Mycoplasma genitalium: prevalence and behavioural risk factors in the general population

Prevalence and associated risk factors of Mycoplasma genitalium infection in women in Western Cameroon: A cross sectional study

Background Mycoplasma genitalium is implicated in genitourinary disorders in both men and women as a sexually transmitted infection (STI). This study aimed to ascertain the prevalence of M. genitalium and identify associated risk factors among women. Aim To investigate the prevalence of M. genitalium and identify various risk-factors associated with M. genitalium infection in women attending the clinic in Western Cameroon. Methods A cross-sectional study was conducted in hospitals from five districts of Western Cameroon on sexually active and non-menstruating women attending for antenatal, prenuptial and contraception consultations,between January 2020 and July 2020. Endocervical swabs (n = 680) were collected, and M. genitalium was detected using real-time PCR targeting the MgPa and pdhD genes. Results A total of 680 women, characterised by a mean age of 27.4 ± 7.5 years, were included in this study. The overall prevalence of the M. genitalium infection was 5.2%. Bivariate analysis revealed that having more than one sexual partner was independently associated with three times higher odds of prevalent M. genitalium infection (OR 2.9, 95% CI: 1.03-8.56). Limitation Cross-sectional design limits exploring temporal relationships with other STIs. Freezing specimens for a year until PCR testing may have compromised detection rates of M. genitalium. Conclusion This study contributes valuable data to the limited understanding of M. genitalium epidemiology. The findings may aid in the formulation of national clinical standards for testing and screening strategies, emphasising the importance of addressing associated risk factors in the targeted population.

High cure rates of Mycoplasma genitalium following empiric treatment with azithromycin alongside frequent detection of macrolide resistance in Austria

BACKGROUND

Mycoplasma genitalium (MG) is an emerging sexually transmitted infection, often harboring resistance-associated mutations to azithromycin (AZM). Global surveillance has been mandated to tackle the burden caused by MG, yet no data are available for Austria. Thus, we aimed to investigate the prevalence of MG, disease characteristics, and treatment outcomes at the largest Austrian HIV-and STI clinic.

METHODS

All MG test results at the Medical University of Vienna from 02/2019 to 03/2022 were evaluated. Azithromycin resistance testing was implemented in 03/2021.

RESULTS

Among 2671 MG tests, 199 distinct and mostly asymptomatic (68%; 135/199) MG infections were identified, affecting 10% (178/1775) of all individuals. This study included 83% (1479/1775) men, 53% (940/1775) men who have sex with men (MSM), 31% (540/1754) HIV+, and 15% (267/1775) who were using HIV pre-exposure prophylaxis (PrEP). In logistic regression analysis, 'MSM' (aOR 2.55 (95% CI 1.65-3.92)), 'use of PrEP' (aOR 2.29 (95% CI 1.58-3.32)), and 'history of syphilis' (aOR 1.57 (95% CI 1.01-2.24) were independent predictors for MG infections. Eighty-nine percent (178/199) received treatment: 11% (21/178) doxycycline (2 weeks), 52% (92/178) AZM (5 days), and 37% ( 65/178) moxifloxacin (7-10 days) and 60% (106/178) had follow-up data available showing negative tests in 63% (5/8), 76% (44/58) and 85% (34/40), respectively. AZM resistance analysis was available for 57% (114/199)) and detected in 68% (78/114). Resistance-guided therapy achieved a cure in 87% (53/61), yet, empiric AZM-treatment (prior to 03/2021) cleared 68% (26/38).

CONCLUSIONS

Mycoplasma genitalium was readily detected in this Austrian observational study, affected predominantly MSM and often presented as asymptomatic disease. We observed a worryingly high prevalence of AZM resistance mutations; however, empiric AZM treatment cleared twice as many MG infections as expected.

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 infection among gay, bisexual and other men who have sex with men in Montréal, Canada

Background

The bacteria Mycoplasma genitalium has been identified as a causative agent of urethritis in men, especially in gay, bisexual and other men who have sex with men (gbMSM). Canadian clinic-based data have identified a high prevalence of M. genitalium and resistance to antibiotic treatments. This article estimates the prevalence of M. genitalium infections among Montréal gbMSM, explores correlates for M. genitalium infection and estimates the prevalence of mutations associated with antimicrobial resistance (AMR).

Methods

Engage Cohort Study is a multi-site longitudinal study on sexually active gbMSM, aged 16 years and older, recruited via respondent-driven sampling in Montréal, Toronto and Vancouver. Participants completed a questionnaire on behaviour and were tested for sexually transmitted and blood-borne infections at each visit. For this sub-study, Montréal participants with a follow-up visit that occurred between November 2018 and November 2019 were included.

Results

A total of 2,064 samples were provided by 716 participants. Prevalence of M. genitalium infection was 5.7% at rectal and/or urethral sites, 4.0% at rectal site and 2.2% at urethral site. Correlates for M. genitalium infection were younger age and reporting six or more sexual partners in the past six months. Prevalence of macrolide resistance associated mutations (MRAM), quinolone resistance associated mutations (QRAM) and either MRAM or QRAM, was 82%, 29% and 85%, respectively.

Conclusion

This first population-based study among gbMSM in Canada documents a high prevalence of urethral and rectal M. genitalium infection and high levels of AMR. Our results highlight the importance of access to testing and AMR detection when indicated.

[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.

Viruses, bacteria and parasites: infection of the male genital tract and fertility

BACKGROUND

Infertility affects one couple out of six worldwide. Male infertilty can result from congenital or acquired factors, of which pathogens that reach the genital tract through sexual contact or blood dissemination. The impact of major viral, bacterial and parasitic infections on the male genital tract and fertility has been summarized.

RESULTS AND CONCLUSIONS

A systematic review of articles published in the Google Scholar and PubMed databases was conducted. It turns out that viruses, as well as bacteria and parasites are major inducers of male genital tract infections and ensuing infertility through damage to the organs and subsequent loss of function and/or through direct damage to the sperm cells. Moreover, not only male infertility results from such infections but these can also be transmitted to women and even to the offspring, thus highlighting the need to efficiently detect, treat and prevent them.

Emerging multidrug resistance contributes to treatment failure in Mycoplasma genitalium infected patients in China

The increased treatment failure in patients with sexually transmitted Mycoplasma genitalium infection is associated with antimicrobial resistance. We performed a retrospective survey of antimicrobial clinical outcomes in M. genitalium-infected patients. In addition, we detected macrolide, fluoroquinolone and tetracycline resistance-associated markers to determine their role in treatment failure. The overall incidence of treatment failure was 28.29%, regardless of the drug used. In the present study, the prevalence of macrolide resistance-associated mutations in the 23S rRNA gene was 64%; that of fluroquinolone resistance-associated S83/D87 substitutions in the parC gene was 67.5%; and that of the tetracycline resistance-associated C1192T mutation in the 16S rRNA gene was 22.5%. Furthermore, evidence of dual antimicrobial resistance was found in 46.4% of pretreatment samples, and triple antimicrobial resistance was identified in 9.9%. These findings regarding the emergence of multidrug-resistant strains of M. genitalium in China are concerning and emphasize the importance of guiding M. genitalium treatment with antimicrobial resistance assays.

Prevalence of selected sexually transmitted infectious agents in a cohort of asymptomatic soldiers in Austria

BACKGROUND

According to the World Health Organization (WHO), more than one million sexually transmitted infections (STIs) are acquired every day worldwide. Although STIs may be asymptomatic in many cases, they can cause severe symptoms and can also lead to adverse pregnancy outcomes and both male and female infertility. Asymptomatic carriers seem to play an important role in terms of the distribution of STIs; however, studies revealing the prevalence of STIs in asymptomatic individuals are rare.

METHODS

In the current study, 654 leftovers of standard urine samples from healthy, asymptomatic Austrian soldiers were investigated for the prevalence of Trichomonas vaginalis, Chlamydia trachomatis, and genital mycoplasmas (Mycoplasma hominis, Mycoplasma genitalium, Ureaplasma urealyticum, Ureaplasma parvum, and Candidatus Mycoplasma girerdii) by specific PCRs.

RESULTS

We detected T. vaginalis, M. hominis, U. urealyticum, U. parvum, and C. trachomatis in the investigated samples with prevalence of 7.6%, 4%, 2.4%, 5.4%, and 3.2%, respectively; neither M. genitalium nor Ca. Mycoplasma girerdii was found in our sample collection.

CONCLUSIONS

Our study introduces data on STIs of a mainly male cohort, which are scarce because most of the available information on sexually transmitted infectious agents arises from fertility clinics (mainly women) or symptomatic patients.

2021 European guideline on the management of Mycoplasma genitalium infections

Mycoplasma genitalium infection contributes to 10-35% of non-chlamydial non-gonococcal urethritis in men. In women, M. genitalium is associated with cervicitis and pelvic inflammatory disease (PID) in 10-25%. Transmission of M. genitalium occurs through direct mucosal contact.

CLINICAL FEATURES AND DIAGNOSTIC TESTS

Asymptomatic infections are frequent. In men, urethritis, dysuria and discharge predominate. In women, symptoms include vaginal discharge, dysuria or symptoms of PID - abdominal pain and dyspareunia. Symptoms are the main indication for diagnostic testing. Diagnosis is achievable only through nucleic acid amplification testing and must include investigation for macrolide resistance mutations.

THERAPY

Therapy for M .genitalium is indicated if M. genitalium is detected. Doxycycline has a cure rate of 30-40%, but resistance is not increasing. Azithromycin has a cure rate of 85-95% in macrolide-susceptible infections. An extended course of azithromycin appears to have a higher cure rate, and pre-treatment with doxycycline may decrease organism load and the risk of macrolide resistance selection. Moxifloxacin can be used as second-line therapy but resistance is increasing.

RECOMMENDED TREATMENT

Uncomplicated M. genitalium infection without macrolide resistance mutations or resistance testing: Azithromycin 500 mg on day one, then 250 mg on days 2-5 (oral). Second-line treatment and treatment for uncomplicated macrolide-resistant M. genitalium infection: Moxifloxacin 400 mg od for 7 days (oral). Third-line treatment for persistent M. genitalium infection after azithromycin and moxifloxacin: Doxycycline or minocycline 100 mg bid for 14 days (oral) may cure 40-70%. Pristinamycin 1 g qid for 10 days (oral) has a cure rate of around 75%. Complicated M. genitalium infection (PID, epididymitis): Moxifloxacin 400 mg od for 14 days. MAIN CHANGES FROM THE 2016 EUROPEAN M.

GENITALIUM GUIDELINE

Due to increasing antimicrobial resistance and warnings against moxifloxacin use, indications for testing and treatment have been narrowed to primarily involve symptomatic patients. The importance of macrolide resistance-guided therapy is emphasised.

Occurrence of urogenital mycoplasmas in men with the common genitourinary diseases

Many serious and fatal infections with urogenital mycoplasmas in immunocompromised patients have been reported. M. genitalium is recognized as a cause of male urethritis and other common genitourinary diseases. The aim of the study was to estimate prevalence of urogenital mycoplasmas which can cause complications in men with common genitourinary diseases. Study included 85 men with genitourinary tract carcinoma (n = 35), urolithiasis (n = 36), and BPH (benign prostatic hyperplasia) (n = 14). The control group consisted of 50 healthy men. FVU (first void urine) samples were examined by PCR for the presence of urogenital mycoplasmas DNA. Occurrence of urogenital mycoplasmas was significantly more common in study group compared with control 24/85 (28.2%) and 7/50 (14%), respectively (p = 0.05). In men with urolithiasis, positive results for mycoplasmas DNA were significantly more frequent than in control: 33.3% vs. 14% (p < 0.05). In patients with urolithiasis DNA of U. urealyticum was most often found, while in the genitourinary carcinoma and BPH groups, U. parvum was more frequent. Incidence of M. fermentans was also significantly higher in the urolithiasis group vs. control (p = 0.03). A higher percentage of positive results for urogenital mycoplasma DNA in study group has been found. Further studies are required to confirm the role of urogenital mycoplasmas in the development of infectious complications among patients with urolithiasis, genitourinary carcinoma, and BPH.

Association of Chlamydia and Mycoplasma infections with susceptibility to ovarian cancer: A systematic review and meta-analysis

BACKGROUND

Ovarian cancer is one of the most prevalent cancers with a high mortality rate in women. Published studies indicate that inflammation, DNA damage, and pelvic inflammatory disease (PID) are the most important risk factors for ovarian cancer and this could be induced and exacerbated by infectious agents such as Chlamydia trachomatis and Mycoplasma genitalium. The aim of this study was to determine the association between Chlamydia and Mycoplasma infections and the risk of ovarian cancer.

METHODS

We carried out a comprehensive search of PubMed, Scopus, Web of Science, Embase, and Google Scholar without limitation on publication date. All relevant studies which investigatived probable potential connection between Chlamydia and Mycoplasma infection and development of ovarian cancer were included.

RESULTS

Eighteen studies comprising a total of 8207 patients were evaluated in the study and this showed that the frequency of infection with Chlamydia and Mycoplasma among ovarian cancer patients was 32.6 % and 23 %, respectively. The results suggested that Chlamydia trachomatis infection increased the overall risk for ovarian cancer by 1.344 fold (OR: 1.344; 95 %CI: 1.19-1.50). Moreover, infection with Mycoplasma infections showed a week but not significant increased risk of ovarian cancer (OR: 1.12; 95 %CI: 0.86-1.44). However, the test for heterogeneity was significant among these studies.

CONCLUSION

This study confirmed the clinical relevance of Chlamydia and Mycoplasma infection and development of the ovarian cancer risk, although the significance was marginal and study heterogeneity was significant. This highlights the need for further studies in this area.

Mycoplasma genitalium infection in women reporting dysuria: A pilot study and review of the literature

Mycoplasma genitalium (MG) infection, a sexually transmitted infection (STI), causes cervicitis and may cause reproductive sequelae and adverse pregnancy outcomes. Some MG-infected women report dysuria, a symptom frequently attributed to urinary tract infection (UTI). Given potential MG-associated morbidity and the likelihood that UTI treatment would be ineffective in eradicating MG, an improved understanding of MG infection frequency and clinical significance in young women reporting dysuria is needed. We conducted MG testing on stored urogenital specimens collected in a pilot study on frequency of STIs in young women presenting to an emergency department for dysuria evaluation and performed a literature review on MG infection frequency in women reporting dysuria. Among 25 women presenting for dysuria evaluation in our pilot study, 6 (24.0%) had MG detected and one-third had co-infection with chlamydia and one-third with trichomoniasis; half with MG detected did not receive an antibiotic with known efficacy against MG, while the other half received azithromycin. In five studies identified in the literature review, dysuria was reported by 7%-19% of women and MG detected in 5%-22%. MG infection is common in young women with dysuria and empiric UTI treatment may not be effective against MG. Studies evaluating the clinical significance of MG infection in women reporting dysuria are needed.

Rectal Mycoplasma genitalium in Patients Attending Sexually Transmitted Disease Clinics in China: An Infection That Cannot Be Ignored

Background

Previous studies have investigated rectal Mycoplasma genitalium (MG) in men who have sex with men (MSM), while little is known about the prevalence of rectal MG infection in individuals attending sexually transmitted disease (STD) clinics in China. We aimed to estimate the prevalence of rectal MG infection in this population and identified the potential risk factors for rectal MG infection.

Methods

A cross-sectional study was conducted among individuals attending STD clinics located in China from June 2018 to August 2020. Univariate and multivariate logistic regression analyses were conducted to explore the association of different risk factors for rectal MG infection.

Results

A total of 1,382 patients were included in the final analyses. A total of 30 of 1377 rectal swabs (2.2%) and 77 of 1374 urogenital samples (5.6%) were positive for MG. In Guangxi, 18 of 47 patients (38.3%) infected with urogenital MG and 5 of 19 patients (26.3%) infected with rectal MG received the recommended treatment. Factors found to be significantly associated with rectal MG infection included: male (adjusted odds ratio (AOR) 0.232, [95% CI: 0.072–0.745]) compared to female, homosexual or bisexual (AOR 40.427, [95% CI: 3.880–421.196]) compared to heterosexual, and those infected with urogenital MG (AOR 7.215, [95% CI: 2.898–17.965]) compared to those who did not get infected with urogenital MG.

Conclusion

Rectal MG infection should be thought of not only in MSM population but also in STD clinic patients, especially females who have urogenital MG infection. Appropriate strategy for rectal MG screening and treatment needs to be developed for these patients in China.

Prevalence and risk factors of Mycoplasma genitalium infection in patients attending a sexually transmitted infection clinic in Reunion Island: a cross-sectional study (2017-2018)

Background

Mycoplasma genitalium (MG) is an emerging sexually transmitted infection (STI) for whose management remains controversial. We aimed to assess the prevalence and risk factors of MG infection in patients attending an STI clinic in Reunion Island.

Methods

Between January 2017 and December 2018, all patients attending the Saint-Pierre STI clinic in Reunion Island were screened for MG, Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG). Urogenital, pharyngeal and/or anal samples were collected based on sexual behaviour and analysed by triplex PCR. Risk factors were identified using a Poisson regression for binary outcome.

Results

Among 2069 screened subjects, the overall prevalence of MG was 4.88% [95% Confidence Interval (CI) 3.98–5.93]. The prevalence of urogenital MG was 4.38%, with women being more affected than men (5.33% vs 3.22%, prevalence ratio (PR) 1.66, p = 0.02). The prevalence of anal MG was 3.06% and that of pharyngeal MG was 0.61%, with men being more affected in both cases. Infection with MG was independently associated with multiple partners (6–10 partners: adjusted prevalence ratio-aPR 2.55, p < 0.048; > 10 partners: aPR 4.33, p < 0.004), previous history of STI (aPR 1.89, p = 0.026), non-use of condoms (aPR 2.56, p < 0.003) and co-infection with CT (aPR 2.56, p < 0.017).

Conclusion

Compared to other countries, the prevalence of MG is high in Reunion Island, especially in women aged under 25 years, and co-infection with CT is common. Routine MG screening and treatment should be performed in at-risk women and co-infection with MG should be considered when deciding on treatment for CT, particularly in regions where azithromycin is still in use.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06193-6.

Lack of resistance to macrolides in Mycoplasma genitalium detected in South African pregnant women

BACKGROUND

Azithromycin regimens have been considered first-line treatment for Mycoplasma genitalium (M. genitalium), a sexually transmitted infection (STI) associated with adverse pregnancy outcomes. However, recent years have seen rapid emergence of macrolide resistance in M. genitalium as a result of widespread administration of azithromycin. Currently, there are limited data on macrolide resistance in pregnant women from KwaZulu-Natal (KZN), South Africa. This study investigated the prevalence of M. genitalium and emerging patterns of macrolide resistance in pregnant women from KZN.

METHODS

This was a sub-study of a larger study which involved laboratory-based detection of STIs in pregnant women. In the main study, pregnant women provided urine samples for detection of STIs. For this study, deoxyribose nucleic acid (DNA) extracted from stored urine was used to determine emerging macrolide resistance by amplification of the 23S ribosomal ribonucleic acid (rRNA) gene of M. genitalium by polymerase chain reaction (PCR) and sequencing of amplicons to identify mutations associated with resistance. The Allplex™ MG & AziR assay was used as a confirmatory assay.

RESULTS

The prevalence of M. genitalium in pregnant women was 5.9% (13 out of 221). Sequencing of PCR amplicons did not reveal the presence of the A2059G and A2058G mutations associated with macrolide resistance. These findings were confirmed by the Allplex™ MG & AziR assay.

CONCLUSION

Despite the lack of resistance to macrolides in this study population, continued antimicrobial resistance surveillance for M. genitalium in pregnant women is important because azithromycin is now part of the South African national STI syndromic management guidelines for vaginal discharge syndrome.

Macrolide and fluoroquinolone associated mutations in Mycoplasma genitalium in a retrospective study of male and female patients seeking care at a STI Clinic in Guangzhou, China, 2016-2018

Background

Antimicrobial resistance in M. genitalium is a growing clinical problem. We investigated the mutations associated with macrolide and fluoroquinolone resistance, two commonly used medical regimens for treatment in China. Our aim is to analyze the prevalence and diversity of mutations among M. genitalium-positive clinical specimens in Guangzhou, south China.

Methods

A total of 154 stored M. genitalium positive specimens from men and women attending a STI clinic were tested for macrolide and fluoroquinolone mutations. M. genitalium was detected via TaqMan MGB real-time PCR. Mutations associated with macrolide resistance were detected using primers targeting region V of the 23S rRNA gene. Fluoroquinolone resistant mutations were screened via primers targeting topoisomerase IV (parC) and DNA gyrase (gyrA).

Results

98.7% (152/154), 95.5% (147/154) and 90.3% (139/154) of M. genitalium positive samples produced sufficient amplicon for detecting resistance mutations in 23S rRNA, gyrA and parC genes, respectively. 66.4% (101/152), 0.7% (1/147) and 77.7% (108/139) samples manifested mutations in 23S rRNA, gyrA and parC genes, respectively. A2072G (59/101, 58.4%) and S83I (79/108, 73.1%) were highly predominating in 23S rRNA and parC genes, respectively. Two samples had amino acid substitutions in gyrA (M95I and A96T, respectively). Two samples had two amino acid substitutions in parC (S83I + D87Y). 48.6% (67/138) of samples harbored both macrolide and fluoroquinolone resistance-associated mutations. The most common combination of mutations was A2072G (23S rRNA) and S83I (parC) (40/67, 59.7%). One sample had three amino acid changes in 23S rRNA, gyrA and parC genes (A2072G + A96T + S83I).

Conclusions

The high antimicrobial resistance rate of M. genitalium in Guangzhou is a very worrying problem and suggests that antimicrobial resistance testing and the development of new antibiotic regimens are crucially needed.

Mycoplasma genitalium coinfection in men with symptomatic gonococcal urethritis

OBJECTIVES

International guidelines recommend Mycoplasma genitalium testing, preferably using an assay to detect macrolide resistance-associated mutations, for men presenting with non-gonococcal urethritis, but there is no specific guidance on such testing for men with gonococcal urethritis.

METHODS

This study aimed to estimate the proportion of men with gonococcal urethritis who have coinfection with M. genitalium through a retrospective analysis of cases of symptomatic urethral gonorrhoea at Western Sydney Sexual Health Centre in 2017 and 2018.

RESULTS

Fourteen of 184 (7.6%, 95% CI 3.7 to 11.5) men with gonococcal urethritis had M. genitalium detected in the urine at the time of presentation. No demographic or behavioural factors predicted M. genitalium coinfection. Coinfection with urethral Chlamydia trachomatis was detected in 29 of 184 (15.8%, 95% CI 10.5 to 21.1). All five men with macrolide-resistant M. genitalium detected returned for treatment with moxifloxacin at a median of 8 days (range 5-16 days) after presentation and treatment of gonorrhoea; three of five were documented to remain symptomatic at this visit.

CONCLUSION

Although M. genitalium coinfection is less common than chlamydia among men with symptomatic gonococcal urethritis, M. genitalium testing, using an assay to detect macrolide resistance, will potentially reduce symptom duration particularly for men with macrolide-resistant infections, but may not be justifiable on cost-benefit analysis.

Mycoplasma genitalium Infections in Women Attending a Sexually Transmitted Disease Clinic in New Orleans

BACKGROUND

Mycoplasma genitalium has been significantly and nonsignificantly associated with cervicitis, urethritis, or vaginal discharge. This study examined the associations of M. genitalium with selected sexually transmitted infections (STIs) and demographic, behavioral, and clinical factors among women attending a sexually transmitted disease (STD) clinic in New Orleans.

METHODS

Women aged ≥18 years who presented to the New Orleans STD clinic provided sociodemographic data and sexual behavior; STI, obstetric, and gynecologic history; and urine, vaginal, endocervical, and rectal specimens. Specimens were tested for M. genitalium, Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, Mycoplasma hominis, Ureaplasma species, and yeast. Bacterial vaginosis (BV) was diagnosed by Nugent score, and cervicitis was defined as ≥30 polymorphonuclear leukocytes per high-power microscopic field on a cervical Gram stain or yellow mucopus on an endocervical swab.

RESULTS

Among 400 women studied, M. genitalium was independently significantly associated with age <25 years (P < .03) and with ≥2 sexual partners in the last 12 months (P < .003). Neisseria gonorrhoeae (adjusted odds ratio [AOR], 1.75; P = .103), C. trachomatis (AOR, 1.43; P = .247), and T. vaginalis (AOR, 1.60; P = .120) independently increased the odds of infection with M. genitalium. Controlling for other STIs and BV, there was a positive trend for M. genitalium to predict cervicitis (AOR, 3.18 [95% confidence interval, .99-10.2]; P = .05).

CONCLUSIONS

Mycoplasma genitalium in our study displayed the clinical features of C. trachomatis and N. gonorrhoeae, the 2 organisms that drive research agendas in diagnosis, treatment, and prevention of bacterial STIs.

Epidemiology of genital infections caused by Mycoplasma hominis, M. genitalium and Ureaplasma urealyticum in Iran; a systematic review and meta-analysis study (2000-2019)

BACKGROUND

Although many species of mycoplasmas regard as normal flora, but some species causes serious genital disease. In Iran several epidemiological studies have documented the prevalence of Mycoplasma hominis, M. genitalium and Ureaplasma urealyticum in genital disorders. This meta-analysis is going to represent the prevalence of M. hominis, M. genitalium and U. urealyticum among Iranian couples and the correlation between mycoplasmas infection and infertility.

METHODS

We search online databases from January 2000 to June 2019. We used following MeSH keywords (Prevalence, M. hominis, M. genitalium, U. urealyticum, male, female, fertility, Infertility, genitourinary tract infection and Iran) with all possible combinations with "OR" and "AND". Finally, forty-four articles from 2670 were chosen for data extraction and analysis by software using STATA version 14.0.

RESULTS

This meta-analysis revealed that the prevalence of U. urealyticum was 17.53% in Iran and the prevalence of M. genitalium and M. hominis were 11.33 and 9.68% respectively. The rate of M. genitalium, M. hominis and U. urealyticum infection in women with symptoms of genitourinary tract infection was higher than men with genitourinary tract infection (6.46% vs 5.4, 7.67% vs 5.88 and 21.04% vs 12.13%, respectively). As expected, the prevalence of M. genitalium, U. urealyticum and M. hominis among infertile women (12.73, 19.58 and 10.81%) were higher than fertile women (3%, 10. 85% and 4. 35%). Similarly, the prevalence of M. hominis and U. urealyticum among infertile men (14 and 21.18%) were higher than fertile men (4 and 3%). Based on this analysis, the rate of U. urealyticum was higher than M. genitalium and M. hominis among infertile men and women compared to the fertile group. The prevalence rate of M. genitalium, M. hominis and U. urealyticum in central provinces is higher than other parts of Iran.

CONCLUSIONS

This meta-analysis reemphasizes a significant relationship between the infertility rate and U. urealyticum, M. genitalium and M. hominis infections. Our finding help to plan the prevalence map of M. hominis, M. genitalium and U. urealyticum in Iran but further studies are needed to suggest routine screening of the pathogens.

Mycoplasma genitalium Detection in Urogenital Specimens from Symptomatic and Asymptomatic Men and Women by Use of the cobas TV/MG Test

Mycoplasma genitalium (MG) infections are a growing concern within the field of sexually transmitted infections. However, diagnostic assays for M. genitalium have been limited in the United States. As most infections are asymptomatic, individuals can unknowingly pass the infection on, and the prevalence is likely to be underestimated. Diagnosis of M. genitalium infection is recommended using a nucleic acid test. This multicenter study assessed the performance of the cobas Trichomonas vaginalis (TV)/MG assay (cobas) for the detection of M. genitalium, using 22,150 urogenital specimens from both symptomatic and asymptomatic men and women collected at geographically diverse sites across the United States.

Mycoplasma genitalium (MG) infections are a growing concern within the field of sexually transmitted infections. However, diagnostic assays for M. genitalium have been limited in the United States. As most infections are asymptomatic, individuals can unknowingly pass the infection on, and the prevalence is likely to be underestimated. Diagnosis of M. genitalium infection is recommended using a nucleic acid test. This multicenter study assessed the performance of the cobas Trichomonas vaginalis (TV)/MG assay (cobas) for the detection of M. genitalium, using 22,150 urogenital specimens from both symptomatic and asymptomatic men and women collected at geographically diverse sites across the United States. The performance was compared to a reference standard of three laboratory-developed tests (LDTs). The specificity of the cobas assay for M. genitalium ranged from 96.0% to 99.8% across symptomatic and asymptomatic men and women. The sensitivities in female vaginal swabs and urine samples were 96.6% (95% confidence interval [CI], 88.5 to 99.1%) and 86.4% (95% CI, 75.5 to 93.0%), respectively. The sensitivities in male urine and meatal swab samples were 100% (95% CI, 94.0 to 100%) and 85.0% (95% CI, 73.9 to 91.9%), respectively. This study demonstrated that the cobas assay was highly sensitive and specific in all relevant clinical samples for the detection of M. genitalium.

Molecular basis of antimicrobial resistance in Mycoplasma genitalium

Mycoplasma genitalium is a sexually transmitted urogenital pathogen, and infection can result in serious symptoms. As M. genitalium is rather difficult to culture, infections are usually detected by molecular methods. Unfortunately, there has recently been a significant increase in resistance to azithromycin and moxifloxacin used for the treatment of M. genitalium infections. The increased resistance to (often empirically prescribed) M. genitalium treatments has resulted in frequent therapy failures and stresses the need for routine detection of antimicrobial resistance. In M. genitalium, antimicrobial resistance is almost always the result of DNA mutations and thus can easily be detected by molecular techniques. Regrettably, many microbiology laboratories do not use molecular techniques for the detection of bacterial antimicrobial resistance. As molecular tests are becoming available for M. genitalium, both for the establishment of infection and the detection of antimicrobial resistance, it is now more important to ensure that knowledge on the resistance mechanisms is transferred from the laboratory to the clinician. This review will provide a brief summary of the current status of antimicrobial resistance, its molecular mechanisms and the impact on the current status of M. genitalium treatment.

Prevalence and incidence of Mycoplasma genitalium in a cohort of HIV-infected and HIV-uninfected pregnant women in Cape Town, South Africa

OBJECTIVE

Mycoplasma genitalium (MG) is a sexually transmitted organism associated with cervicitis and pelvic inflammatory disease in women and has been shown to increase the risk of HIV acquisition and transmission. Little is known about the prevalence and incidence of MG in pregnant women. Our study sought to evaluate the prevalence and incidence of MG infection in HIV-infected and HIV-uninfected pregnant women.

METHODS

We conducted a cohort study of 197 women ≥18 years receiving antenatal care in South Africa from November 2017 to February 2019. We over-recruited HIV-infected pregnant women to compare MG by HIV infection status. Self-collected vaginal swabs, performed at the first antenatal visit, third trimester and within 1 week post partum, were tested for MG using the Aptima assay (Hologic, USA). We report on the prevalence and incidence of MG and used multivariable logistic regression to describe correlates of MG and adverse pregnancy and birth outcomes (preterm delivery, miscarriage and vertical HIV transmission), adjusting for maternal age and HIV infection status.

RESULTS

At first antenatal visit, the median age was 29 years (IQR=24-34) and the gestational age was 19 weeks (IQR=14-23); 47% of women enrolled in the study were HIV-infected. MG prevalence was 24% (95% CI 16% to 34%, n=22) in HIV-infected and 12% (95% CI 6.8% to 20%, n=13) in HIV-uninfected pregnant women. MG incidence during pregnancy and early post partum was 4.7 infections per 100 woman-years (95% CI 1.2 to 12.9) or 3.9 per 1000 woman-months (95% CI 1.0 to 10.7). Adjusting for maternal age, HIV-infected women had over three times the odds of being infected with MG (adjusted OR=3.09, 95% CI 1.36 to 7.06).

CONCLUSION

We found a high prevalence and incidence of MG in pregnant women. Younger maternal age and HIV infection were associated with MG infection in pregnancy. Further research into birth outcomes of women infected with MG, including vertical transmission of HIV infection, is needed.

Molecular Testing for Mycoplasma genitalium in the United States: Results from the AMES Prospective Multicenter Clinical Study

A prospective multicenter clinical study involving subjects from 21 sites across the United States was conducted to validate the performance of a new in vitro diagnostic nucleic acid amplification test (NAAT) for the detection of Mycoplasma genitalium.

A prospective multicenter clinical study involving subjects from 21 sites across the United States was conducted to validate the performance of a new in vitro diagnostic nucleic acid amplification test (NAAT) for the detection of Mycoplasma genitalium. Seven urogenital specimen types (n = 11,556) obtained from 1,778 females, aged 15 to 74 years, and 1,583 males, aged 16 to 82 years, were tested with the Aptima Mycoplasma genitalium assay, an investigational transcription-mediated amplification (TMA) NAAT for the detection of M. genitalium 16S rRNA. Infected status for enrolled subjects was established using results obtained from testing either self-collected vaginal swab or clinician-collected male urethral swab specimens with a composite reference method consisting of three transcription-mediated amplification NAATs targeting unique regions of M. genitalium 16S or 23S rRNA. M. genitalium prevalence was 10.2% in females and 10.6% in males; prevalence was high in both symptomatic and asymptomatic subjects for both sexes. Compared to the subject infected status standard, the investigational test had sensitivity and specificity estimates, respectively, of 98.9% and 98.5% for subject-collected vaginal swabs, 92.0% and 98.0% for clinician-collected vaginal swabs, 81.5% and 98.3% for endocervical swabs, 77.8% and 99.0% for female urine, and 98.2% and 99.6% for male urethral swabs, 88.4% and 97.8% for self-collected penile meatal swabs, and 90.9% and 99.4% for male urine specimens. For all seven specimen types, within-specimen positive and negative agreements between the investigational test and the composite reference standard ranged from 94.2% to 98.3% and from 98.5 to 99.9%, respectively. These results provide clinical efficacy evidence for the first FDA-cleared NAAT for M. genitalium detection in the United States.

Barriers to testing and management of Mycoplasma genitalium infections in primary care

Testing and treatment for Mycoplasma genitalium (MG) infections has recently been facilitated by the increasing availability of molecular tests, but the role of testing in community-based populations is not established. Between 15 May 2017 and 22 November 2017, we tested 561 samples from 547 individuals presenting to primary care in Auckland, New Zealand, requesting investigation for sexually transmitted infections, with concurrent sterile pyuria, using the Aptima MG assay (Hologic, San Diego, CA, USA) in order to establish the prevalence of MG in this group, rates of macrolide resistance and audit primary care’s capacity to manage infections in line with international guidelines. MG was detected in 55 (10%) samples, and co-pathogens were detected in 24 (44%) MG-positive samples. Macrolide resistance mutations were detected in 22/36 (61%) samples subsequently tested using PlexPCR M. genitalium ResistancePlus (Speedx Pvt Ltd., Sydney, Australia). Empiric azithromycin treatment was given to 18 (33%) patients, and test of cure was performed in 15 (27%) patients. Our pilot study demonstrates that sterile pyuria can be a useful marker to direct testing resources in community settings, but highlights important barriers to management of MG in primary care, including clinician knowledge, high prevalence of macrolide resistance and poor completion rates for test of cure.

Current status of countermeasures for infectious diseases and resistant microbes in the field of urology

A worldwide increase in antimicrobial-resistant microbes due to the improper use of antimicrobial agents, along with a lack of progress in developing new antimicrobials, is becoming a societal problem. Although carbapenem-resistant Enterobacteriaceae, which are resistant to carbapenem antimicrobials, first appeared in 1993, treatment options remain limited. Mechanisms behind antimicrobial resistance involve changes to microbial outer membranes, drug efflux pump abnormalities, β-lactamase production and the creation of biofilms around cell bodies. Genetic information related to these forms of antimicrobial resistance exists on chromosomes and plasmids, and when located on the latter can easily be transmitted to other strains, no matter the species, which creates a risk of antimicrobial resistance spreading exceptionally rapidly. To prevent the spread of antimicrobial resistance, the World Health Organization in 2015 published an action plan on antimicrobial resistance, based on which World Health Organization member countries have laid out specific policies and targets. Urinary tract infections are a type of healthcare-associated infection, and the sexually transmitted disease pathogen, Neisseria gonorrhoeae, has been included in a list of microbes that pose a risk to human health published by the US Centers for Disease Control and Prevention. Urologists face numerous problems when attempting to use antimicrobials properly, which is one method of dealing with antimicrobial resistance. Therefore, this article describes the current state of resistant microbes associated with urinary tract infections and countermeasures for antimicrobial resistance, including new antimicrobials.

British Association for Sexual Health and HIV national guideline for the management of infection with Mycoplasma genitalium (2018)

This is the first British Association for Sexual Health and HIV (BASHH) guideline for the diagnosis and management of Mycoplasma genitalium in people aged 16 years and older. The guideline is primarily aimed at level 3 sexually transmitted infection (STI) management services within the UK, although it could also serve as a reference guide for STI services at other levels.

Pooling of urine samples for molecular detection of Chlamydia trachomatis, Neisseria gonorrhoeae and Mycoplasma genitalium as a screening strategy among young adults in Catalonia

INTRODUCTION

Bacterial sexually transmitted infections (STIs) have an important impact on reproductive health, highlighting the increase in Chlamydia trachomatis infection rates among young people. To reduce the costs of STI detection, the pooling strategy is beneficial for high-throughput tests in low-prevalence populations using non-invasive samples.

OBJECTIVES

(1) To describe the performance of a 7-STI PCR assay using the pooling of three urine samples to detect C. trachomatis, Neisseria gonorrhoeae and Mycoplasma genitalium; (2) to estimate the cost saving of the pooling strategy; (3) to describe the prevalence, risk factors and coinfections of C. trachomatis, N. gonorrhoeae and M. genitalium in young people ≤25 years in Catalonia.

METHODS

cross-sectional prevalence study conducted in 2016 among young people ≤25 years of age seen in sexual and reproductive health centres throughout Catalonia from pools of three urine samples. A standardized questionnaire was used to collect clinical-epidemiological and behavioural variables.

RESULTS

1032 young people were tested. The prevalence of C. trachomatis, N. gonorrhoeae and M. genitalium was 8.5%, 0.6% and 3.5%, respectively. The pooling strategy provided a 33% savings in reagent costs.

CONCLUSIONS

The pooling strategy implemented for epidemiological studies in our context provides a savings that has an impact on the viability of STI detection programmes. In the same way, this study shows that C. trachomatis prevalence continues to increase in this population and, for the first time in Catalonia, the prevalence of M. genitalium in young people is shown.

Extragenital Mycoplasma genitalium infections among men who have sex with men

OBJECTIVES

There are limited data on the prevalence of Mycoplasma genitalium (Mgen) coinfection with rectal chlamydia (Chlamydia trachomatis (CT)) and rectal gonorrhoea (Neisseria gonorrhoeae (NG)) infections and few studies examining the prevalence of pharyngeal Mgen in men who have sex with men (MSM). Using transcription-mediated amplification assay, this study aimed to determine the proportion of rectal CT and rectal NG infections in MSM who are coinfected with rectal Mgen, and the proportion of MSM with Mgen detected in the pharynx in order to inform clinical practice.

METHODS

This was a cross-sectional study conducted at Melbourne Sexual Health Centre in Australia. Consecutively collected rectal swabs from MSM that tested positive for CT (n=212) or NG (n=212), and consecutively collected pharyngeal samples (n=480) from MSM were tested for Mgen using the Aptima Mycoplasma genitalium Assay (Hologic, San Diego). Samples were linked to demographic data and symptom status.

RESULTS

Rectal Mgen was codetected in 27 of 212 rectal CT (13%, 95% CI 9 to 18) and in 29 of 212 rectal NG (14%, 95% CI 9 to 19) samples, with no difference in the proportion positive for Mgen. MSM with rectal CT/Mgen coinfection had more sexual partners than those with rectal CT monoinfection (mean 6 vs 11, p=0.06). MSM with rectal NG/Mgen coinfection were more likely to be HIV-positive than those with rectal NG monoinfection (OR=2.96, 95% CI 1.21 to 7.26, p=0.023). MSM with rectal CT/Mgen coinfection were more likely to be using pre-exposure prophylaxis than MSM with rectal NG/Mgen coinfection (OR 0.25, 95% CI 0.10 to 0.65, p=0.002). Pharyngeal Mgen was uncommon and detected in 8 of 464 samples (2%, 95% CI 1% to 3%). Pharyngeal Mgen was associated with having a rectal STI (OR=10.61, 95% CI 2.30 to 48.87, p=0.002), and there was a borderline association with being HIV-positive (p=0.079).

CONCLUSION

These data indicate one in seven MSM treated for rectal CT or rectal NG will have undiagnosed Mgen that is potentially exposed to azithromycin during treatment of these STIs. Rectal Mgen coinfection was associated with specific risk factors which may inform testing practices. Pharyngeal Mgen was uncommon.

Macrolide and fluoroquinolone resistance-associated mutations in Mycoplasma genitalium in Johannesburg, South Africa, 2007-2014

BACKGROUND

Antimicrobial resistance in Mycoplasma genitalium is rising globally with resultant clinical treatment failure. We investigated the prevalence of mutations in the macrolide and fluoroquinolone resistance-determining regions of M. genitalium in Johannesburg, South Africa, and ascertained their association with HIV serostatus.

METHODS

Stored M. genitalium positive specimens, collected from STI and HIV patients enrolled in the Gauteng STI National Microbiological Surveillance programme (2007-2014) and a large HIV outpatient clinic-based study (2007) in Johannesburg, were tested for antimicrobial resistance.

RESULTS

We determined the prevalence of 23S rRNA gene mutations conferring macrolide resistance and mutations in the quinolone resistance-determining regions (QRDR) of the gyrA and parC genes in 266 M. genitalium positive DNA extracts. No macrolide resistance-associated mutations were detected in any of the specimens analysed. QRDR mutations with known M. genitalium-associated fluoroquinolone resistance were not detected in gyrA, however, one specimen (0.4%) contained a D87Y amino acid alteration in parC, which has been linked to fluoroquinolone treatment failure. The most common parC amino acid change detected, of unknown clinical significance, was P62S (18.8%). We found no significant association between QRDR mutations in M. genitalium and HIV-infection.

CONCLUSIONS

Ongoing antimicrobial resistance surveillance in M. genitalium is essential, as macrolide resistance may emerge given the recent incorporation of azithromycin into the 2015 South African national STI syndromic management guidelines.

Does the Sex Risk Quiz Predict Mycoplasma genitalium Infection in Urban Adolescents and Young Adult Women?

BACKGROUND

Mycoplasma genitalium (MG) is a common sexually transmitted infection (STI), but there are limited strategies to identify individuals at risk of MG. Previously, a sex risk quiz was used to predict STIs including Chlamydia trachomatis, Neisseria gonorrhoeae, and/or Trichomonas vaginalis. The original quiz categorized individuals 25 years or younger as at risk of STIs, but the Centers for Disease Control and Prevention identifies females younger than 25 years as at risk of STIs. In this study, the quiz was changed to categorize females younger than 25 years as high risk. The objective was to determine if the age-modified risk quiz predicted MG infection.

METHODS

A cross-sectional analysis of a prospective longitudinal study was performed including female adolescents and young adults (AYAs) evaluated in multiple outpatient clinics. Participants completed an age-modified risk quiz about sexual practices. Scores ranged from 0 to 10 and were categorized as low risk (0-3), medium risk (4-7), and high risk (8-10) based on the STI prevalence for each score. Vaginal and/or endocervical and/or urine specimens were tested for MG, T. vaginalis, C. trachomatis, and N. gonorrhoeae using the Aptima Gen-Probe nucleic amplification test.

RESULTS

There were 693 participants. Most participants reported having 0 to 1 sexual partners in the last 90 days (91%) and inconsistent condom use (84%). Multivariable logistic regression analysis controlling for race, education, and symptom status demonstrated that a medium-risk score predicted MG infection among AYAs younger than 25 years (adjusted odds ratio, 2.56 [95% confidence interval, 1.06-6.18]).

CONCLUSION

A risk quiz may be useful during clinical encounters to identify AYA at risk of MG.

Prevalence of Mycoplasma genitalium in different population groups: systematic review andmeta-analysis

BACKGROUND

Mycoplasma genitalium is a common cause of non-gonococcal non-chlamydial urethritis and cervicitis. Testing of asymptomatic populations has been proposed, but prevalence in asymptomatic populations is not well established. We aimed to estimate the prevalence of M. genitalium in the general population, pregnant women, men who have sex with men (MSM), commercial sex workers (CSWs) and clinic-based samples, METHODS: We searched Embase, Medline, IndMED, African Index Medicus and LILACS from 1 January 1991 to 12 July 2016 without language restrictions. We included studies with 500 participants or more. Two reviewers independently screened and selected studies and extracted data. We examined forest plots and conducted random-effects meta-analysis to estimate prevalence, if appropriate. Between-study heterogeneity was examined using the I2 statistic and meta-regression.

RESULTS

Of 3316 screened records, 63 were included. In randomly selected samples from the general population, the summary prevalence was 1.3% (95% CI 1.0% to 1.8%, I2 41.5%, three studies, 9091 people) in countries with higher levels of development and 3.9% (95% CI 2.2 to 6.7, I2 89.2%, three studies, 3809 people) in countries with lower levels. Prevalence was similar in women and men (P=0.47). In clinic based samples, prevalence estimates were higher, except in asymptomatic patients (0.8%, 95% CI 0.4 to 1.4, I2 0.0%, three studies, 2889 people). Summary prevalence estimates were, in the following groups: pregnant women 0.9% (95% CI 0.6% to 1.4%, I2 0%, four studies, 3472 people), MSM in the community 3.2% (95% CI 2.1 to 5.1, I2 78.3%, five studies, 3012 people) and female CSWs in the community 15.9% (95% CI 13.5 to 18.9, I2 79.9%, four studies, 4006 people).

DISCUSSION

This systematic review can inform testing guidelines for M. genitalium. The low estimated prevalence of M. genitalium in the general population, pregnant women and asymptomatic attenders at clinics does not support expansion of testing to these groups.

REGISTRATION NUMBERS

PROSPERO: CRD42015020420.

Mycoplasma genitalium infections in Cuba: surveillance of urogenital syndromes, 2014-2015

Mycoplasma genitalium is an emerging sexually transmitted pathogen implicated in urethritis in men and several inflammatory reproductive tract syndromes in women. The prevalence of M. genitalium infections in Cuban patients with urogenital syndromes is unknown. The aim of this study was to analyse the prevalence of M. genitalium infection in sexually-active Cuban men and women with urogenital syndromes as a part of aetiological surveillance of urogenital syndromes in Cuba. Samples from men and women with urogenital syndromes submitted to the Mycoplasma Reference Laboratory for mycoplasma diagnosis from 1 January 2014 to 1 June 2015 were analysed by polymerase chain reaction (PCR) for detection of M. genitalium. A total of 971 samples were received and processed. Of the patients tested, 5.7% (47/824) of women and 27.9% (41/147) of men were positive for M. genitalium. This paper presents the largest study of M. genitalium infections among Cuban patients with urogenital syndromes and is Cuba's first M. genitalium survey. We suggest that M. genitalium should be considered in the Cuban sexually transmitted infection management protocols as an important pathogen, particularly in men.

Mycoplasma genitalium Infection in Adults Reporting Sexual Contact with Infected Partners, Australia, 2008-2016

Data on the likelihood of Mycoplasma genitalium infection in sexual contacts, particularly for men who have sex with men (MSM), are needed to form an evidence base for guidelines. We conducted a cross-sectional analysis of patients attending a sexual health clinic in Melbourne, Victoria, Australia, during 2008-2016. We calculated the proportion of contacts with M. genitalium infection and determined factors associated with infection. Among those patients reporting sexual contact with an M. genitalium-infected person, 48.2% of women, 31.0% of heterosexual men, and 41.7% of MSM were infected. Among heterosexual contacts, women were twice as likely to be infected; among MSM, rectal infection was more common than urethral infection; and among persons within heterosexual partnerships, concordance of infection was high. High positivity among female and MSM contacts and high concordance in heterosexual partnerships provide some justification for presumptive treatment; however, clinicians should consider antimicrobial drug resistance and toxicity of quinolones.

Risk factors for Mycoplasma genitalium endometritis and incident infection: a secondary data analysis of the T cell Response Against Chlamydia (TRAC) Study

OBJECTIVE

Assess risk factors for incident and endometrial Mycoplasma genitalium infection and determine if M. genitalium is associated with histological endometritis, an indicator of pelvic inflammatory disease.

METHODS

This study was a secondary data analysis within the T cell Response Against Chlamydia (TRAC) Study, a prospective evaluation of 246 women with or at risk for Chlamydia trachomatis from urban outpatient clinics, who were followed quarterly for 12 months. Risk factors for incident M. genitalium infection were determined by Cox regression. Relative risks were estimated by Poisson regression with robust error measurements for models examining the association between M. genitalium and endometritis (histological evidence of plasma cells in endometrial stroma and neutrophils in the endometrial epithelium) and for models examining risk factors for detection of endometrial M. genitalium infection.

RESULTS

M. genitalium prevalence was 16.7%, incidence was 25.3 per 100 person-years and 23% had repeated positive tests. Black race (non-black HR_adj 0.4, 95% CI 0.2 to 0.9), less education (HR_adj 2.4, 95% CI 1.2 to 5.1) and a new sexual partner (HR_adj 3.1, 95% CI 1.7 to 5.4) were associated with incident M. genitalium. M. genitalium was associated with endometritis (RR_adj 2.0, 95% CI 1.1 to 3.7). Trichomonas vaginalis (RR_adj 2.0, 95% CI 1.2 to 3.4) and endometrial C. trachomatis (RR_adj 1.7, 95% CI 1.1 to 2.8) were associated with endometrial M. genitalium.

CONCLUSIONS

M. genitalium is prevalent in women at high risk for C. trachomatis, persists over multiple follow-up visits and is associated with histological endometritis. Studies are needed to determine if screening for M. genitalium will improve reproductive outcomes.

Highlighting the clinical need for diagnosing Mycoplasma genitalium infection

Despite Mycoplasma genitalium (MG) being increasingly recognised as a genital pathogen in men and women, awareness and utility of commercially available MG-testing has been low. The opinion of UK sexual health clinicians and allied professionals was sought on how MG-testing should be used. Thirty-two consensus statements were developed by an expert group and circulated to clinicians and laboratory staff, who were asked to evaluate their level of agreement with each statement; 75% agreement was set as the threshold for defining consensus for each statement. A modified Delphi approach was used and high levels of agreement obviated the need to test the original statement set further. Of 201 individuals who received questionnaires, 60 responded, most (48) being sexual health consultants, more than 10% of the total in the UK. Twenty-seven (84.4%) of the statements exceeded the 75% threshold. Respondents strongly supported MG-testing of patients with urethritis, pelvic inflammatory disease or unexplained persistent vaginal discharge, or post-coital bleeding. Fewer favoured testing patients with proctitis and support was divided for routinely testing Chlamydia-positive patients. Testing of current sexual contacts of MG-positive patients was supported, as was a test of cure for MG-positive patients, although agreement fell below the 75% threshold. Respondents agreed that all consultant- or specialist-led services should have access to testing for MG (98.3%). There was strong agreement for having MG-testing available for specific patient groups, which may reflect concern over antibiotic resistance and the desire to comply with clinical guidelines that recommend MG-testing in sexual health clinic settings.

Should we screen for the sexually-transmitted infection Mycoplasma genitalium? Evidence synthesis using a transmission-dynamic model

There is increasing concern about Mycoplasma genitalium as a cause of urethritis, cervicitis, pelvic inflammatory disease (PID), infertility and ectopic pregnancy. Commercial nucleic acid amplification tests (NAATs) are becoming available, and their use in screening for M. genitalium has been advocated, but M. genitalium's natural history is poorly-understood, making screening's effectiveness unclear. We used a transmission-dynamic compartmental model to synthesise evidence from surveillance data and epidemiological and behavioural studies to better understand M. genitalium's natural history, and then examined the effects of implementing NAAT testing. Introducing NAAT testing initially increases diagnoses, by finding a larger proportion of infections; subsequently the diagnosis rate falls, due to reduced incidence. Testing only symptomatic patients finds relatively little infection in women, as a large proportion is asymptomatic. Testing both symptomatic and asymptomatic patients has a much larger impact and reduces cumulative PID incidence in women due to M. genitalium by 31.1% (95% range:13.0%-52.0%) over 20 years. However, there is important uncertainty in M. genitalium's natural history parameters, leading to uncertainty in the absolute reduction in PID and sequelae. Empirical work is required to improve understanding of key aspects of M. genitalium's natural history before it will be possible to determine the effectiveness of screening.

Should we screen for the sexually-transmitted infection Mycoplasma genitalium? Evidence synthesis using a transmission-dynamic model

There is increasing concern about Mycoplasma genitalium as a cause of urethritis, cervicitis, pelvic inflammatory disease (PID), infertility and ectopic pregnancy. Commercial nucleic acid amplification tests (NAATs) are becoming available, and their use in screening for M. genitalium has been advocated, but M. genitalium's natural history is poorly-understood, making screening's effectiveness unclear. We used a transmission-dynamic compartmental model to synthesise evidence from surveillance data and epidemiological and behavioural studies to better understand M. genitalium's natural history, and then examined the effects of implementing NAAT testing. Introducing NAAT testing initially increases diagnoses, by finding a larger proportion of infections; subsequently the diagnosis rate falls, due to reduced incidence. Testing only symptomatic patients finds relatively little infection in women, as a large proportion is asymptomatic. Testing both symptomatic and asymptomatic patients has a much larger impact and reduces cumulative PID incidence in women due to M. genitalium by 31.1% (95% range:13.0%-52.0%) over 20 years. However, there is important uncertainty in M. genitalium's natural history parameters, leading to uncertainty in the absolute reduction in PID and sequelae. Empirical work is required to improve understanding of key aspects of M. genitalium's natural history before it will be possible to determine the effectiveness of screening.

The prevalence of, and risk factors for, mycoplasma genitalium infection among infertile women in Ibadan: A cross-sectional study

BACKGROUND

The association of mycoplasma genitalium (M. genitalium) with infertility has been documented. The infections are asymptomatic and difficult to diagnose. Understanding the associated risk factors will help in facilitating better screening measures for at-risk groups.

OBJECTIVE

The aim was to determine the prevalence of, and risk factors for, M. genitalium infection among infertile women in Ibadan.

MATERIALS AND METHODS

In this cross-sectional study, 402 women (267 infertile and 135 fertile) referred to 2 hospitals in Ibadan between March and November 2015 were enrolled. Information was obtained, using structured questionnaire, on sociodemographic and behavioral characteristics of the respondents while endocervical swabs were obtained for detection of M. genitalium. MgPa gene was diagnosed using the conventional Polymerase chain reaction. Bands corresponding to 495kb were documented as positive for M. genitalium.

RESULTS

Among the infertile women, 43 (16.1%) had evidence of M. genitalium infection as against 3 (2.2%) of women without infertility (p<0.001). Associated risk factors included having more than one lifetime sexual partner (OR=10.13, 95% CI: 3.76-33.97); husbands having other sexual partners (OR=12.88, 95% CI: 2.08-90.63); being a serial monogamist (OR=6, 95% CI: 4.35-8.27) and low socio-economic status (OR=2.80, 95% CI: 1.28-6.10). No relationship exists between the previous history of sexually transmitted infections and M. genitalium.

CONCLUSION

The risk factors for M. genitalium infection are similar to those peculiar to other sexually transmitted infections. Its routine screening should be incorporated into the current protocol for microbiological evaluation of infertile women.

Prevalence and significance of Mycoplasma genitalium in women living with HIV in Denmark

OBJECTIVE

Mycoplasma genitalium (M. genitalium) is a sexually transmitted pathogen associated with urethritis, cervicitis, and pelvic inflammatory disease. Previous studies have shown a strong association between M. genitalium and HIV infection, therefore screening and treatment for M. genitalium has been suggested as part of HIV prevention strategies. The objective of this study was to determine the prevalence of M. genitalium in women living with HIV (WLWH) in Denmark, and to compare the result with data on symptoms from the lower abdomen, sexual habits and immune status. 234 women, recruited from Danish HIV centres as part of a larger observational study on aspects of living with HIV as a woman (the SHADE study), were included.

RESULTS

We tested cervical samples for M. genitalium by specific PCR. We found three samples positive (1.3%). The women were between 30 and 50 years old, all were of Asian origin, sexually active, and on antiretroviral treatment with supressed HIV RNA and CD4 count >350 cells/µL. None reported symptoms from the lower abdomen. The prevalence of M. genitalium infection in WLWH in Denmark is low, thus systematic screening for M. genitalium in this group does not seem relevant.

Mycoplasma genitalium Infection in Men

Mycoplasmagenitalium is one of the major causes of nongonococcal urethritis (NGU) worldwide but an uncommon sexually transmitted infection (STI) in the general population. The risk of sexual transmission is probably lower than for Chlamydia trachomatis. Infection in men is usually asymptomatic and it is likely that most men resolve infection without developing disease. The incubation period for NGU caused by Mycoplasma genitalium is probably longer than for NGU caused by C. trachomatis. The clinical characteristics of symptomatic NGU have not been shown to identify the pathogen specific etiology. Effective treatment of men and their sexual partner(s) is complicated as macrolide antimicrobial resistance is now common in many countries, conceivably due to the widespread use of azithromycin 1 g to treat STIs and the limited availability of diagnostic tests for M. genitalium. Improved outcomes in men with NGU and better antimicrobial stewardship are likely to arise from the introduction of diagnostic M. genitalium nucleic acid amplification testing including antimicrobial resistance testing in men with symptoms of NGU as well as in their current sexual partner(s). The cost effectiveness of these approaches needs further evaluation. The evidence that M. genitalium causes epididymo-orchitis, proctitis, and reactive arthritis and facilitates human immunodeficiency virus transmission in men is weak, although biologically plausible. In the absence of randomized controlled trials demonstrating cost effectiveness, screening of asymptomatic men cannot be recommended.

Which azithromycin regimen should be used for treating Mycoplasma genitalium? A meta-analysis

BACKGROUND

There is increasing evidence that azithromycin 1 g is driving the emergence of macrolide resistance in Mycoplasma genitalium worldwide. We undertook a meta-analysis of M. genitalium treatment studies using azithromycin 1 g single dose and azithromycin 500 mg on day 1 then 250 mg daily for 4 days (5-day regimen) to determine rates of treatment failure and resistance in both regimens.

METHODS

The online databases PubMed and Medline were searched using terms "Mycoplasma genitalium", "macrolide" or "azithromycin" and "resistance" up to April 2016. Studies were eligible if they: used azithromycin 1 g or 5 days, assessed patients for macrolide resistant genetic mutations prior to treatment and patients who failed were again resistance genotyped. Random effects meta-analysis was used to estimate failure and resistance rates.

RESULTS

Eight studies were identified totalling 435 patients of whom 82 (18.9%) had received the 5-day regimen. The random effects pooled rate of treatment failure and development of macrolide antimicrobial resistance mutations with azithromycin 1 g was 13.9% (95% CI 7.7% to 20.1%) and 12.0% (7.1% to 16.9%), respectively. Of individuals treated with the 5-day regimen, with no prior doxycycline treatment, fewer (3.7%; 95% CI 0.8% to 10.3%, p=0.012) failed treatment, all of whom developed resistance (p=0.027).

CONCLUSION

Azithromycin 1 g is associated with high rates of treatment failure and development of macrolide resistance in M. genitalium infection with no pre-existing macrolide mutations. There is moderate but conflicting evidence that the 5-day regimen may be more effective and less likely to cause resistance.

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

Objectives

Resistance to both macrolides and fluoroquinolones has been reported in Mycoplasma genitalium; however, due to limited diagnostics, studies are often small and confined to specific geographical areas. This study sought to determine the rate of predicted resistance in M. genitalium-positive specimens referred for diagnostic testing.

Methods

Seventy-four M. genitalium-positive specimens, referred to the national reference laboratory (2010-2013) from 19 centres across England, were blinded and anonymised. Specimens were examined for markers predictive of resistance to macrolides and fluoroquinolones using PCR followed by sequence analysis of 23S rRNA gene, or gyrA and parC, respectively.

Results

23S rRNA gene PCR sequencing revealed that 82.4% (61/74) of specimens harboured a single nucleotide polymorphism (SNP) associated with macrolide resistance. Differences were observed between the rates of predicted macrolide resistance in male (95.1% (58/61)) and female (23.1% (3/13)) patients (P = <0.001). By contrast, all specimens for which sequencing data were available (73/74) yielded wild-type gyrA sequences; and 58/61 (95.1%) had wild-type parC genes. Three specimens (3/61 4.9%) had SNPs in the parC gene associated with fluoroquinolone treatment failure, and all three also had predicted resistance to macrolides.

Conclusions

Eighty-two per cent and 4.9% of M. genitalium specimens had SNPs associated with macrolide and fluoroquinolone resistance, respectively. Due to lack of widespread availability of testing for M. genitalium in the UK, this study sample was likely to be sourced from patients who may have already failed first-line macrolide therapy. Nevertheless, this study highlights the need for both greater access to M. genitalium diagnostics and genetic antimicrobial resistance testing.

Multidrug-resistant Mycoplasma genitalium infections in Europe

In Japan and Australia, multidrug-resistant Mycoplasma genitalium infections are reported with increasing frequency. Although macrolide-resistant M. genitalium strains are common in Europe and North America, fluoroquinolone-resistant strains are still exceptional. However, an increase of multidrug-resistant M. genitalium in Europe and America is to be expected. The aim of this paper is to increase awareness on the rising number of multidrug-resistant M. genitalium strains. Here, one of the first cases of infection with a genetically proven multidrug-resistant M. genitalium strain in Europe is described. The patient was a native Dutch 47-year-old male patient with urethritis. Mycoplasma genitalium was detected, but treatment failed with azithromycin, doxycycline and moxifloxacin. A urogenital sample was used to determine the sequence of the 23S rRNA, gyrA, gyrB and parC genes. The sample contained an A2059G single nucleotide polymorphism (SNP) in the 23S rRNA gene and an SNP in the parC gene, resulting in an amino acid change of Ser83 → Ile, explaining both azithromycin and moxifloxacin treatment failure. The SNPs associated with resistance were probably generated de novo, as a link with high-prevalence areas was not established. It is, thus, predictable that there is going to be an increase of multidrug-resistant M. genitalium strains in Europe. As treatment options for multidrug-resistant M. genitalium are limited, the treatment of M. genitalium infections needs to be carefully considered in order to limit the rapid increase of resistance to macrolides and fluoroquinolones.

Clinical laboratory assessments for Mycoplasma genitalium in a high-prevalence sexually-transmitted infection community reveal epidemiologic dichotomies with Trichomonas vaginalis

INTRODUCTION

Mycoplasma genitalium is an emerging agent of sexually-transmitted infection and is responsible for clinically-significant genital tract disease in both females and males. Similar to scenarios recently experienced with the urogenital flagellate Trichomonas vaginalis, an evolving molecular diagnostic reference standard based on transcription-mediated amplification allows for accurate detection of the organism, plus additional insight into disease epidemiology. Areas covered. The basis for this article includes primary peer-reviewed literature plus compilations of data derived from routine clinical laboratory screening of females and males for agents of sexually-transmitted infection. Introductory laboratory and epidemiologic data related to T. vaginalis provides not only a foreshadowing to the dichotomies inherent to M. genitalium prevalence but also advocacy of a common non-invasive specimen source that could be used to screen females for both agents. This review also documents increased prevalence rates of M. genitalium in both females and males by way of transcription-mediated amplification. Expert commentary. Molecular detection of M. genitalium should be a consideration in the development of comprehensive sexually-transmitted infection screening programs for both females and males. Transcription-mediated amplification has additionally identified novel facets of M. genitalium and T. vaginalis epidemiology that warrant further investigation.

The Ballseye programme: a mixed-methods programme of research in traditional sexual health and alternative community settings to improve the sexual health of men in the UK

Background

Sexually transmitted infection (STI) diagnoses are increasing and efforts to reduce transmission have failed. There are major uncertainties in the evidence base surrounding the delivery of STI care for men.

Aim

To improve the sexual health of young men in the UK by determining optimal strategies for STI testing and care

Objectives

To develop an evidence-based clinical algorithm for STI testing in asymptomatic men; model mathematically the epidemiological and economic impact of removing microscopy from routine STI testing in asymptomatic men; conduct a pilot randomised controlled trial (RCT) of accelerated partner therapy (APT; new models of partner notification to rapidly treat male sex partners of people with STIs) in primary care; explore the acceptability of diverse venues for STI screening in men; and determine optimal models for the delivery of screening.

Design

Systematic review of the clinical consequences of asymptomatic non-chlamydial, non-gonococcal urethritis (NCNGU); case–control study of factors associated with NCNGU; mathematical modelling of the epidemiological and economic impact of removing microscopy from asymptomatic screening and cost-effectiveness analysis; pilot RCT of APT for male sex partners of women diagnosed withChlamydia trachomatisinfection in primary care; stratified random probability sample survey of UK young men; qualitative study of men’s views on accessing STI testing; SPORTSMART pilot cluster RCT of two STI screening interventions in amateur football clubs; and anonymous questionnaire survey of STI risk and previous testing behaviour in men in football clubs.

Settings

General population, genitourinary medicine clinic attenders, general practice and community contraception and sexual health clinic attenders and amateur football clubs.

Participants

Men and women.

Interventions

Partner notification interventions: APTHotline [telephone assessment of partner(s)] and APTPharmacy [community pharmacist assessment of partner(s)]. SPORTSMART interventions: football captain-led and health adviser-led promotion of urine-based STI screening.

Main outcome measures

For the APT pilot RCT, the primary outcome, determined for each contactable partner, was whether or not they were considered to have been treated within 6 weeks of index diagnosis. For the SPORTSMART pilot RCT, the primary outcome was the proportion of eligible men accepting screening.

Results

Non-chlamydial, non-gonococcal urethritis is not associated with significant clinical consequences for men or their sexual partners but study quality is poor (systematic review). Men with symptomatic and asymptomatic NCNGU and healthy men share similar demographic, behavioural and clinical variables (case–control study). Removal of urethral microscopy from routine asymptomatic screening is likely to lead to a small rise in pelvic inflammatory disease (PID) but could save > £5M over 20 years (mathematical modelling and health economics analysis). In the APT pilot RCT the proportion of partners treated by the APTHotline [39/111 (35%)], APTPharmacy [46/100 (46%)] and standard patient referral [46/102 (45%)] did not meet national standards but exceeded previously reported outcomes in community settings. Men’s reported willingness to access self-sampling kits for STIs and human immunodeficiency virus infection was high. Traditional health-care settings were preferred but sports venues were acceptable to half of men who played sport (random probability sample survey). Men appear to prefer a ‘straightforward’ approach to STI screening, accessible as part of their daily activities (qualitative study). Uptake of STI screening in the SPORTSMART RCT was high, irrespective of arm [captain led 28/56 (50%); health-care professional led 31/46 (67%); poster only 31/51 (61%)], and costs were similar. Men were at risk of STIs but previous testing was common.

Conclusions

Men find traditional health-care settings the most acceptable places to access STI screening. Self-sampling kits in football clubs could widen access to screening and offer a public health impact for men with limited local sexual health services. Available evidence does not support an association between asymptomatic NCNGU and significant adverse clinical outcomes for men or their sexual partners but the literature is of poor quality. Similarities in characteristics of men with and without NCNGU precluded development of a meaningful clinical algorithm to guide STI testing in asymptomatic men. The mathematical modelling and cost-effectiveness analysis of removing all asymptomatic urethral microscopy screening suggests that this would result in a small rise in adverse outcomes such as PID but that it would be highly cost-effective. APT appears to improve outcomes of partner notification in community settings but outcomes still fail to meet national standards. Priorities for future work include improving understanding of men’s collective behaviours and how these can be harnessed to improve health outcomes; exploring barriers to and facilitators of opportunistic STI screening for men attending general practice, with development of evidence-based interventions to increase the offer and uptake of screening; further development of APT for community settings; and studies to improve knowledge of factors specific to screening men who have sex with men (MSM) and, in particular, how, with the different epidemiology of STIs in MSM and the current narrow focus on chlamydia, this could negatively impact MSM’s sexual health.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Background review for the 2016 European guideline on Mycoplasma genitalium infections

Mycoplasma genitalium is a cause of 10-35% of non-chlamydial non-gonococcal urethritis in men and in women, and is associated with cervicitis and pelvic inflammatory disease (PID). Transmission of M. genitalium occurs through direct mucosal contact. In women, symptoms include vaginal discharge, dysuria or symptoms of PID - abdominal pain and dyspareunia. In men, urethritis, dysuria and discharge predominates. Asymptomatic infections are frequent. In this review, we present the evidence base for the recommendations in the 2016 European guideline on M. genitalium infections and describe indications for testing, recommended diagnostic methods, treatment and patient management. The guideline was prepared on behalf of the European branch of The International Union against Sexually Transmitted Infections; the European Academy of Dermatology and Venereology; the European Dermatology Forum; the European Society of Clinical Microbiology and Infectious Diseases; the Union of European Medical Specialists. The European Centre for Disease Prevention and Control and the European Office of the World Health Organisation also contributed to their development.