited knowledge of resistance to macrolides or other antibiotics at the local level.Footnote 14,Footnote 15

Antimicrobial resistance (AMR) must be considered when choosing a course of treatment for M. genitalium.

The Expert Working Group for the Canadian Guidelines on Sexually Transmitted Infections reviewed the rapidly evolving scientific literature available to date on M. genitalium treatment efficacy, safety and escalating AMR issues. Their review resulted in the recommendations presented below.

Antimicrobial resistance considerations

Due to limited access to M. genitalium testing in Canada at this time, currently known and emerging AMR patterns should be taken into consideration when initially treating patients who present with acute NGU or cervicitis.

  • In a multi-site Canadian study, resistance mutations to macrolides and fluoroquinolones were found in 47.3% and 1.9% of specimens, respectively.Footnote 14
  • 58% of M. genitalium infections in a Toronto study carried macrolide resistance-mediating mutations, however no treatment failures were observed in cases treated with a multi-day course of azithromycin.Footnote 15 In the same study, 20% of patients harboured strains with mutations previously reported to mediate moxifloxacin resistance; treatment failures were suspected in 16% of patients.Footnote 15
  • In an Alberta study, over half of specimens for which sequencing data was available had mutations associated with macrolide resistance, and 12.2% of specimens from men and 2.6% of specimens from women had a parC mutation signifying possible moxifloxacin resistance.Footnote 16
  • Decreased susceptibility to tetracyclines has been reported in studies conducted in the US and Japan.Footnote 41 -Footnote 44

General treatment considerations

  • Azithromycin has been shown to be more effective than doxycycline in treating M. genitalium in most settings,Footnote 41,Footnote 42,Footnote 45,Footnote 46 but not all.Footnote 43
  • Although azithromycin is recommended as the preferred agent over moxifloxacin (as it is more widely used, less costly, has a narrower spectrum, a shorter duration of therapy and fewer side effects), rising resistance to macrolides may rapidly preclude the use of this medication as the initial choice of therapy.
  • Given that azithromycin (1 g) may select for macrolide resistance, patients failing this regimen for the treatment of cervicitis or urethritis would not benefit from retreatment with the multi-day regimen.Footnote 45
  • In patients presenting with uncomplicated NGU and cervicitis, documented cure rates of M. genitalium are:
  • In vitro comparisons of the activity of fluoroquinolones against M. genitalium showed that moxifloxacin had the highest bactericidal activity.Footnote 51
  • Moxifloxacin has been shown to be an effective treatment option for those with M. genitalium infection if treatment failure occurs with azithromycin.Footnote 47,Footnote 49,Footnote 52,Footnote 53
    • Although cure rates as high as 100% have been reported with moxifloxacin, treatment failures have also been reported and may be related to fluoroquinolone resistance.Footnote 54,Footnote 55
  • Patients who fail both macrolide and moxifloxacin treatment have been successfully treated with pristinamycin;Footnote 56 this drug is not currently available in Canada.

Rationale:

Suspected treatment failure (i.e., persistent or recurrent urethritis or cervicitis); or confirmed macrolide-resistant M. genitalium

Note:

  • Seven days appears to be as effective as 10 days.Footnote 52

PID with probable or confirmed M. genitalium infection

  • Moxifloxacin 400 mg PO once daily for 14 days [B-l]Footnote 64,Footnote 65
    • Moxifloxacin should be used in addition to standard treatment regimens for PID. Refer to the Pelvic Inflammatory Disease chapter for recommended parenteral and outpatient treatment regimens.

Note:

  • An American study demonstrated that a cefoxitin and doxycycline regimen is not effective for M. genitalium-associated PID.Footnote 66

Reporting and partner notification

  • M. genitalium is not a reportable infection in Canada.
  • Although insufficient evidence exists to provide recommendations for routine partner notification, treatment of current partners should be considered (regardless of symptoms) to prevent reinfection of the index case.
    • It is not necessary to screen partners for M. genitalium.
    • Treat sexual partners with the same therapy as the index case.

Follow-up

  • Insufficient data are available to guide recommendations for test of cure. It should be done in cases that remain persistently symptomatic after the completion of appropriate treatment for M. genitalium and in regions with documented high prevalenceFootnote a of antibiotic resistance.
  • The appropriate timing of a test of cure is uncertain. Some experts recommend waiting at least 3 weeks after the completion of treatment, as earlier testing can lead to the detection of residual M. genitalium nucleic acid (i.e., a false positive result) despite cure.Footnote 48
  • In the event of persistent M. genitalium infection after treatment with azithromycin and/or moxifloxacin antimicrobial resistance testing should ideally be done.Footnote 48
Footnote a

2014 data suggest high prevalence of azithromycin-resistant mycoplasma from the Toronto, Ontario region.Footnote 15

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Acknowledgement

The Government of Canada would like to thank the following individuals for their contribution to the development of this chapter.

  • Mycoplasma Genitalium Sub Working Group: Max Chernesky, Annie-Claude Labbé, Irene Martin, Ameeta Singh
  • External Reviewers: J.S Jensen, Lisa Manhart

References

Footnote 1

Taylor-Robinson D, Jensen JS. Mycoplasma genitalium: from chrysalis to multicolored butterfly. Clin Microbiol Rev 2011;24(3):498-514.

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Footnote 2

Cazanave C, Manhart LE, Bébéar C. Mycoplasma genitalium, an emerging sexually transmitted pathogen. Med Mal Infect 2012;42(9):381-392.

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Footnote 3

Manhart LE, Broad JM, Golden MR. Mycoplasma genitalium: should we treat and how? Clin Infect Dis 2011;53 Suppl 3:S129-S142.

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Footnote 4

Manhart LE, Holmes KK, Hughes J, Houston L, Totten PA. Mycoplasma genitalium among young adults in the United States: an emerging sexually transmitted infection. Am J Public Health 2007;97(6):1118-1125.

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Footnote 5

Sonnenberg P, Ison C, Clifton S, Field N, Tanton C, Soldan K, et al. The epidemiology of Mycoplasma genitalium in the British population: Findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3). HIV medicine 2014;15:11-11.

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Footnote 6

Mobley VL, Hobbs MM, Lau K, Weinbaum BS, Getman DK, Sena AC. Mycoplasma genitalium infection in women attending a sexually transmitted infection clinic: diagnostic specimen type, coinfections, and predictors. Sex Transm Dis 2012 Sep;39(9):706-709.

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Footnote 7

Huppert JS, Mortensen JE, Reed JL, Kahn JA, Rich KD, Hobbs MM. Mycoplasma genitalium detected by transcription-mediated amplification is associated with Chlamydia trachomatis in adolescent women. Sex Transm Dis 2008 Mar;35(3):250-254.

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Footnote 8

Chalker VJ, Jordan K, Ali T, Ison C. Real-time PCR detection of the mg219 gene of unknown function of Mycoplasma genitalium in men with and without non-gonococcal urethritis and their female partners in England. J Med Microbiol 2009 Jul;58(Pt 7):895-899.

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Footnote 9

Falk L, Fredlund H, Jensen JS. Signs and symptoms of urethritis and cervicitis among women with or without Mycoplasma genitalium or Chlamydia trachomatis infection. Sex Transm Infect 2005 Feb;81(1):73-78.

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Footnote 10

Svenstrup HF, Dave SS, Carder C, Grant P, Morris-Jones S, Kidd M, et al. A cross-sectional study of Mycoplasma genitalium infection and correlates in women undergoing population-based screening or clinic-based testing for Chlamydia infection in London. BMJ Open 2014 Feb 6;4(2):e003947-2013-003947.

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Footnote 11

Gaydos C, Maldeis NE, Hardick A, Hardick J, Quinn TC. Mycoplasma genitalium compared to chlamydia, gonorrhoea and trichomonas as an aetiological agent of urethritis in men attending STD clinics. Sex Transm Infect 2009 Oct;85(6):438-440.

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Footnote 12

Mena L, Wang X, Mroczkowski TF, Martin DH. Mycoplasma genitalium infections in asymptomatic men and men with urethritis attending a sexually transmitted diseases clinic in New Orleans. Clin Infect Dis 2002 Nov 15;35(10):1167-1173.

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Footnote 13

Napierala Mavedzenge S, Weiss HA. Association of Mycoplasma genitalium and HIV infection: a systematic review and meta-analysis. AIDS 2009 Mar 13;23(5):611-620.

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Footnote 14

Chernesky MA, Jang D, Martin I, Hoang LMN, Naidu P, Levett PN, et al. Mycoplasma genitalium Antibiotic Resistance-Mediating Mutations in Canadian Women With or Without Chlamydia Trachomatis Infection. Sex Transm Dis 2017 Jul;44(7):433-435.

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Footnote 15

Gesink D, Racey CS, Seah C, Zitterman S, Mitterni L, Juzkiw J, et al. Mycoplasma genitalium in Toronto, Ont: Estimates of prevalence and macrolide resistance. Can Fam Physician 2016;62(2):e96-101.

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Footnote 16

Gratrix J, Plitt S, Turnbull L, Smyczek P, Brandley J, Scarrott R, et al. Prevalence and antibiotic resistance of Mycoplasma genitalium among STI clinic attendees in Western Canada: a cross-sectional analysis. BMJ Open 2017 07/10;7(7).

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Footnote 17

Hancock EB, Manhart LE, Nelson SJ, Kerani R, Wroblewski JK, Totten PA. Comprehensive assessment of sociodemographic and behavioral risk factors for Mycoplasma genitalium infection in women. Sex Transm Dis 2010 Dec;37(12):777-783.

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Footnote 18

Brabin L, Roberts C, Barr F, Agbaje S, Harper G, Briggs N. Sex hormone patterns and serum retinol concentrations in adolescent girls. J Reprod Med Obstet Gynecol 2004;49(1):41-51.

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Footnote 19

Manhart LE, Kay N. Mycoplasma genitalium: Is It a sexually transmitted pathogen? Curr Infect Dis Rep 2010 Jul;12(4):306-313.

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Footnote 20

Su R. Genital infections with Mycoplasma genitalium. Hong Kong J Dermatol Venereol 2010;18(1):16-24.

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Footnote 21

Hjorth SV, Björnelius E, Lidbrink P, Falk L, Dohn B, Berthelsen L, et al. Sequence-Based Typing of Mycoplasma genitalium Reveals Sexual Transmission. Journal of Clinical Microbiology 2006 June 01;44(6):2078-2083.

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Footnote 22

Weinstein SA, Stiles BG. A review of the epidemiology, diagnosis and evidence-based management of Mycoplasma genitalium. Sex Health 2011;8(2):143-158.

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Footnote 23

Lis R, Rowhani-Rahbar A, Manhart LE. Mycoplasma genitalium Infection and Female Reproductive Tract Disease: A Meta-Analysis. Clin Infect Dis 2015 Apr 21.

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Footnote 24

Bjartling C, Osser S, Persson K. Mycoplasma genitalium in cervicitis and pelvic inflammatory disease among women at a gynecologic outpatient service. Am J Obstet Gynecol 2012;206(476):e1-8.

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Footnote 25

Falk L. The overall agreement of proposed definitions of mucopurulent cervicitis in women at high risk of Chlamydia infection Acta Derm Venereol 2010 Sep;90(5):506-511.

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Footnote 26

Taylor-Robinson D, Jensen JS, Svenstrup H, Stacey CM. Difficulties experienced in defining the microbial cause of pelvic inflammatory disease Int J STD AIDS 2012 Jan;23(1):18-24.

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Footnote 27

Wiesenfeld HC, Hillier SL, Meyn L, Trucco G, Amortegui A, Macio IS, et al. O04.6 Mycoplasma Genitalium- Is It a Pathogen in Acute Pelvic Inflammatory Disease (PID)? Sexually Transmitted Infections 2013 July 01;89(Suppl 1):A34-A34.

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Footnote 28

Anagrius C, Lore B, Jensen JS. Mycoplasma genitalium: prevalence, clinical significance, and transmission. Sex Transm Infect 2005 Dec;81(6):458-462.

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Footnote 29

Short VL, Totten PA, Ness RB, Astete SG, Kelsey SF, Haggerty CL. Clinical presentation of Mycoplasma genitalium infection versus Neisseria gonorrhoeae infection among women with pelvic inflammatory disease. Clin Infect Dis 2009;48(1):41-47.

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Footnote 30

Short VL, Jensen JS, Nelson DB, Murray PJ, Ness RB, Haggerty CL. Mycoplasma genitalium among young, urban pregnant women. Infect Dis Obstet Gynecol 2010;2010:984760.

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Footnote 31

Ballard RC, Fehler HG, Htun Y, Radebe F, Jensen JS, Taylor-Robinson D. Coexistence of urethritis with genital ulcer disease in South Africa: influence on provision of syndromic management Sex Transm Infect 2002 Aug;78(4):274-277.

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Footnote 32

Hoosen A, le Roux MC, Adam A. P3-S1.23 Mycoplasma genitalium in South African men with and without symptoms of urethritis: diagnosis and bacterial load Sex Transm Infect 2011;87(Suppl 1):A275.

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Footnote 33

Thurman AR, Musatovova O, Perdue S, Shain RN, Baseman JG, Baseman JB. Mycoplasma genitalium symptoms, concordance and treatment in high-risk sexual dyads. Int J STD AIDS 2010 Mar;21(3):177-183.

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Footnote 34

Falk L, Fredlund H, Jensen JS. Symptomatic urethritis is more prevalent in men infected with Mycoplasma genitalium than with Chlamydia trachomatis. Sex Transm Infect 2004 Aug;80(4):289-293.

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Footnote 35

Francis SC, Kent CK, Klausner JD, Rauch L, Kohn R, Hardick A, et al. Prevalence of rectal Trichomonas vaginalis and Mycoplasma genitalium in male patients at the San Francisco STD clinic, 2005-2006 Sex Transm Dis 2008 Sep;35(9):797-800.

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Footnote 36

Kjaergaard N, Kristensen B, Hansen ES, Farholt S, Schonheyder HC, Uldbjerg N, et al. Microbiology of semen specimens from males attending a fertility clinic. APMIS 1997 Jul;105(7):566-570.

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Footnote 37

Chernesky M, Jang D, Smieja M, Arias M, Martin I, Weinbaum B, et al. Urinary Meatal Swabbing Detects More Men Infected With Mycoplasma genitalium and Four Other Sexually Transmitted Infections Than First Catch Urine. Sexually Transmitted Diseases 2017;44(8):489-491.

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Footnote 38

Dize L, Agreda P, Quinn N, Barnes MR, Hsieh YH, Gaydos CA. Comparison of self-obtained penile-meatal swabs to urine for the detection of C. trachomatis, N. gonorrhoeae and T. vaginalis. Sexually transmitted infections 2013;89(4):305-307.

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Footnote 39

Jensen JS. Protocol for the detection of Mycoplasma genitalium by PCR from clinical specimens and subsequent detection of macrolide resistance-mediating mutations in region V of the 23SrRNA gene. Methods in Molecular Biology 2012;903:129-139.

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Footnote 40

Shimada Y, Deguchi T, Nakane K, Masue T, Yasuda M, Yokoi S, et al. Emergence of clinical strains of Mycoplasma genitalium harbouring alterations in ParC associated with fluoroquinolone resistance. Int J Antimicrob Agents 2010;36:255-258.

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Footnote 41

Mena LA, Mroczkowski TF, Nsuami M, Martin DH. A randomized comparison of azithromycin and doxycycline for the treatment of Mycoplasma genitalium-positive urethritis in men. Clin Infect Dis 2009;48(12):1649-1654.

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Footnote 42

Schwebke JR, Rompalo A, Taylor S, Sena AC, Martin DH, Lopez LM, et al. Re-evaluating the treatment of nongonococcal urethritis: emphasizing emerging pathogens—a randomized clinical trial. Clin Infect Dis 2011;52(2):163-170.

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Footnote 43

Manhart LE, Khosropour CM, Gillespie CW, Lowens MS, Golden MR, Totten PA. Treatment outcomes for persistent Mycoplasma genitalium- associated NGU: evidence of moxifloxacin treatment failures. Sex Transm Infect 2013;89(S1):A29.

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Footnote 44

Hamasuna R, Osada Y, Jensen JS. Antibiotic susceptibility testing of Mycoplasma genitalium by TaqMan 5' nuclease real-time PCR. Antimicrob Agents Chemother 2005;49(12):4993-4998.

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Footnote 45

Anagrius C, Loré B, Jensen JS. Treatment of Mycoplasma genitalium. Observations from a Swedish STD clinic. PLoS One 2013;8(4):e61481.

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Footnote 46

Björnelius E, Anagrius C, Bojs G, Carlberg H, Johannisson G, Johansson E, et al. Antibiotic treatment of symptomatic Mycoplasma genitalium infection in Scandinavia: a controlled clinical trial. Sex Transm Infect 2008;84(1):72-76.

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Footnote 47

Jernberg E, Moghaddam A, Moi H. Azithromycin and moxifloxacin for microbiological cure of Mycoplasma genitalium infection: an open study. Int J STD AIDS 2008;19(10):676-679.

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Footnote 48

Horner P, Blee K, Adams E. Time to manage Mycoplasma genitalium as an STI: but not with azithromycin 1g! . Curr Opin Infect Dis 2014;27(1):68-74.

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Footnote 49

Bradshaw CS, Chen MY, Fairley CK. Persistence of Mycoplasma genitalium following azithromycin therapy. PLoS One 2008;3(11):e3618.

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Footnote 50

The effectiveness of 1 g of azithromycin for Mycoplasma genitalium infections: a five year review. Paper# 179. 2010 Australasian Sexual Health Conference. Sydney, Australia; 2010.

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Footnote 51

Bébéar CM, de Barbeyrac B, Pereyre S, Renaudin H, Clerc M, Bébéar C. Activity of moxifloxacin against the urogenital mycoplasmas Ureaplasma spp., Mycoplasma hominis and Mycoplasma genitalium and Chlamydia trachomatis . Clin Microbiol Infect 2008;14(8):801-805.

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Footnote 52

Bradshaw CS, Jensen JS, Tabrizi SN, Read TR, Garland SM, Hopkins CA, et al. Azithromycin failure in Mycoplasma genitalium urethritis. Emerg Infect Dis 2006 Jul;12(7):1149-1152.

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Footnote 53

Walker J, Fairley CK, Bradshaw CS, Tabrizi SN, Twin J, Chen MY, et al. Mycoplasma genitalium incidence, organism load, and treatment failure in a cohort of young Australian women. Clin Infect Dis 2013;56:1094-1100.

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Footnote 54

Couldwell DL, Tagg KA, Jeoffreys NJ, Gilbert GL. Failure of moxifloxacin treatment in Mycoplasma genitalium infections due to macrolide and fluoroquinolone resistance. Int J STD AIDS 2013 Oct;24(10):822-828.

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Footnote 55

Terada M, Izumi K, Ohki E, Yamagishi Y, Mikamo H. Antimicrobial efficacies of several antibiotics against uterine cervicitis caused by Mycoplasma genitalium. J Infect Chemother 2012;18(3):313-317.

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Footnote 56

Jensen JS, Cusini M, Gomberg M, Moi H. Background review for the 2016 European guideline on Mycoplasma genitalium infections. J Eur Acad Dermatol Venereol 2016 Oct;30(10):1686-1693.

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Footnote 57

Pond MJ, Nori AV, Witney AA, Lopeman RC, Butcher PD, Sadiq ST. High prevalence of antibiotic-resistant Mycoplasma genitalium in nongonococcal urethritis: the need for routine testing and the inadequacy of current treatment options. Clin Infect Dis 2014;58:631-637.

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Footnote 58

Drasa K, Koci E. 491 Azithromycin vs. clarithromycin and both combination in treatment of Mycoplasma genitalium. European Urology Supplements; 25th Annual Congress of the European Association of Urology Abstract Book 2010 /4;9(2):172.

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Footnote 59

Ito S, Shimada Y, Yamaguchi Y, Yasuda M, Yokoi S, Ito S, et al. Selection of Mycoplasma genitalium strains harbouring macrolide resistance-associated 23S rRNA mutations by treatment with a single 1 g dose of azithromycin. Sex Transm Infect 2011;87(5):412-414.

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Footnote 60

Jensen JS, Bradshaw CS, Tabrizi SN, Fairley CK, Hamasuna R. Azithromycin treatment failure in Mycoplasma genitalium-positive patients with nongonococcal urethritis is associated with induced macrolide resistance. Clin Infect Dis 2008;47(12):1546-1553.

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Footnote 61

Twin J, Jensen JS, Bradshaw CS, Garland SM, Fairley CK, Min LY, et al. Transmission and selection of macrolide resistant Mycoplasma genitalium infections detected by rapid high resolution melt analysis. PLoS One 2012;7(4):e35593.

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Footnote 62

Yew HS, Anderson T, Coughlan E, Werno A. Induced macrolide resistance in Mycoplasma genitalium isolates from patients with recurrent nongonococcal urethritis. J Clin Microbiol 2011;49(4):1695-1696.

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Footnote 63

Kikuchi M, Ito S, Yasuda M, Tsuchiya T, Hatazaki K, Takanashi M, et al. Remarkable increase in fluoroquinolone-resistant Mycoplasma genitalium in Japan. J Antimicrob Chemother 2014 Sep;69(9):2376-2382.

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Footnote 64

Heystek M, Ross JDC. A randomized double-blind comparison of moxifloxacin and doxycycline/metronidazole/ciprofloxacin in the treatment of acute, uncomplicated pelvic inflammatory disease. Int J STD AIDS 2009;20(10):690-695.

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Footnote 65

Ross JDC, Cronjé HS, Paszkowski T, Rakoczi I, Vildaite D, Kureishi A, et al. Moxifloxacin versus ofloxacin plus metronidazole in uncomplicated pelvic inflammatory disease: results of a multicentre, double blind, randomised trial. Sex Transm Infect 2006;82(6):446-451.

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Footnote 66

Haggerty CL, Totten PA, Astete SG, Lee S, Hoferka SL, Kelsey SF, et al. Failure of cefoxitin and doxycycline to eradicate endometrial Mycoplasma genitalium and the consequence for clinical cure of pelvic inflammatory disease. Sex Transm Infect 2008;84(5):338-342.

Return to footnote 66 referrer

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