Mycoplasma genitalium infection and female reproductive tract disease: a meta-analysis

Women with persistent/recurrent vaginal discharge should be offered multiplex-7 PCR testing

BACKGROUND

Recurrent vaginal discharge is an important cause of repeated visits to the gynaecologists. Failure to correctly identify the causative organism with standard microscopy and culture techniques results in repeated unsuccessful treatment and the risk of developing antibiotic resistance. Multiplex PCR test is increasingly being used for investigating infections where multiple organisms may be involved.

METHODS

This was a retrospective review of women attending the Feto Maternal Centre, Doha Qatar with the complaint of persistent/recurrent vaginal discharge over a period of 8 years who were tested by both the standard approach and a multiplex 7-PCR.

RESULTS

A total of 536 women with vulvovaginal discharge (474 with persistent/recurrent discharge and 62 with first episode) had been investigated with 7-PCR and treated. 7-PCR was able to identify a possible infective organism in 85% of those with persistent/recurrent discharge and 95% of those presenting with symptoms for the first time. The most common microorganisms were the sexually transmitted infections Ureplasma urealyticum, Mycoplasma genitalium and Gardnerella vaginalis. At follow-up 88.2% of symptoms had been eradicated.

CONCLUSION

Multiplex 7-PCR is more likely to identify an infective cause of vulvovaginal discharge than standard microbiology tests. The most common organisms identified were Ureplasma urealyticum, Mycoplasma genitalium and Gardnerella vaginalis. While the standard tests can identify other pathogens that may be associated with vulvovaginal discharge 7-PCR offers an advantage in that it is able from a single swab to screen for 7 organisms. Since it does not screen for Candida albicans, we feel that whenever this is offered, standard screening for candida should be offered unless the PCR test kit included screening for candida. We suggest that multiplex-PCR should be considered as the standard screening test for women presenting with first episode or recurrent vulvovaginal discharge.

Trends in infections detected in women with cervicitis over a decade

Objectives

There is a growing body of evidence that in the absence of Chlamydia trachomatis and/or Neisseria gonorrhoeae, Mycoplasma genitalium and bacterial vaginosis (BV) are associated with cervicitis. We aimed to describe infections detected among cervicitis cases over a decade and establish how commonly M. genitalium and BV were detected among non-chlamydial/non-gonococcal cases to inform testing and treatment practices.

Methods

We conducted a retrospective case-series to determine the number of cervicitis cases diagnosed with genital infections (C. trachomatis, N. gonorrhoeae, M. genitalium and BV) among women attending the largest public sexual health service in Australia from 2011 to 2021. We determined the proportion of cervicitis cases with one or more genital infections detected, and trends in testing and detection of each infection over time.

Results

Over a decade 813 cervicitis cases were diagnosed; 421 (52%, 95%CI: 48%-55%) had no infection detected; 226/729 (31%, 95%CI: 28%-35%) had BV, 163/809 (20%, 95%CI: 17%-23%) C. trachomatis, 48/747 (6%, 95%CI: 5%-8%) M. genitalium, and 13/793 (2%, 95%CI: 1%-3%) N. gonorrhoeae. Of the 665 (82%) cases tested for all four infections, 268 (40%) had one infection and 73 (11%) had >1 infection detected. Of the 517/665 (78%) non-chlamydial/non-gonococcal cases, 164 (32%) had BV and 16 (3%) had M. genitalium as the sole infections detected; a further 13 cases (3%) were co-infected with BV and M. genitalium. The proportion of cases tested for BV (90%) did not change overtime, but detection increased from 32% to 45% (Ptrend < 0.001). The proportion of cases tested for M. genitalium increased from 84% in 2011 to 96% in 2019 (Ptrend = 0.006), with M. genitalium-detection in cervicitis increasing from 3% to 7% (Ptrend = 0.046).

Conclusions

In our study population, chlamydia or gonorrhoea were not detected in ∼75% of cervicitis cases; 1 in 3 of these cases had BV and/or M. genitalium, and both increased in prevalence over time. These data highlight the need for clinicians to consider BV and M. genitalium when assessing and managing cervicitis.

In vitro test of the novel antibiotic lefamulin alone and in combination with doxycycline against Mycoplasma genitalium

Mycoplasma genitalium, a sexually transmitted bacterium, is a significant cause of urethritis in men and various reproductive tract infections in women, including cervicitis, pelvic inflammatory disease, endometritis, and potentially infertility. Treatment has become increasingly challenging due to the emergence of resistance to both first-line (azithromycin) and second-line (moxifloxacin) antibiotics. The need for new treatment options is critical. This study evaluates the in vitro efficacy of the novel antibiotic lefamulin against 54 M. genitalium isolates, including highly resistant variants. Additionally, the potential synergistic effects of combining lefamulin with doxycycline were assessed in eight selected isolates. Lefamulin exhibited strong antibacterial activity across all tested isolates, with minimal inhibitory concentrations (MICs) ranging from 0.0005 to 0.064 µg/mL. Minimal bactericidal concentrations ranged from 0.001 to 0.128 µg/mL and were equal to the MIC in 40 of 54 isolates and within two- and fourfold MIC in the rest of the isolates. Notably, lefamulin's MIC values were significantly lower than those of azithromycin, doxycycline, and moxifloxacin, underscoring its potent efficacy. Checkerboard assays revealed no antagonistic interaction between lefamulin and doxycycline, with some additive effects observed in certain isolates. These findings highlight lefamulin's potential as a highly effective treatment for M. genitalium infections, particularly those involving multi-drug-resistant strains. Given the increasing rates of resistance and the limitations of current therapies, lefamulin may represent a promising new option for managing this challenging pathogen. Further clinical studies are warranted to confirm these in vitro results and explore the therapeutic potential of lefamulin in combination with doxycycline.

Antimicrobial Resistance in Curable Sexually Transmitted Infections

PURPOSE OF REVIEW

Antimicrobial resistance in sexually transmitted infections (STIs) has become an urgent global public health threat, raising the specter of untreatable infections. This review summarizes the determinants of resistance among the five most common curable STIs Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium, Treponema pallidum, and Trichomonas vaginalis, as well as strategies to mitigate the spread of resistance.

RECENT FINDINGS

Genetic mutations are key drivers of resistance for N. gonorrhoeae and M. genitalium. Resistance in T. vaginalis can also occur because of genetic mutations, yet differential regulation of genes critical in antibiotic metabolism as well as co-infection with organisms that inactivate therapy play important roles. While resistance in C. trachomatis and T. pallidum has not been a substantial clinical concern, resistance selection via the continued widespread use of antimicrobials remains possible. While resistance determinants are diverse and differ by pathogen, the strategies required to mitigate the continued emergence of resistance are similar: prevention of infection and treatment diversification. Underpinning those strategies, surveillance remains essential for monitoring and responding to the threat of drug-resistant infections.

An automated commercial open access assay for detection of Mycoplasma genitalium macrolide resistance

Azithromycin, a macrolide antibioticum, is the first-line treatment for Mycoplasma genitalium (MG), but resistant MG is an increasing problem. Macrolide resistance-mediated mutations (MRM) has been linked to point mutations in region V of the MG 23S rRNA gene. We have evaluated an open access analyzer (Panther Fusion, Hologic Inc) for detectability of MRM (mutations A2071G and A2072G) and MG wild type (WT) in clinical samples. Also, the agreement of the Panther Fusion assay results with a corresponding established In-house MRM-WT PCR (ABI 7500) was calculated. Left over material from 55 clinical samples positive for MG by the Aptima test (Hologic) based on transcription-mediated amplification (TMA), collected from January to February 2023 in Region Skåne, Sweden, was analyzed. Specific amplification curves were generated for positive controls of MG mutations (A2071G and A2072G) and WT by the Panther Fusion assay. The limit of detection (LOD) was 5.3 copies/mL for WT, 8.1 copies/mL for mutation A2071G, and 81 copies/mL for mutation A2072G. The overall concordance was 91% between the Panther Fusion and the In-house PCR (Kappa 0.621, 95% CI; 0.327-0.914) for detection of WT or MRM in MG-positive clinical samples. The Panther Fusion detected MRM in 20% (11/55) and WT in 62% (34/55) of the samples. The corresponding In-house PCR results were 25% (14/55) and 65% (36/55). In summary, the Panther Fusion assay demonstrated detection of low copy number of MRM and WT of MG. Among clinical samples substantial agreement between the Panther Fusion and In-house PCR results was observed. Integrating MG-analysis (TMA) and MRM-WT assay on the Panther platform could make MRM testing more readily available. However, the Panther Fusion had a lower success rate (82% vs 90%) for macrolide susceptibility testing, hence testing with a complementary method should be considered for samples where neither WT nor MRM MG are detectable.

Implementation of Mycoplasma genitalium Diagnostics with Macrolide-Resistance Detection Improves Patient Treatment Outcomes in Bulgaria

Background/Objectives: The increasing prevalence of Mycoplasma genitalium infections with macrolide-resistance, causing high azithromycin failure rates, is a major concern internationally. In response to this challenge, diagnostics that simultaneously detect M. genitalium and genetic markers for macrolide-resistance enable the therapy to be individually tailored, i.e., to implement resistance-guided therapy (RGT). This study aimed to evaluate patient treatment outcomes of M. genitalium therapy, guided by a macrolide-resistance assay in Bulgaria. Methods: Consecutively referred M. genitalium infection cases (n = 17) were analyzed for macrolide-resistance mutations (MRMs) and specific antimicrobial treatment was recommended accordingly (MRMs-negative infections received azithromycin and MRMs-positive infections received moxifloxacin). The treatment outcome based on test-of-cure was recorded, and the treatment failure rates and time to achieve a microbiological cure were compared to treatment outcomes in patients treated before the implementation of RGT. Results: Among patients given RGT (n = 17), the overall treatment failure rate was 1/17 (5.9%). This was significantly lower than the rate (47.6%) observed in patients treated pre-RGT (p = 0.002). The time to achieve a microbiological cure was 29.4 days (CI 24.5-34.3), compared to 45.2 days (CI 36.5-53.7) pre-RGT (p = 0.001). Conclusions: The implementation of M. genitalium diagnostics with macrolide-resistance detection improved treatment outcomes in Bulgaria, with significantly lower treatment failure rates and reduced time to achieve a microbiological cure. In light of the limited treatment options and concerns about their decreasing efficacy in response to misuse and overuse, a diagnostic macrolide-resistance assay is critical to direct the appropriate first-line treatment, to maintain the efficacy of antimicrobial treatment (antibiotic stewardship) and to minimize the spread of antimicrobial resistance.

Detection of human IgG antibodies against Mycoplasma genitalium using a recombinant MG075 antigen

Mycoplasma genitalium is a sexually transmitted pathogen, which can cause a range of reproductive tract diseases in both men and women. To disentangle the relationship between M. genitalium infection(s) and subsequent reproductive health complications at the population level, accurate serological tools are needed. The major challenge in developing specific M. genitalium serological tests is the extensive cross-reactivity with the closely related ubiquitous respiratory tract pathogen, M. pneumoniae. In this report, we describe the development of an immunoblot assay based on a recombinant fragment of the M. genitalium MG075 protein present in lipid-associated membrane extracts. A sensitivity of 87.1% was achieved based on testing antibody responses in sera from 101 adults with PCR-confirmed M. genitalium infection. A specificity of 95.2% was obtained through evaluation of sera from 166 children under 15 years of age with and without M. pneumoniae infection, who were unlikely to have been exposed to sexually transmitted M. genitalium. The development of a serological assay capable of accurately distinguishing M. genitalium and M. pneumoniae, will enable a better understanding of associations between M. genitalium and adverse reproductive sequelae.

Lefamulin for Mycoplasma genitalium treatment failure in Australia and the USA: a case series and pilot open-label parallel arm randomised trial

OBJECTIVES

Mycoplasma genitalium (MG) causes urethritis and is associated with cervicitis, pelvic inflammatory disease and preterm delivery. Antimicrobial resistance is widespread and cure rates are declining. Lefamulin, a novel pleuromutilin, may be effective in cases of treatment failure.

METHODS

Under compassionate access in Australia and a pilot open-label parallel arm randomised clinical trial in the USA, patients with urogenital MG infection and microbiological treatment failure or contraindications to moxifloxacin were treated with lefamulin monotherapy (600 mg orally two times per for 7 days) or sequential doxycycline-lefamulin (doxycycline 100 mg orally two times per day for 7 days followed by lefamulin for 7 days) (1:1 randomisation in the USA). Two additional regimens were also evaluated in Australia: combination therapy with doxycycline plus lefamulin for 7 days and extended lefamulin therapy with doxycycline for 7 days followed by lefamulin for 14 days. Microbiological cure (negative MG NAAT) was assessed 21-35 days after completing lefamulin. Sustained cure was assessed 42-49 days after treatment.

RESULTS

Seventeen heavily pretreated Australian (seen between October 2020 and December 2023) and 11 US cases (recruited between April 2022 and February 2023; 5 randomised to lefamulin monotherapy, 6 randomised to sequential doxycycline-lefamulin) received lefamulin-containing regimens. Sequential doxycycline-lefamulin demonstrated microbiological cure 21-35 days post-treatment in 6 of 12 (50%) Australian and US patients. Three of five (60%) US patients but none of five (0%) Australian patients were cured with lefamulin monotherapy. Combination therapy with doxycycline and lefamulin was ineffective (n=0/2), but extended lefamulin therapy cured two of three (67%). Gastrointestinal side effects occurred in 77% (Australia) and 91% (USA).

CONCLUSION

While cure rates were low, lefamulin was effective in some individuals with MG treatment failure. Additional antibacterial agents for multidrug-resistant infections are needed.

Molecular Exploration of Mycoplasma fermentans and Mycoplasma genitalium in Mexican Women with Cervicitis

Genital Mycoplasmas are implicated in adverse pregnancy outcomes and the development of infertility. However, the role of Mycoplasma fermentans in these outcomes has not been adequately studied; therefore, its participation in these sufferings requires further investigation. This study aimed to evaluate the prevalence of M. fermentans in pregnant and non-pregnant women. End-point PCR was used to analyze two hundred and twenty-eight endocervical samples for M. hominis, M. genitalium, M. fermentans, M. pirum, Ureaplasma urealyticum, and U. parvum diagnoses. The prevalence of Mycoplasma spp. was as follows: U. parvum was found in 83 samples (36.4%), U. urealyticum in 39 instances (17.1%), M. hominis in 36 (15.7%), M. fermentans in 32 (14%), M. genitalium in 15 (6.6%), and M. pirum in 0 samples. No association was found between the Mycoplasma spp. and some infertility conditions or adverse pregnancy. However, M. fermentans and M. hominis were found to be associated with bacterial vaginosis (RR = 3.4 CI 95% 1.85-6.3, p < 0.005). In conclusion, M. fermentans and M. hominis were isolated more often in women with bacterial vaginosis, which suggests that these bacteria could contribute to the development of this pathology.

Detection of Mycoplasma DNA Using Conventional Polymerase Chain Reaction in Canine Abortion, Stillbirth, and Neonatal Mortality Cases in Central Italy

Mycoplasma spp. has been involved in canine infertility, but research on this topic is limited and shows conflicting results, as it has also been isolated from vaginal swabs of healthy dogs. This study aimed to retrospectively research Mycoplasma DNA by a conventional dual Polymerase Chain Reaction from 114 cases of canine abortion, stillbirth, and neonatal mortality that occurred in Central Italy. In addition, four fetal membranes from dystocic dams were analyzed. In total, 7 out of 114 cases (6.14%) and one of the fetal membranes tested positive for Mycoplasma DNA. From five of them (62.5%), other microorganisms were identified, particularly Canid herpesvirus-1 (2/8, 25%) and Escherichia coli, Staphylococcus aureus, and/or Staphylococcus pseudintermedius (3/8, 37.5%), notoriously responsible for infertility in bitches or neonatal mortality. In two different litters, only one puppy of each one tested positive for Mycoplasma DNA. Additionally, Mycoplasma DNA was detected in fetal membranes collected during a cesarean section of a bitch whelping Mycoplasma-negative puppies, supporting that Mycoplasma spp. is part of the normal genital microflora of the female. The detection of Mycoplasma DNA in association with other major pathogens and its detection in the female genital tract without transmission to puppies support the hypothesis that Mycoplasma belongs to the autochthonous genital microflora or, at most, may play a secondary role in canine abortion and neonatal mortality.

Rapid and visual detection of Mycoplasma genitalium using recombinase polymerase amplification combined with lateral flow strips

Mycoplasma genitalium (MG) is an important sexually transmitted pathogen that can cause urethritis in males and pelvic inflammatory disease in females. Due to its complex growth requirements and lengthy incubation times, culturing MG in clinical laboratories is impractical. Here we describe a rapid and visual assay combining recombinase polymerase amplification (RPA) with lateral flow (LF) strips to detect MG (MG-RPA-LF). The limit of detection (LoD) of this method was 33.6 genome equivalents (GE) per reaction, using a dilution series of purified genomic DNA. Clinical performance was evaluated by testing 100 urogenital swabs. Compared to the Simultaneous Amplification and Testing assay, our MG-RPA-LF assay showed a sensitivity of 94 % (95 % CI, 82 %-98 %) and a specificity of 100 % (95 % CI, 91 %-100 %). The overall concordance between the two methods was 97 % (95 % CI, 91 %-99 %) with a κ coefficient of 0.94 (P < 0.001). Without cumbersome and expensive instruments, this method is anticipated to be a promising alternative to diagnose MG infection, especially in resource-poor settings.

Mycoplasma genitalium in pregnancy, including specific co-infections, is associated with lower birthweight: A prospective cohort study

BACKGROUND

Mycoplasma genitalium infection in pregnancy is increasingly reported at similar frequencies to other sexually transmitted infections (STIs). Knowledge on its contribution to adverse pregnancy outcomes is very limited, especially relative to other STIs or bacterial vaginosis (BV). Whether M. genitalium influences birthweight remains unanswered.

METHODS

Associations between birthweight and M. genitalium and other STIs (Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis) and BV in pregnancy were examined in 416 maternal-newborn pairs from a prospective cohort study in Papua New Guinea.

FINDINGS

Compared to uninfected women, M. genitalium (-166.9 g, 95% confidence interval [CI]: -324.2 to -9.7 g, p = 0.038) and N. gonorrhoeae (-274.7 g, 95% CI: -561.9 to 12.5 g, p = 0.061) infections were associated with lower birthweight in an adjusted analysis. The association for C. trachomatis was less clear, and T. vaginalis and BV were not associated with lower birthweight. STI prevalence was high for M. genitalium (13.9%), N. gonorrhoeae (5.0%), and C. trachomatis (20.0%); co-infections were frequent. Larger effect sizes on birthweight occurred with co-infections of M. genitalium, N. gonorrhoeae, and/or C. trachomatis.

CONCLUSION

M. genitalium is a potential contributor to lower birthweight, and co-infections appear to have a greater negative impact on birthweight. Trials examining the impact of early diagnosis and treatment of M. genitalium and other STIs in pregnancy and preconception are urgently needed.

FUNDING

Funding was received from philanthropic grants, the National Health and Medical Research Council, and the Burnet Institute. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Vaginitis and risk of sexually transmitted infections: results of a multi-center U.S. clinical study using STI nucleic acid amplification testing

Significant increases in rates of sexually transmitted infections (STIs) caused by Trichomonas vaginalis (TV), Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), and Mycoplasma genitalium (MG) are occurring in the United States. We present results of a U.S. study examining the intersection of STIs and vaginitis. Among 1,051 women with diagnoses for the presence or absence of bacterial vaginosis (BV) and/or symptomatic vulvovaginal candidiasis (VVC), 195 (18.5%) had one or more STIs, including 101 (9.6%) with TV, 24 (2.3%) with CT, 9 (0.8%) with NG, and 93 (8.8%) with MG. STI prevalence in BV-positive women was 26.3% (136/518), significantly higher than STI prevalence of 12.5% (59/474) in BV-negative women (P < 0.0002). Unlike infections with CT or NG, solo infections of MG or TV were each significantly associated with a diagnosis of BV-positive/VVC-negative (OR 3.0751; 95% CI 1.5797-5.9858, P = 0.0113, and OR 2.873; 95% CI 1.5687-5.2619, P = 0.0017, respectively) and with mixed infections containing MG and TV (OR 3.4886; 95% CI 1.8901-6.439, P = 0.0042, and OR 3.1858; 95% CI 1.809-5.6103, P = 0.0014, respectively). TV and MG infection rates were higher in all Nugent score (NS) categories than CT and NG infection rates; however, both STIs had similar comparative prevalence ratios to CT in NS 6-10 vs NS 0-5 (CT: 3.06% vs 1.4%, 2.2-fold; MG: 10.7% vs 6.1%, 1.8-fold; TV: 14.5% vs 7.0%, 2.1-fold). NG prevalence was relatively invariant by the NS category. These results highlight the complexity of associations of STIs with two major causes of vaginitis and underscore the importance of STI testing in women seeking care for abnormal vaginal discharge and inflammation.

IMPORTANCE

This study reports high rates for sexually transmitted infections (STIs) in women seeking care for symptoms of vaginitis and bacterial vaginosis, revealing highly complex associations of STIs with two of the major causes of vaginal dysbiosis. These results underscore the importance of STI testing in women seeking care for abnormal vaginal discharge and inflammation.

Sexually Transmitted Infections in People with Human Immunodeficiency Virus

Sexually transmitted infections (STIs) are more commonly seen in patients with human immunodeficiency virus (PWH). Routine sexual history taking and appropriate multisite screening practices support prompt identification and treatment of patients, which in turn reduces morbidity and spread of STIs including HIV. Nucleic acid amplification testing has high accuracy for diagnosing many of the major STIs. Diagnosis of syphilis remains complex, requiring 2 stage serologic testing, along with provider awareness of the myriad symptoms that can be attributable to this disease. Prevention through mechanisms such as vaccines and postexposure prophylaxis hold promise to reduce the burden of STIs in PWH.

Prevalence and Risk Factors for Antimicrobial Resistance of Mycoplasma genitalium Infections in a High-Risk Population

Background/Objectives:Mycoplasma genitalium (MG) infections and antibiotic resistance are increasing in prevalence while treatment options are limited. Limited data exist regarding MG resistance in Israel. Our aim was to study the prevalence of MG resistance in a sexually transmitted infection (STI) clinic in Israel. Methods: We performed a single-center retrospective study among patients attending an STI clinic during 2019-2020. MG isolates were tested to detect their resistance to azithromycin and fluoroquinolones (FQs) using commercial kits (Allplex™ MG & AziR Assay, Allplex™ MG & MoxiR Assay). We collected patient data regarding the risk factors for STIs and resistance. A multivariate logistic regression model was used to identify the risk factors for resistance. Results: Of the 142 patients who tested positive for MG, 50 (35.2%) and 22 (15.5%) had resistant mutations to azithromycin and FQ, respectively, and 13 (9.2%) showed resistance to both agents. In a multivariate logistic regression model, men who have sex with men (RR 7.01 95% CI 3.00-16.33) and past STIs (RR 2.33 95% CI 1.01-5.34) were independent risk factors for azithromycin resistance. Conclusions: We found a high prevalence of azithromycin resistance and, to a lesser degree, FQ resistance. These findings may help design the treatment guidelines and support routine resistance testing in high-risk populations.

Prevalence of Mycoplasma genitalium Infection and Macrolide and Fluoroquinolone Resistance Mutations Among US Air Force Service Members With HIV, 2016-2020

Background

Mycoplasma genitalium (MG) infection is a public health concern due to antimicrobial resistance (AMR). Data are limited on repeat MG infection and AMR among US Air Force service members with HIV.

Methods

US Air Force service members seeking HIV care were screened for MG infection during the surveillance period (16 May 2016-16 March 2020). Baseline and repeat MG prevalence rates were estimated. An extended Cox proportional hazards regression model evaluated characteristics associated with repeat MG infection. MG-positive rectal samples were tested for macrolide or fluoroquinolone resistance.

Results

Among 299 male patients from a total of 308 patients followed during the surveillance period, baseline prevalence of MG infection was 19.7% (n = 59); among the 101 patients who screened positive for MG at any time during the surveillance period, repeat MG was 35% (n = 36). Characteristics independently associated with increased risk of repeat infection were sexually transmitted infection history vs none (adjusted hazard ratio [aHR], 2.33; 95% CI, 1.26-4.31), a sexually transmitted infection coinfection vs no positive test result in the medical records (aHR, 5.13; 95% CI, 2.78-9.49), and a new HIV diagnosis (<1 vs ≥1 year; aHR, 2.63; 95% CI, 1.45-3.73). AMR in MG-positive rectal specimens was 88% (43/49) indicating macrolide resistance, 18% (10/56) quinolone resistance, and 18% (10/56) both.

Conclusions

Macrolide and fluoroquinolone resistance mutations were common. Testing for co-occurring MG infection and AMR mutations may be warranted in guiding treatment for sexually transmitted infections such as chlamydia or gonorrhea detected at HIV diagnosis.

Antimicrobial treatment and resistance in sexually transmitted bacterial infections

Sexually transmitted infections (STIs) have been part of human life since ancient times, and their symptoms affect quality of life, and sequelae are common. Socioeconomic and behavioural trends affect the prevalence of STIs, but the discovery of antimicrobials gave hope for treatment, control of the spread of infection and lower rates of sequelae. This has to some extent been achieved, but increasing antimicrobial resistance and increasing transmission in high-risk sexual networks threaten this progress. For Neisseria gonorrhoeae, the only remaining first-line treatment (with ceftriaxone) is at risk of becoming ineffective, and for Mycoplasma genitalium, for which fewer alternative antimicrobial classes are available, incurable infections have already been reported. For Chlamydia trachomatis, in vitro resistance to first-line tetracyclines and macrolides has never been confirmed despite decades of treatment of this highly prevalent STI. Similarly, Treponema pallidum, the cause of syphilis, has remained susceptible to first-line penicillin.

Mycoplasmoides genitalium nucleic acid semi-quantitation and molecular macrolide resistance detection via automated assays: gender and specimen source considerations

A laboratory-developed test (LDT) using analyte-specific reagents has been optimized on a commercial platform to detect macrolide resistance-associated mutations (MRM) in 23S rRNA from Mycoplasmoides genitalium from primary clinical specimens. In this study, MRM-LDT was applied to a multi-specimen source study set. One thousand four hundred ninety-five primary specimens testing positive for M. genitalium by commercial transcription-mediated amplification (TMA) were initially titered by the TMA assay using serial 10-fold dilutions to semi-quantitate target nucleic acid burden. Primary specimens were then processed for MRM detection using the MRM-LDT. Findings were stratified by gender and specimen source. The mean log10 target nucleic acid titer of a TMA-positive specimen was 3.51 (median 3; range 0-10). Male specimens (n = 1145) demonstrated a mean log10 M. genitalium TMA titer of 3.67; that value observed in 350 female specimens was 2.98 (P < 0.0001). The MRM-LDT detection rate (88.7%) from specimens with log10 M. genitalium TMA titers ≥ 4 was increased over specimens with log10 titers ≤ 1 (4.5%; P < 0.0002). In females, MRM-LDT was positive from 51.3% of vaginal swab and 34.7% of urine specimens (P = 0.01). In males, MRM-LDT was positive from 65.0% of rectal swab and 55.7% of urine specimens (P = 0.002). Differences were also observed in log10 M. genitalium TMA titers as a function of specimen source. M. genitalium macrolide resistance rates among multiple specimen sources, as determined by MRM-LDT, are high in the United States and can be consistent with target nucleic acid burden within the primary specimen. Caveats experienced within subgroupings support MRM reflex testing on primary M. genitalium-positive specimens.

IMPORTANCE

First-line macrolide treatment failure is of increasing concern with Mycoplasmoides genitalium in multiple settings. Recent sexually-transmitted infection treatment guidelines from the United States Centers for Disease Control and Prevention have predicated therapeutic approaches on the availability of a macrolide resistance/susceptibility result from a primary clinical specimen. In this report, we investigate potential correlation between macrolide resistance mutation detection rates (identified by a molecular amplified laboratory-developed test) and transcription-mediated amplification-based rRNA target semi-quantitation. Data reveal that rRNA semi-quantitation and laboratory-developed test detection rate differences exist as a function of gender and specimen source. These data can guide providers in proper specimen selection not only for the laboratory diagnosis of M. genitalium but also macrolide resistance mutation determination from primary clinical specimens.

Cost-effectiveness of resistance-guided therapy for Mycoplasma genitalium in Australia

The recommended first-line treatment for Mycoplasma genitalium infections is azithromycin. However, the prevalence of macrolide resistance for M. genitalium has increased to more than 50% worldwide. In 2013, Australia introduced a resistance-guided therapy (RGT) strategy to manage M. genitalium infections. This study assesses the cost-effectiveness of the RGT approach compared to no RGT (i.e., without macrolide resistance profile test) in women, men who have sex with men (MSM), and men who have sex with women (MSW) in Australia. We constructed dynamic transmission models of M. genitalium infections in women, MSM, and MSW in Australia, each with a population of 100,000. These models compared the costs and quality-adjusted life-years (QALYs) gained between RGT and no RGT scenarios from a healthcare perspective over ten years. All costs are reported in 2022 Australian dollars (Australian $). In our model, RGT is cost saving in women and MSM, with the incremental net monetary benefit of $1.3 million and $17.9 million, respectively. In MSW, the RGT approach is not cost-effective, with an incremental cost-effectiveness ratio of -$106.96 per QALY gained. RGT is cost saving compared to no RGT for M. genitalium infections in women and MSM, supporting its adoption as the national management strategy for these two population groups.

Clinical Updates in Sexually Transmitted Infections, 2024

Sexually transmitted infections (STIs) continue to increase in the United States with more than 2.5 million cases of gonorrhea, chlamydia, and syphilis reported to the Centers for Disease Control and Prevention in 2022. Untreated STIs in women can lead to adverse outcomes, including pelvic inflammatory disease, infertility, chronic pelvic pain, and pregnancy complications such as ectopic pregnancy, early pregnancy loss, stillbirth, and neonatal transmission. STI-related guidelines can be complex and are frequently updated, making it challenging to stay informed on current guidance. This article provides high-yield updates to support clinicians managing STIs by highlighting changes in screening, diagnosis, and treatment. One important topic includes new guidance on syphilis screening, including a clarified description of high community rates of syphilis based on Healthy People 2030 goals, defined as a case rate of primary or secondary syphilis > 4.6 per 100,000. Reproductive aged persons living in counties above this threshold should be offered syphilis screening. Additionally, American College of Obstetricians & Gynecologists now recommends syphilis screening three times during pregnancy regardless of risk-at the first prenatal visit, during the third trimester, and at delivery. In addition, new guidance to support consideration for extragenital screening for gonorrhea and chlamydia in women at sites such as the anus and pharynx is discussed. Other topics include the most recent chlamydia, gonorrhea, trichomoniasis, and pelvic inflammatory disease treatment recommendations; screening and treatment guidance for Mycoplasma genitalium; genital herpes screening indications and current diagnostic challenges; and the diagnosis and management of mpox in women and during pregnancy.

Comparison of two testing strategies for Mycoplasma genitalium in emergency department patients across a statewide health system

PURPOSE

Mycoplasma genitalium (Mgen) is a sexually transmitted infection (STI) that has an estimated prevalence in the general population of 2.3% in women and 1.1% in men aged 21-23 years. (Hilbert and Reno, 2018) A cross-sectional study conducted in a community emergency department (ED) determined that the prevalence of Mgen was 14.8% in asymptomatic female patients. (Centers for Disease Control and Prevention (CDC). Sexually Transmitted Infections Treatment Guidelines, 2021) The Centers for Disease Control and Prevention (CDC) 2021 STI Treatment Guidelines recommend testing for Mgen in select circumstances. This study aims to determine what testing strategy in ED patients results in the most appropriate treatment of Mgen based on CDC recommendations.

METHODS

This multicenter, retrospective, pre- and post-intervention cohort study assessed adherence to CDC recommendations for appropriate management of Mgen in ED patients. Inclusion criteria were patients at least 18 years of age discharged from one of the 15 ED sites within the health system studied who were tested for Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis (T. vaginalis), and Mgen. Subjects were excluded if they were pregnant, sexually assaulted, or had indeterminate STI results. For cohort 1, which included patients evaluated from May 2022 through July 2022, Mgen was incorporated into the standard STI testing panel. Cohort 2 consisted of patients evaluated from September 2022 through November 2022; testing for Mgen in cohort 2 was optional, and a testing algorithm based on CDC recommendations was disseminated to ED sites. The primary endpoint was the number of subjects treated appropriately for Mgen in accordance with CDC recommendations. Cohort 1 secondary endpoints included overall prevalence of Mgen in patients who presented to ED sites for STI testing and prevalence in ICD-10 code diagnosed PID. Secondary endpoints for both cohorts included baseline characteristics of patients who tested positive for Mgen.

RESULTS

Percent appropriate treatment did not differ significantly between cohort 1 (21%) and cohort 2 (20%), (p > 0.9). However, greater than three times as many subjects were inappropriately treated for Mgen in cohort 1 when the health system studied did not adhere to current CDC Mgen testing recommendations. The overall prevalence of Mgen in ED patients who were tested for STIs was 13.1%. The prevalence of PID ICD-10 diagnosis code in patients positive for Mgen was 2.9%. Based on results of a risk factor analysis to determine if certain baseline characteristics are indicators for a positive infection with Mgen, a positive Mgen result was significantly associated with a positive result for T. vaginalis (p = 0.042).

CONCLUSIONS

Evidence regarding the preferred testing strategy for Mgen is currently limited. This study demonstrates that testing all STI presenting patients for Mgen results in antibiotic overuse, so adhering to CDC testing recommendations is important. Prevalence of positive Mgen result in ED patients tested for STIs was similar to results of previously published literature. Risk factor analysis results could be used as a screening method to determine what patients should be considered for Mgen testing. Based on the results of this study, we recommend against including Mgen on the standard ED STI testing panel at this time.

Mycoplasma genitalium: Key Information for the Primary Care Clinician

Mycoplasma genitalium (MG) is an emerging sexually transmitted infection, which appears to be a cause of urethritis and cervicitis and has been associated with pelvic inflammatory disease (PID), epididymitis, proctitis, infertility, complications during pregnancy, and human immunodeficiency virus (HIV) transmission. Three Food and Drug Administration (FDA) approved tests are available. Testing should be focused to avoid inappropriate antibiotic use. The Center of Disease Control and Prevention (CDC) guidelines recommend testing for persistent male urethritis, cervicitis, and proctitis and state that testing should be considered in cases of PID. Testing is also recommended for sexual contacts of patients with MG. Testing is not recommended in asymptomatic patients, including pregnant patients, who do not have a history of MG exposure. Although resistance-guided therapy is recommended, there are currently no FDA approved tests for MG macrolide resistance, and tests are not widely available in the United States. The CDC recommends 2-step treatment with doxycycline followed by azithromycin or moxifloxacin. Moxifloxacin is recommended if resistance testing is unavailable or testing demonstrates macrolide resistance..

Detection of resistance to macrolides and fluoroquinolones in Mycoplasma genitalium by targeted next-generation sequencing

Mycoplasma genitalium is fastidious to culture, and its detection in human clinical specimens relies mainly on molecular methods. Phenotypic determination of antibiotic susceptibility for this bacterium is not a timely or feasible option for most clinical laboratories. This study sought to determine whether next-generation sequencing technologies can effectively be employed in determining genetic mutations associated with drug resistance in M. genitalium samples collected in Aptima Hologic tubes and possibly integrating them into viable workflows in public health laboratories. Following analysis by a custom-designed bioinformatics pipeline, at least one mutation/sample has been identified in 94/98 specimens in at least one of seven loci (macrolides: rrl, rplD, rplV; fluoroquinolones: parC, parE, gyrA, gyrB) described previously to be connected to antibiotic resistance. This method identified a total of 469 single nucleotide polymorphisms (SNPs) (452 mutations): 134 of 23S rRNA SNPs and 318 amino acid mutations: 114 substitutions and 204 synonymous; the turnaround time (sample to analyzed sequence) was typically 3 days. The assays and workflows described in this work demonstrated that the determination of a drug resistance profile for macrolides and fluoroquinolones of M. genitalium samples by using next-generation sequencing in clinical samples is a feasible approach that can be implemented in clinical laboratories, following thorough and extensive validation studies.IMPORTANCEThe mechanisms of drug resistance in Mycoplasma genitalium are complex and involve several genetic loci. The molecular methods for accurately characterizing resistance to fluoroquinolones and macrolides in this organism are often not available or approved for patient use and do not cover all genetic determinants. To this end, we propose a next-generation sequencing-based method with a turnaround time of 3 days that includes the investigation of all drug resistance loci of M. genitalium. Following adaptation, validation, and verification for routine clinical use, assays based on this method may yield molecular results that can be used to guide proper treatment regimens and for surveillance of drug resistance in the general population.

A multicenter retrospective electronic health record database evaluation of subjects with Mycoplasma genitalium

BACKGROUND

Mycoplasma genitalium is a sexually transmitted infection (STI) increasing in prevalence. The recent availability of nucleic acid amplification tests (NAATs) has led to updated diagnostic and treatment guidelines. As medication therapy experts, pharmacists can facilitate appropriate antimicrobial selection and stewardship and optimize best patient-care practices in the setting of M. genitalium infection.

OBJECTIVE

This study aimed to evaluate patient demographics, therapeutic approaches, and complications of patients with laboratory evidence of M. genitalium hypothesizing that younger adolescent females are affected by this organism, receive suboptimal treatment, and have more complications than adults.

METHODS

This was a retrospective cohort study using TriNetX multicenter electronic health record data of subjects aged 12 years and older with evidence of M. genitalium DNA detected via NAATs. The cohort was divided into 2 age groups: adolescents (12-21 years) and adults (older than 21 years). We evaluated age, sex, race, ethnicity, diagnostic codes, and medication codes.

RESULTS

Our study included 1126 subjects (192 adolescents [17.1%] and 934 adults [82.9%]) who tested positive for M. genitalium. Subjects in the adolescent group had higher odds of being women (2.52 [1.80, 3.54], P < 0.001), having inflammatory diseases of female pelvic organs diagnostic codes (1.51 [1.06, 2.16], P = 0.025), increased odds of azithromycin prescription (1.70 [1.17, 2.48], P = 0.005), and decreased odds of moxifloxacin prescription (0.41 [0.26, 0.64], P < 0.001).

CONCLUSIONS

Our study revealed a higher prevalence of M. genitalium infection in adults and adolescents with increased odds of receiving azithromycin and decreased odds of receiving moxifloxacin. Both age groups had decreased odds of receiving doxycycline compared with azithromycin despite guidelines recommending initial empirical antibiotic treatment with doxycycline and growing macrolide resistance. Suboptimal treatment of this infection may lead to lifelong complications. Pharmacists may provide crucial guidance and education to both patients and health care providers regarding appropriate treatment for M. genitalium.

2023 Korean sexually transmitted infections treatment guidelines for Mycoplasma genitalium by KAUTII

The Korean Association of Urogenital Tract Infection and Inflammation and the Korea Disease Control and Prevention Agency updated the Korean sexually transmitted infections (STIs) guidelines to respond to the changing epidemiologic trends, evolving scientific evidence, and advances in laboratory diagnostics and research. The main recommendations in the Mycoplasma genitalium infection parts of the Korean STIs guidelines 2023 revision are as follows: 1) For initial treatment: azithromycin 500 mg orally in a single dose, then 250 mg once daily for 4 days. 2) In case of treatment failure or recurrence, a macrolide susceptibility/resistance test is required, when susceptibility/resistance test is not feasible, doxycycline or minocycline 100 mg orally twice daily for 7 days, followed by azithromycin 1 g orally on the first day, then azithromycin 500 mg orally once daily for 3 days and then a test-of-cure should be considered 3 weeks after completion of therapy. 3) In case of macrolide sensitivity, doxycycline or minocycline 100 mg orally twice daily for 7 days, followed by azithromycin 1 g orally initial dose, then azithromycin 500 mg orally once daily for 3 days. 4) In case of macrolide resistance, doxycycline or minocycline 100 mg orally twice daily for 7 days, followed by moxifloxacin 400 mg orally once daily for 7 days. In the Korean STIs guideline 2023, macrolide resistance-guided antimicrobial therapy was emphasized due to the increased prevalence of macrolide resistance worldwide. Therefore, in case of treatment failure or recurrence, a macrolide susceptibility/resistance test is required.

Mycoplasma genitalium in the US (MyGeniUS): Surveillance Data From Sexual Health Clinics in 4 US Regions

BACKGROUND

Mycoplasma genitalium (MG) is on the CDC Watch List of Antimicrobial Resistance Threats, yet there is no systematic surveillance to monitor change.

METHODS

We initiated surveillance in sexual health clinics in 6 cities, selecting a quota sample of urogenital specimens tested for gonorrhea and/or chlamydia. We abstracted patient data from medical records and detected MG and macrolide-resistance mutations (MRMs) by nucleic acid amplification testing. We used Poisson regression to estimate adjusted prevalence ratios (aPRs) and 95% CIs, adjusting for sampling criteria (site, birth sex, symptom status).

RESULTS

From October-December 2020 we tested 1743 urogenital specimens: 57.0% from males, 46.1% from non-Hispanic Black persons, and 43.8% from symptomatic patients. MG prevalence was 16.6% (95% CI: 14.9-18.5%; site-specific range: 9.9-23.5%) and higher in St Louis (aPR: 1.9; 1.27-2.85), Greensboro (aPR: 1.8; 1.18-2.79), and Denver (aPR: 1.7; 1.12-2.44) than Seattle. Prevalence was highest in persons <18 years (30.4%) and declined 3% per each additional year of age (aPR: .97; .955-.982). MG was detected in 26.8%, 21.1%, 11.8%, and 15.4% of urethritis, vaginitis, cervicitis, and pelvic inflammatory disease (PID), respectively. It was present in 9% of asymptomatic males and 15.4% of asymptomatic females, and associated with male urethritis (aPR: 1.7; 1.22-2.50) and chlamydia (aPR: 1.7; 1.13-2.53). MRM prevalence was 59.1% (95% CI: 53.1-64.8%; site-specific range: 51.3-70.6%). MRMs were associated with vaginitis (aPR: 1.8; 1.14-2.85), cervicitis (aPR: 3.5; 1.69-7.30), and PID cervicitis (aPR: 1.8; 1.09-3.08).

CONCLUSIONS

MG infection is common in persons at high risk of sexually transmitted infections; testing symptomatic patients would facilitate appropriate therapy. Macrolide resistance is high and azithromycin should not be used without resistance testing.

Treatment of bacterial sexually transmitted infections in Europe: gonorrhoea, Mycoplasma genitalium, and syphilis

This review explores the therapeutic challenges of sexually transmitted infections (STI) in Europe, which include increasing antimicrobial resistance and limited progress in drug discovery. We primarily focus on gonorrhoea, Mycoplasma genitalium, and syphilis infections. For gonorrhoea with escalating resistance rates we explore the possibility of combining ceftriaxone with another antibiotic or using alternative antibiotics to mitigate resistance emergence, and we provide insights on the ongoing evaluation of new antimicrobials, like gepotidacin and zoliflodacin. In the case of M. genitalium, which exhibits high resistance rates to first and second-line treatments, we emphasize the importance of resistance-guided therapy in regions with elevated resistance levels, and highlight the limited alternative options, such as pristinamycin and minocycline. Furthermore, we address the challenges posed by syphilis, where the primary treatment consists of penicillin or doxycycline, with challenges arising in neurosyphilis, allergy, pregnancy, and supply shortages and discuss the ongoing evaluation of alternative antimicrobials (e.g., ceftriaxone, cefixime, linezolid). Our findings identify priority actions and provide concrete solutions for long-term effective management of STIs and antimicrobial resistance mitigation.

[Urethritis-spectrum of pathogens, diagnostics and treatment]

A broad spectrum of bacteria, fungi, protozoa and viruses can cause urethritis. In particular, N. gonorrhoeae, C. trachomatis, M. genitalium and T. vaginalis are the focus of diagnostic considerations as classic pathogens associated with sexually transmitted infections (STI). A step-by-step procedure is needed to make a definitive diagnosis. Microscopy with a staining preparation provides an initial differentiation between gonoccocal and non-gonococcal urethritis in symptomatic men as a point-of-care (POC) test. Nucleic acid amplification technology (NAAT) is used for specific and sensitive pathogen detection and, as a multiplex diagnostic test, offers the possibility of detecting several organisms from the same sample. In addition, compared to culture, no vital organisms are required, which allows the collection and use of more diverse and less invasive biological samples (e.g. first stream urine in men or vaginal swabs). Susceptibility testing by culture remains essential for N. gonorrhoeae as resistance is emerging. The treatment of urethritis depends on the suspected or proven pathogen according to the current guidelines. Treatment failure can be caused by many factors (coinfection, lack of therapy adherence, reinfection or resistance of the pathogen) and requires a repeated diagnostic and therapeutic procedure and differentiated approach.

Detection of macrolide and fluoroquinolone resistance-associated 23S rRNA and parC mutations in Mycoplasma genitalium by nested real-time PCR

Background

Traditional drug susceptibility testing cannot be performed in clinical laboratories due to the slow-growing characteristics of Mycoplasma genitalium when cultured in vitro. Sanger sequencing is the standard method for detecting drug resistance-associated mutations. It has been used in some laboratories to guide the choice of macrolide antibiotics for Mycoplasma genitalium infected patients. Furthermore, resistance to fluoroquinolone has become another emerging clinical challenge.

Objective

Sequencing analysis can detect unknown mutations, but it is time-consuming, requires professional analytical skills and the appropriate testing equipment. The main objective of this study was to establish a nested real-time PCR method for the simultaneous detection of 23S rRNA and parC genotypes in relation to the macrolide and fluoroquinolone resistance.

Results

105 MG-positive samples and 27 samples containing other pathogens were used for validation. The limit of the nested real-time PCR detection was 500 copies/reaction and there was no cross-reaction with Ureaplasma urealyticum, Mycoplasma hominis, Chlamydia trachomatis, Neisseria gonorrhoeae, Human papillomavirus, Herpes simplex virus, Candida albicans and Ureaplasma parvum, but the 23S rRNA assay cross-reacted with Mycoplasma pneumoniae. Compared with sequencing results, the sensitivity of 23S rRNA was 100% (95% CI; 93.3 -100), the specificity was 94.3% (95% CI; 79.4 - 99.0), the overall consistency was 98% (95% CI; 92.5 - 99.7) and kappa value was 0.96 (P < 0.001); the sensitivity of parC was 100% (95% CI; 93.4 - 100), the specificity was 89.7% (95% CI; 71.5 - 97.3) and the overall consistency was 96.9% (95% CI; 90.7 - 99.2) with a kappa value of 0.92 (P < 0.001).

Conclusions

The results of this sensitive and rapid alternative for identifying resistant genotypes of Mycoplasma genitalium are intuitive and easy to interpret, especially for mixed MG populations. Although the relevant 23S rRNA primers need further adjustment, this reliable method would provide an effective diagnostic tool for the selection of antibiotics in clinical practice.

Gynecologists and pelvic inflammatory disease: do we actually know what to do?: A cross-sectional study in Jordan

Pelvic inflammatory disease (PID) is an upper genital tract infection caused by a variety of aerobic and anaerobic microorganisms ascending from the cervix or vagina. Though PID is mainly a sexually transmitted disease; 15% are non-sexually transmitted.[1] In our study, we aim to assess gynecologists' understanding and awareness of PID; as it presents an important health issue affecting the Jordanian community and similar communities with the same cultural and religious backgrounds. A cross-sectional study was conducted using an online questionnaire that received responses from 172 gynecologists in Jordan. The questionnaire aimed at testing gynecologists' knowledge of different aspects of PID starting with diagnosis and ending with management. 68.6% of gynecologists acknowledged that PID is a problem in Jordan. However, obvious confusion was observed in the scopes of clinical presentation, choosing the most reliable PID investigations, and treatment. PID is not being addressed properly in a sexually conservative community that has low rates of sexually transmitted diseases like Jordan, which is misleading and dangerous. In addition, we think there is a lack of certain standards on how to define PID and acknowledge its effect on the community as well as the disappointing level of knowledge about different aspects of PID gynecologists show, starting with its prevalence and ending with treatment policy. Clearer guidelines for the diagnosis, management, and prevention of PID should be adopted. These findings should be acknowledged by all doctors from neighboring countries as well as those within similar communities to Jordan.

A prospective preconception cohort study of the association between Mycoplasma genitalium and fecundability in Kenyan women trying to conceive

STUDY QUESTION

Is Mycoplasma genitalium-infection associated with reduced fecundability?

SUMMARY ANSWER

Preconception M. genitalium-infection was associated with 27% lower fecundability though confidence intervals were wide, and the association between M. genitalium and fecundability may be dependent on concurrent bacterial vaginosis (BV).

WHAT IS KNOWN ALREADY

M. genitalium has been associated with cervicitis, pelvic inflammatory disease, infertility, and preterm birth, but the extent to which M. genitalium is causally related to adverse reproductive sequelae in women is debated.

STUDY DESIGN, SIZE, DURATION

Kenyan women enrolled in a prospective preconception cohort provided vaginal fluid specimens and underwent monthly pregnancy testing. Stored samples from 407 women who had been trying to conceive for ≤6 months were tested for M. genitalium using a nucleic acid amplification test.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Data on first day of last menstrual period, sexual behavior, pregnancy status, and vaginal specimens were collected at monthly preconception visits. The association between M. genitalium detected at the visit prior to each pregnancy test and fecundability was estimated using discrete time proportional probabilities models. Secondary analyses explored the influence of concurrent BV on the association between M. genitalium and fecundability.

MAIN RESULTS AND THE ROLE OF CHANCE

The 407 participants experienced 1220 menstrual cycles and 213 pregnancies. The prevalence of M. genitalium at enrollment was 7.7%. After adjustment for age, frequency of condomless sex in the last 4 weeks, and study site, M. genitalium was associated with a 27% lower fecundability, but confidence intervals were wide (adjusted fecundability ratio (aFR) 0.73, 95% CI 0.44, 1.23). In secondary analyses, when compared to cycles without M. genitalium or BV at the visit prior, women with both M. genitalium and BV at the visit prior had a 51% lower fecundability (aFR = 0.49, 95% CI 0.22, 1.09) whereas there was no association of M. genitalium alone (aFR = 0.98 (95% CI 0.54, 1.76)), and a smaller reduction in fecundability for women with BV only (aFR = 0.80 (95% CI 0.60, 1.07)).

LIMITATIONS, REASONS FOR CAUTION

Results should be interpreted cautiously given the relatively low prevalence of M. genitalium and wide confidence intervals.

WIDER IMPLICATIONS OF THE FINDINGS

In this cohort of Kenyan women trying to conceive, the association between M. genitalium and fecundability was influenced by concurrent BV status, suggesting there may be a synergistic effect of M. genitalium and BV on fecundability.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by a National Institutes of Health grant (NICHD R01 HD087346-RSM). R.S.M. received additional support for mentoring (NICHD K24 HD88229). E.M.L. was supported by pre- and post-doctoral fellowships (NIAID T32 AI07140, NICHD F32 HD100202). Data collection and management were completed using REDCap electronic data capture tools hosted at the University of Washington's Institute of Translational Health Science supported by grants from NCATS/NIH (UL1 TR002319). The content of this paper is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. R.S.M. receives research funding, paid to the University of Washington, from Hologic Corporation and consulting fees from Lupin Pharmaceuticals. L.E.M. receives research funding and material for research studies, paid to the University of Washington, from Hologic Corporation and Nabriva Therapeutics, travel support from Hologic, and consulting fees from Health Advances. E.M.L.'s contributions to this study primarily occurred while affiliated with the University of Washington; at the time of submission, E.M.L. was an employee of and holds stock or stock grants for AbbVie, Inc. The other authors have no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

Prevalence and Factors Associated With Mycoplasma genitalium Infection in At-Risk Female Adolescents in Bronx County, New York

BACKGROUND

Mycoplasma genitalium infection can adversely affect female reproductive health, but data are limited about prevalence and characteristics of the infection in female adolescents. We employed a sensitive assay to detect M. genitalium infection, and we describe its characteristics in a clinical sample of women younger than 21 years.

METHODS

We recruited females aged 13 to 20 years in children's hospital clinics whose clinicians were testing for chlamydia/gonorrhea. Participants completed a questionnaire providing demographics, sexual history, and current symptoms. Urine/endocervical samples were tested for chlamydia/gonorrhea and partitioned for M. genitalium testing using Aptima M. genitalium assay. We reviewed records for the clinic visit to document examination, diagnosis, and results of sexually transmitted infection (STI) testing. We compared prevalence of M. genitalium infection by demographics, sexual history, symptoms, and signs.

RESULTS

Of 153 participants mean age 18.07 ± 1.68 years, 58% self-identified as Hispanic, 27% Black, 64% straight/heterosexual, 27% bisexual, 1% gay/lesbian, 29% reported a prior STI diagnosis. Prevalence of M. genitalium was 11.1% (17/153), 13 of 17 were asymptomatic, 2 of 17 had pelvic inflammatory disease (PID), 3 of 17 coinfected with chlamydia or gonorrhea. Prevalence of chlamydia was 6.6% and of gonorrhea 2.6%. A logistic regression model indicated independent associations of bisexual orientation versus all other orientations (adjusted odds ratio [aOR], 4.80; 95% confidence interval [CI], 1.38-16.67), self-reported prior STI (aOR, 3.83; 95% CI, 1.10-13.37), and self-reported prior PID (aOR, 9.12; 95% CI, 1.02-81.72) with higher odds of M. genitalium infection.

CONCLUSIONS

Findings suggest that in at-risk female populations younger than 21 years, M. genitalium is a prevalent STI and symptomatic adolescents may warrant testing and treatment. Further study of harms and benefits of testing asymptomatic bisexual female adolescents or those with prior STI/PID is needed.

Retrospective Evaluation of Mycoplasma genitalium Prevalence and Macrolide Resistance in a Study Cohort of Pregnant Women in Birmingham, AL, From 1997 to 2001

ABSTRACT

In a prospective study conducted in 2020 to 2021, macrolide resistance-associated mutations were found in 41% of pregnant persons in Birmingham, AL, with Mycoplasma genitalium detected. We retrospectively evaluated M. genitalium in 203 pregnant persons participating in a study conducted in 1997 to 2001 in Birmingham and adjacent areas and found a prevalence of 11% (95% confidence interval, 6.9%-15.7%), but no macrolide resistance-associated mutations.

Global analysis on the mutations associated with multidrug-resistant urogenital mycoplasmas and ureaplasmas infection: a systematic review and meta-analysis

BACKGROUND

The emergence of multidrug-resistant (MDR) strains of genital pathogens, notably Mycoplasma genitalium and Ureaplasma spp., constitutes a significant global threat today. The present study aimed to evaluate the prevalence and trend of changes in MDR mycoplasma and ureaplasma strains.

METHODS

An exhaustive search was performed across the ISI Web of Science, PubMed, Scopus, ScienceDirect, and Google Scholar databases to accumulate relevant studies without restrictions until April 2023. We used event rate and corresponding 95% confidence intervals to determine the frequency of resistance-related mutations and examine the trend of antibiotic resistance changes.

RESULTS

The data from 27 studies, including 24,662 patients across 14 countries, were evaluated. Out of the total studies, 20 focused on M. genitalium infections, and five on Ureaplasma spp. The frequency of resistance-associated mutations to macrolides, tetracyclines, and fluoroquinolones in clinical strains of M. genitalium was 43.5%, 13.1%, and 18.6%, respectively. The prevalence of M. genitalium strains with double resistance and MDR was 11.0% and 17.4%, respectively. The incidence of both double-drug-resistant and MDR strains was higher in the World Health Organization (WHO) Western Pacific Region than in European and American populations. For Ureaplasma strains, resistance-associated mutations to macrolides, tetracyclines, and fluoroquinolones were 40.8%, 25.7%, and 90.3%, respectively. The rate of antibiotic resistance was higher in the African population compared to the European and WHO Western Pacific Regions. The rate of MDR Ureaplasma infections was 13.2%, with a higher incidence in the African population compared to the WHO Western Pacific and European regions.

CONCLUSION

The proliferation and spread of MDR Mycoplasma and Ureaplasma strains present a significant public health challenge. The situation is indeed alarming, and the rising trend of MDR M. genitalium and MDR Ureaplasma infections suggests that therapies involving macrolides and fluoroquinolones may become less effective.

Efficacy of Minocycline for the Treatment of Mycoplasma genitalium

Background

High levels of macrolide resistance and increasing fluoroquinolone resistance are making Mycoplasma genitalium increasingly difficult to treat. Minocycline is an alternative treatment for patients with macrolide-resistant M genitalium infections that have failed moxifloxacin, or for those with fluoroquinolone contraindications or resistance. Published efficacy data for minocycline for M genitalium are limited.

Methods

We evaluated minocycline 100 mg twice daily for 14 days at Melbourne Sexual Health Centre (MSHC). Microbial cure was defined as a negative test of cure within 14-90 days after completing minocycline. The proportion cured and 95% confidence intervals (CIs) were calculated, and logistic regression was used to explore factors associated with treatment failure. We pooled data from the current study with a prior adjacent case series of patients with M genitalium who had received minocycline 100 mg twice daily for 14 days at MSHC.

Results

Minocycline cured 60 of 90 (67% [95% CI, 56%-76%]) infections. Adherence was high (96%) and side effects were mild and self-limiting. No demographic or clinical characteristics were associated with minocycline failure in regression analyses. In the pooled analyses of 123 patients, 83 (68% [95% CI, 58%-76%]) were cured following minocycline.

Conclusions

Minocycline cured 68% of macrolide-resistant M genitalium infections. These data provide tighter precision around the efficacy of minocycline for macrolide-resistant M genitalium and show that it is a well-tolerated regimen. With high levels of macrolide resistance, increasing fluoroquinolone resistance, and the high cost of moxifloxacin, access to nonquinolone options such as minocycline is increasingly important for the clinical management of M genitalium.

gyrA Mutations in Mycoplasma genitalium and Their Contribution to Moxifloxacin Failure: Time for the Next Generation of Resistance-Guided Therapy

BACKGROUND

Although single nucleotide polymorphisms (SNPs) in Mycoplasma genitalium parC contribute to fluoroquinolone treatment failure, data are limited for the homologous gene, gyrA. This study investigated the prevalence of gyrA SNPs and their contribution to fluoroquinolone failure.

METHODS

Samples from 411 patients (male and female) undergoing treatment for M. genitalium infection (Melbourne Sexual Health Centre, March 2019-February 2020) were analyzed by Sanger sequencing (gyrA and parC). For patients treated with moxifloxacin (n = 194), the association between SNPs and microbiologic treatment outcome was analyzed.

RESULTS

The most common parC SNP was G248T/S83I (21.1% of samples), followed by D87N (2.3%). The most common gyrA SNP was G285A/M95I (7.1%). Dual parC/gyrA SNPs were found in 8.6% of cases. One third of infections harboring parC G248T/S83I SNP had a concurrent SNP in gyrA conferring M95I. SNPs in gyrA cooccurred with parC S83I variations. Treatment failure was higher in patients with parC S83I/gyrA dual SNPs when compared with infections with single S83I SNP alone from analysis of (1) 194 cases in this study (81.2% vs 45.8%, P = .047), and (2) pooled analysis of a larger population of 535 cases (80.6% vs 43.2%; P = .0027), indicating a strong additive effect.

CONCLUSIONS

Compared with parC S83I SNP alone, M. genitalium infections with dual mutations affecting parC/gyrA had twice the likelihood of failing moxifloxacin. Although antimicrobial resistance varies by region globally, these data indicate that gyrA should be considered as a target for future resistance assays in Australasia. We propose a strategy for the next generation of resistance-guided therapy incorporating parC and gyrA testing.

Update in Epidemiology and Management of Mycoplasma genitalium Infections

Mycoplasma genitalium is a frequent cause of urogenital syndromes in men and women and is associated with adverse sequelae in women. M genitalium also infects the rectum, and may cause proctitis, but rarely infects the pharynx. Diagnosis requires nucleic acid amplification testing. Antibiotic resistance is widespread: more than half of infections are resistant to macrolides and fluoroquinolone resistance is increasing. Resistance-guided therapy is recommended for symptomatic patients, involving initial treatment with doxycycline to reduce organism load followed by azithromycin for macrolide-sensitive infections or moxifloxacin for macrolide-resistant infections. Neither screening nor tests of cure are recommended in asymptomatic persons.

A case of pneumococcal pneumonia and pelvic-peritonitis in a menstrual endovaginal cup user, which came first?

INTRODUCTION

Streptococcus pneumoniae infrequently causes genital tract infections but - in particular predisposing circumstances - it can be a transient part of vaginal flora and thus pelvic infections can occur. Possible conditions associated with pneumococcal pelvic-peritonitis include the use of intrauterine contraceptive devices, recent birth and gynecologic surgery. The underlying mechanism of these occurrences is likely to be the ascending infection from the genital tract via the fallopian tubes.

CASE PRESENTATION

We present a case of pelvic-peritonitis and pneumonia due to Streptococcus pneumoniae in a healthy young woman wearing a menstrual endovaginal cup. Following the radiological findings of a cystic formation in the right ovary and ascites effusions in all peritoneal recesses an emergency exploratory laparoscopy with right ovariectomy was performed. After resolution of abdominal sepsis, parenchymal consolidation complicated into necrotizing pneumonia, hence the patient underwent a right lower lobectomy.

DISCUSSION

The menstrual cup is a self-retaining intravaginal menstrual fluid collection device, considered as a safe alternative to tampons and pads, which use is associated with rare adverse effects. Few cases of infectious disease have been described, where the underlying mechanism may consist of bacterial replication within the blood accumulated in the uterine environment, with subsequent ascension into the genital tract.

CONCLUSION

In the rare occurrence of pneumococcal pelvic-peritonitis considering all possible infectious sources is paramount, as is assessing the possible involvement of intravaginal devices, increasingly used nowadays but of which potential complications are still poorly described.

Characterization of Virulence-Associated Traits in Mycoplasma penetrans Strains Acting as Likely Etiological Agents of Idiopathic Nongonococcal Urethritis

Mycoplasma penetrans is an emerging pathogen with a reduced genome. This bacterium has only previously been cultured from individuals with chronic immunodeficiencies. Here we report the characteristics of 4 M. penetrans isolates from the urine of immunocompetent males with nongonococcal urethritis, in comparison with strain HF-2 from an immunocompromised patient. Several features exhibited distinct differences between these isolates and HF-2. Unlike HF-2, all 4 were resistant to azithromycin. They exhibited greater sialic acid-dependent binding to erythrocytes, gliding motility speed, and H2O2 production than HF-2. All new isolates produced thinner capsules than HF-2. Invasiveness varied, with some isolates being more invasive than HF-2 and some less invasive. Cytotoxicity to HeLa cells was similar to HF-2, and all strains could clear extracellular traps produced by innate immune cells. We conclude that subtle differences among M. penetrans strains may be critical for this organism to establish an infection in an otherwise healthy individual.

In Vitro Susceptibility and Resistance of Mycoplasma genitalium to Nitroimidazoles

Mycoplasma genitalium is a sexually transmitted reproductive tract pathogen of men and women. M. genitalium infections are increasingly difficult to treat due to poor efficacy of doxycycline and acquired resistance to azithromycin and moxifloxacin. A recent clinical trial suggested that metronidazole may improve cure rates for women with pelvic inflammatory disease and reduced the detection of M. genitalium when included with standard doxycycline plus ceftriaxone treatment. As data regarding susceptibility of mycoplasmas to nitroimidazoles are lacking in the scientific literature, we determined the in vitro susceptibility of 10 M. genitalium strains to metronidazole, secnidazole, and tinidazole. MICs ranged from 1.6 to 12.5 μg/mL for metronidazole, 3.1 to 12.5 μg/mL for secnidazole, and 0.8 to 6.3 μg/mL for tinidazole. None of these agents was synergistic with doxycycline in checkerboard broth microdilution assays. Tinidazole was superior to metronidazole and secnidazole in terms of MIC and time-kill kinetics and was bactericidal (>99.9% killing) at concentrations below reported serum concentrations. Mutations associated with nitroimidazole resistance were identified by whole-genome sequencing of spontaneous resistant mutants, suggesting a mechanism for reductive activation of the nitroimidazole prodrug by a predicted NAD(P)H-dependent flavin mononucleotide (FMN) oxidoreductase. The presence of oxygen did not affect MICs of wild-type M. genitalium, but a nitroimidazole-resistant mutant was defective for growth under anaerobic conditions, suggesting that resistant mutants may have a fitness disadvantage in anaerobic genital sites. Clinical studies are needed to determine if nitroimidazoles, especially tinidazole, are effective for eradicating M. genitalium infections in men and women.

Mycoplasma genitalium antibiotic resistance-associated mutations in genital and extragenital samples from men-who-have-sex-with-men attending a STI clinic in Verona, Italy

Background

Mycoplasma genitalium (MG) is one of the most warning emerging sexually transmitted pathogens also due to its ability in developing resistance to antibiotics. MG causes different conditions ranging from asymptomatic infections to acute mucous inflammation. Resistance-guided therapy has demonstrated the best cure rates and macrolide resistance testing is recommended in many international guidelines. However, diagnostic and resistance testing can only be based on molecular methods, and the gap between genotypic resistance and microbiological clearance has not been fully evaluated yet. This study aims at finding mutations associated with MG antibiotic resistance and investigating the relationship with microbiological clearance amongst MSM.

Methods

From 2017 to 2021, genital (urine) and extragenital (pharyngeal and anorectal swabs) biological specimens were provided by men-who-have-sex-with-men (MSM) attending the STI clinic of the Infectious Disease Unit at the Verona University Hospital, Verona, Italy. A total of 1040 MSM were evaluated and 107 samples from 96 subjects resulted positive for MG. Among the MG-positive samples, all those available for further analysis (n=47) were considered for detection of mutations known to be associated with macrolide and quinolone resistance. 23S rRNA, gyrA and parC genes were analyzed by Sanger sequencing and Allplex™ MG and AziR Assay (Seegene).

Results

A total of 96/1040 (9.2%) subjects tested positive for MG in at least one anatomical site. MG was detected in 107 specimens: 33 urine samples, 72 rectal swabs and 2 pharyngeal swabs. Among them, 47 samples from 42 MSM were available for investigating the presence of mutations associated with macrolide and quinolone resistance: 30/47 (63.8%) showed mutations in 23S rRNA while 10/47 (21.3%) in parC or gyrA genes. All patients with positive Test of Cure (ToC) after first-line treatment with azithromycin (n=15) were infected with 23S rRNA-mutated MG strains. All patients undergoing second-line moxifloxacin treatment (n=13) resulted negative at ToC, even those carrying MG strains with mutations in parC gene (n=6).

Conclusion

Our observations confirm that mutations in 23S rRNA gene are associated with azithromycin treatment failure and that mutations in parC gene alone are not always associated with phenotypic resistance to moxifloxacin. This reinforces the importance of macrolide resistance testing to guide the treatment and reduce antibiotic pressure on MG strains.

Latest Advances in Laboratory Detection of Mycoplasma genitalium

Mycoplasma genitalium is an important sexually transmitted pathogen affecting both men and women. Its extremely slow growth in vitro and very demanding culture requirements necessitate the use of molecular-based diagnostic tests for its detection in clinical specimens. The recent availability of U.S. Food and Drug Administration (FDA)-cleared commercial molecular-based assays has enabled diagnostic testing to become more widely available in the United States and no longer limited to specialized reference laboratories. Advances in the knowledge of the epidemiology and clinical significance of M. genitalium as a human pathogen made possible by the availability of molecular-based testing have led to updated guidelines for diagnostic testing and treatment that have been published in various countries. This review summarizes the importance of M. genitalium as an agent of human disease, explains the necessity of obtaining a microbiological diagnosis, describes currently available diagnostic methods, and discusses how the emergence of antimicrobial resistance has complicated treatment alternatives and influenced the development of diagnostic tests for resistance detection, with an emphasis on developments over the past few years.

Advances in Diagnostics of Sexually Transmitted Infections

Sexually transmitted infections (STIs) are caused by various pathogens, many of which have common symptoms. Diagnostic tests are critical to supporting clinical evaluations in making patient management decisions. Molecular diagnostics are the preferred test type when available, especially in asymptomatic patients for many STIs. However, for some infections, serology offers the best insight into infectious status. Clinicians should be aware of the performance characteristics of the available STI diagnostic tests and understand how to use them. Point-of-care tests are helpful to implement rapid and accurate treatment responses, which are particularly helpful in certain at-risk populations.

The association between genital mycoplasma infection and spontaneous abortion: A systematic review and meta-analysis

Epidemiological findings on the association between genital mycoplasma infection (GMI) and spontaneous abortion are inconsistent. Therefore, this meta-analysis aims to determine whether mycoplasma infection during pregnancy increases the risk of spontaneous abortion. An electronic database search was conducted using China National Knowledge Infrastructure, Elsevier, PubMed, SinoMed, The Cochrane Library, and Wanfang Database from database establishment to October 2021. Sixteen case-controls and 3 prospective cohorts were included. The meta-analysis showed that GMI was positively associated with spontaneous abortion (odds ratio (OR) 2.35, 95% confidence interval (CI) 1.50, 3.67). Of them, case-control studies showed that the GMI proportion in the spontaneous abortion group was higher than that in the normal group (OR 2.13, 95% CI 1.33, 3.43); the cohort study showed that the spontaneous abortion rate in the GMI group was higher than those in non-infected groups (relative risk 5.17, 95% CI 2.07, 12.95; risk difference 0.18, 95% CI 0.09, 0.27). Each outcome indicator was relatively robust in the sensitivity analysis, and no significant publication bias was found in the funnel plots. Our data support that GMI during pregnancy increases the risk of spontaneous abortion. Thus, the monitoring and timely treatment of GMI before pregnancy of GMI are essential to decrease the risk of spontaneous abortion.

Knowledge on ethnogynaecology of Indian Tribes- a comprehensive review

ETHNOPHARMACOLOGICAL RELEVANCE

Ethnogynaecology is an emerging branch of science dealing with the treatment of gynaecological ailments by tribals, local healers, and traditional practitioners. The ethnogynaecological importance of medicinal plants in India is a fertile area to conduct more scientific studies to evaluate their potentialities, to isolate bioactive compounds, and thereby to develop drugs for the common gynaecological health-related issues faced by women everywhere.

OBJECTIVES

The Indigenous medical knowledge systems of India have not been properly documented with special reference to ethnogynaecology. This review aims to document the knowledge of ethnogynaecology among tribals, villagers, and local people inhabiting different parts of India and the bioactive compounds responsible for the action. This review provides a vast record of medicinal plants and their parts used, types of formulations, dosage, and ethno-gynaecological usage.

MATERIALS AND METHODS

The detailed investigation of ethnobotanical and ethnogynaecological-related literature published between 1985 and 2021 by different scientific tools such as journals, books, and current electronic databases like Springer Link, SciFinder, Google Scholar, Web of Science, Wiley, ACS, Science Direct and Pubmed have been considered for the present study. The study included 300 articles published between 1985 and 2021 by scientific search using various standard databases. The tribals, vaidyas, traditional practitioners, indigenous medical healers, and local people of different regions in India have recognized the importance of ethnogynaecological uses of plants. The study on ethnogynaecology is limited to a few common but significant gynaecological issues including abortion, contraception, infertility, menstruation, leucorrhoea, and obstetrics. The phytocompound compounds isolated from various parts of the plants and responsibility for the gynaecological action were documented.

RESULTS

The major ethnogynaecological disorders recorded by various studies are leucorrhoea, abortion, contraceptives, infertility and related issues, and obstetrics including the irregular physiological process of menstruation. The ethnogynaecological and ethnobotanical information has been recorded from almost all the states of India; the highest number of records on ethnogynaecology was reported from the state of Madhya Pradesh. The most explored tribal populations to record ethnogynaecological knowledge belong to the following tribes: Bhil, Munda, Irula, Kani, Malayali, Meena, Paliyar, Muthuvar, Oraon, Narikuravar, Mannan, Malayarayan, and Malapandaram. Moreover, limited or no study has been attempted to prove the knowledge of ethnogynaecology of these tribes and the efficiency of their crude drugs against pharmacological actions. The paste prepared from various parts of the plants has been used widely as primary health care materials for abortion, obstetrics, menstruation, female infertility and male infertility. Phenols, glucoside, steroids and fatty acids reported with cytotoxic activities are connected to several gynaecological disorders whereas flavonoid, coumarin, sitosterol disrupt pregnancy. The phenolic compounds induced spontaneous abortion due to the major composition aristolochic acid, ceryl alcohol, β-sitosterol. Coreopsin, butin, isobutrin, monospermoside, palastrin, butrin. Mucunine, lecithin, prurieninine, gluthione and luteolin, Indicine, kaempferol, apigenin and quercetin effected therapeutic activity against leucorrhoea. Lignin, friedelin and beta-sitosterol are reported with abortifacient properties and therapeutic ability for leucorrhoea and menorrhagia. Tannins, mimusopsic acids, taraxerol and spinaserol effected fertility problems in women and tannins, saponins, flavonoids, steroids, terpenoids and alkaloids which effected infertility.

CONCLUSION

This review reported comprehensive data on ethnogynaecological knowledge published from available literature and evident that the indigenous medical system of Indian tribes has also contributed considerably to the healthcare system and drug development of India. The fresh plant parts were identified as effective materials against various gynaecological illnesses including infertility. The root is considered an excellent plant part against obstetrics followed by abortion, menstruation, and leucorrhoea. These studies need experimental proof as well as standardization to confirm their efficiency. Promoting the sustainable use and the equitable sharing of benefits to the knowledge provider is a pathway for harnessing the conservation of this knowledge.

Management of Pelvic Inflammatory Disease in Clinical Practice

Pelvic inflammatory disease (PID) is a common reproductive health disorder among women of reproductive age. The treatment of PID has slowly evolved, reflecting changing antibiotic susceptibility and advancements in therapeutics and research; however, it has been largely unchanged over the last several decades. The most recent treatment recommendations consider the severity of infection, clinical presentation, and the polymicrobial nature of the disease. In addition, the role of novel organisms like Mycoplasma genitalium in PID is of emerging significance. PID treatment guidance offers oral and parenteral treatment options based on the patient's clinical status; however, deviations from the published guidelines are a general concern. Point of care (POC) testing for precision care, provision of adherence support, optimizing self-management and prevention strategies, and other alternative or synergistic approaches that maximize treatment outcomes will be instrumental for addressing the current challenges in PID diagnosis and management.

Distribution of Macrolide Resistant Mycoplasma genitalium in Urogenital Tract Specimens From Women Enrolled in a US Clinical Study Cohort

BACKGROUND

This study evaluated the distribution of macrolide-resistant Mycoplasma genitalium in multiple urogenital specimens collected from women enrolled in a prospective multicenter US clinical study.

METHODS

Four female urogenital specimens (vaginal swab, urine, endocervical swab, ectocervical brush/spatula) collected from each subject were tested using a transcription-mediated amplification (TMA) assay for M. genitalium. TMA-positive specimens were evaluated by reverse transcription-polymerase chain reaction and bidirectional Sanger sequencing of M. genitalium 23S rRNA to identify the presence of macrolide-resistance-mediating mutations (MRMs) at base positions 2058/2059.

RESULTS

Of 140 women with ≥1 TMA-positive specimens, 128 (91.4%) yielded M. genitalium 23S rRNA sequence. MRMs were found in 52% of vaginal specimens, 46.3% of urine specimens, 37.8% of endocervical specimens, and 46% of ectocervical specimens. There were 44 unique specimen type/sequence phenotype combinations of M. genitalium infection. Most (81; 63.3%) women had single specimen-sequence phenotype (macrolide-susceptible, MRM, or both) infections, while 24 (18.8%) women had multiple specimen-sequence phenotype concordant infections, and 23 (17.9%) women had multiple specimen-sequence phenotype discordant infections. The sensitivity for any single specimen type to detect overall urogenital tract macrolide-resistant M. genitalium infection status was 96.3% for vaginal swab samples, 82.6% for urine samples, 70.8% for endocervical swab samples, and 82.1% for ectocervical brush/spatula liquid Pap samples.

CONCLUSIONS

The distribution of M. genitalium infections in female urogenital tract specimens is highly complex, with multiple phenotypic combinations of the organism infecting a significant proportion of women at different anatomic specimen collection sites. Vaginal swab sampling yielded the highest sensitivity for identifying women with macrolide-resistant M. genitalium urogenital tract infections.