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We evaluated the ResistancePlus® MG assay in providing macrolide resistance-guided treatment (RGT) for Mycoplasma genitalium infection at a UK sexual health centre. M. genitalium -positive samples from men with urethritis and women with pelvic inflammatory disease (PID) were tested for macrolide resistance-mediating mutations (MRMMs). MRMM-positive infections were given moxifloxacin 400 mg; otherwise 2 g azithromycin (1 g single dose and then 500 mg OD) was given. Among 57  M. genitalium -positive patients (32 men and 25 women), MRMMs were detected in 41/57 (72% [95% confidence interval (95% CI) 58-83%). Thirty-two of 43 patients given RGT attended for test of cure. Treatment failure rate was significantly lower at 1/32 (3%) than 10/37 (27%) before RGT ( n = 37 [men = 23 and women = 17]; p = 0.008). Treatment failure was lower in male urethritis (0/15 vs. 7/21 p = 0.027) but not in female PID. There was a trend of a shorter time to negative test of cure (TOC) in male urethritis (55.1 [95% 43.7-66.4] vs. 85.1 [95% CI CI 64.1-106.0] days, p = 0.077) but not in female PID. Macrolide resistance is higher than previous UK reports and higher than expected. RGT reduces overall treatment failure and is particularly beneficial in M. genitalium urethritis. Fluoroquinolone resistance will continue to rise with increasing fluoroquinolone use, and RGT is critical to direct appropriate azithromycin use and prevent overuse of moxifloxacin.

Background: Mycoplasma genitalium (Mgen) causes non-gonococcal urethritis (NGU) and is believed to cause pelvic inflammatory disease (PID). High rates of macrolide resistance are well documented globally for Mgen. In Brighton, patients with NGU and PID are tested for Mgen and test of cure (TOC) offered post-treatment., Methods: Demographic, clinical and treatment history data were collected over a 12-month period for all Mgen-positive patients in a Brighton-based genitourinary clinic., Results: There were 114 patients with Mgen. 18% (61/339) of men with NGU and 9% (15/160) of women with PID had Mgen. 62/114 (54%) returned for first test TOC 4 weeks after treatment. 27/62 (44%) had a positive TOC; 25/27 (92.6%) had received azithromycin first line (500 mg stat then 250 mg OD for 4 days), 1/27 (3.7%) had received moxifloxacin first line (400 mg OD for 14 days) and 1/27 (3.7%) had received doxycycline first line (100 mg BD for 7 days). 20/27 (74%) returned for a second TOC 4 weeks later. 5/20 (25%) patients were positive on second TOC; 3/5 (60%) had received azithromycin second line and 2/5 (40%) had received moxifloxacin second line. Patients were more likely to have a positive TOC if they were at risk of reinfection (9/27 positive TOC vs 3/35 negative TOC; p=0.02). Patients given moxifloxacin were more likely to have a negative TOC (1/27 positive TOC vs 9/35 negative TOC; p=0.03) than those who received other antibiotic regimens., Conclusions: Treatment failure rates for Mgen following azithromycin use are substantial, raising concerns regarding resistance. However, reinfection risk may contribute, suggesting a requirement for improved public awareness and clinician knowledge., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

We present 2 cases of Mycoplasma genitalium infection that were successfully treated with moxifloxacin despite the presence of quinolone resistance-associated mutations in these strains.

Competing Interests: Competing interests: We have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.

Competing Interests: Competing interests: None declared.

There is growing concern worldwide for macrolide resistance in M. genitalium following liberal use of 1 g azithromycin to treat non-gonococcal urethritis and confirmed C. trachomatis infection. Moxifloxacin is the second-line treatment for M. genitalium and still has excellent efficacy against it. However, recent reports indicating that quinolone resistance is more prevalent than previously thought are worrying. Routine testing of symptomatic men and women for M. genitalium is not currently recommended in BASHH guidelines, and attempts to implement such testing have been hampered by a lack of commercially available assays. We present a case of M. genitalium urethritis which failed to respond to four different antibiotic regimens, resulting in multiple visits to the clinic and anxiety for the patient., Competing Interests: Competing interests: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

We evaluated the ResistancePlus® MG assay in providing macrolide resistance-guided treatment (RGT) for Mycoplasma genitalium infection at a UK sexual health centre. M. genitalium-positive samples from men with urethritis and women with pelvic inflammatory disease (PID) were tested for macrolide resistance-mediating mutations (MRMMs). MRMM-positive infections were given moxifloxacin 400 mg; otherwise 2 g azithromycin (1 g single dose and then 500 mg OD) was given. Among 57 M. genitalium-positive patients (32 men and 25 women), MRMMs were detected in 41/57 (72% [95% confidence interval (95% CI) 58-83%). Thirty-two of 43 patients given RGT attended for test of cure. Treatment failure rate was significantly lower at 1/32 (3%) than 10/37 (27%) before RGT (n = 37 [men = 23 and women = 17]; p = 0.008). Treatment failure was lower in male urethritis (0/15 vs. 7/21 p = 0.027) but not in female PID. There was a trend of a shorter time to negative test of cure (TOC) in male urethritis (55.1 [95% 43.7-66.4] vs. 85.1 [95% CI CI 64.1-106.0] days, p = 0.077) but not in female PID. Macrolide resistance is higher than previous UK reports and higher than expected. RGT reduces overall treatment failure and is particularly beneficial in M. genitalium urethritis. Fluoroquinolone resistance will continue to rise with increasing fluoroquinolone use, and RGT is critical to direct appropriate azithromycin use and prevent overuse of moxifloxacin. [ABSTRACT FROM AUTHOR]