Mycoplasma genitalium, often called M. genitalium, is a tiny bacterium that can cause sexually transmitted infections (STIs). It is similar to chlamydia but even smaller and harder to detect. This bacterium lives in the urinary and genital tracts of humans.

Signs & Symptoms

Mycoplasma genitalium is a sexually transmitted infection that can cause various symptoms, though some individuals may be asymptomatic. Here are the common symptoms for both men and women:

In Men:

1. Urethritis: Inflammation of the urethra, causing pain during urination.
2. Discharge: A clear or white discharge from the penis.
3. Dysuria: Pain or burning sensation during urination.
4. Testicular Pain: Sometimes associated with discomfort or pain in the testicles.

In Women:

1. Cervicitis: Inflammation of the cervix, causing abnormal vaginal discharge.
2. Pelvic Pain: Pain in the lower abdomen or pelvic area.
3. Dysuria: Pain or burning sensation during urination.
4. Intermenstrual Bleeding: Bleeding between menstrual periods or after sexual intercourse.
5. Vaginal Discharge: Abnormal vaginal discharge that may be clear, white, or yellowish.

Potential Complications:

• Pelvic Inflammatory Disease (PID): In women, Mycoplasma genitalium can lead to PID, which can cause serious reproductive health issues, including infertility.
• Epididymitis: In men, it can cause inflammation of the epididymis, leading to pain and swelling in the scrotum.
• Preterm Birth: Infection during pregnancy may be linked to preterm birth and other complications.
• Increase risk of HIV: Increased risk of acquiring and transmitting HIV for both men and women

Why is Screening for Mycoplasma Genitalium Important?

Criteria for When Screening is Recommended:

Screening for Mycoplasma genitalium is not routine. Instead, it is recommended under specific circumstances:

1. Persistent Symptoms: If you have persistent or recurrent urethritis, cervicitis, or PID after being treated for chlamydia or gonorrhea.
2. High-Risk Groups: Individuals with multiple sexual partners or those attending sexual health clinics.
3. Test of Cure (TOC): After treatment, especially in areas with high antibiotic resistance, to ensure the infection is cleared.

Differences Between Routine Screening and Targeted Testing:

• Routine Screening: Usually involves regular checks for common STIs like chlamydia and gonorrhea. It is done for everyone, regardless of symptoms.
• Targeted Testing: Focuses on individuals with specific symptoms or risks. For Mycoplasma genitalium, this means testing when other infections are ruled out but symptoms persist.

Impact of Screening on Public Health and Individual Outcomes:

Screening for Mycoplasma genitalium can have significant benefits:

• Public Health: Reduces the spread of the infection and antibiotic-resistant strains. Early detection and appropriate treatment prevent complications and transmission.
• Individual Health: Helps avoid severe complications such as PID, infertility, and chronic pain. Ensures that you receive proper treatment and follow-up care.

Challenges in Implementing Widespread Screening:

1. Limited Awareness: Both healthcare providers and the general public may not be fully aware of Mycoplasma genitalium and its risks.
2. Testing Availability: Specific tests for M. genitalium, like Nucleic Acid Amplification Tests (NAAT), are not always readily available or may be costly.
3. Antibiotic Resistance: The rising resistance to common antibiotics complicates treatment strategies, making it crucial to use targeted testing to guide therapy.

Public Health Significance:

M. genitalium holds significant public health importance. Why? It is a common cause of non-gonococcal urethritis (NGU) in men. In women, it can lead to cervicitis and pelvic inflammatory disease (PID). The bacterium's resistance to antibiotics is rising, making it harder to treat.

The prevalence of Mycoplasma genitalium in Canada varies by region and population:

• General Population: Studies show 1-3% prevalence.
• High-Risk Populations: Among those attending sexual health clinics, prevalence can reach up to 4-5%.
• Antibiotic Resistance: About 58% of detected cases show macrolide resistance.

In Toronto, a study found that 4.5% of men and 3.2% of women tested positive for M. genitalium. This highlights the need for increased awareness and testing.

How is Mycoplasma Genitalium Diagnosed in Canada?

Overview of Diagnostic Tests Used, with Emphasis on NAAT:

Diagnosing Mycoplasma genitalium in Canada primarily relies on Nucleic Acid Amplification Tests (NAAT). These tests detect the genetic material of the bacteria, making them highly accurate. NAAT is considered the gold standard for identifying M. genitalium due to its sensitivity and specificity. Other methods like culture tests are not practical because M. genitalium grows slowly and requires special media.

Sample Types for Testing:

Samples for M. genitalium testing can come from various body sites:

• Urine: Often used for men and women. It's non-invasive and easy to collect.
• Cervical: Swabs taken from the cervix, primarily used for women.
• Vaginal: Swabs taken from the vaginal wall.
• Urethral: Swabs taken from the urethra, used in both men and women.
• Endometrial: Samples from the lining of the uterus, typically used when pelvic inflammatory disease (PID) is suspected.

Importance of Ruling Out Other STIs:

Before diagnosing Mycoplasma genitalium, it's crucial to rule out other common STIs like chlamydia and gonorrhea. This is because symptoms of M. genitalium overlap with these infections.

1. Persisting Symptoms: If symptoms persist after treating chlamydia or gonorrhea, it's essential to test for M. genitalium.
2. Accurate Diagnosis: Ensures that the treatment is specific to the infection, preventing misuse of antibiotics and reducing the risk of resistance.

Guidelines for Follow-Up Testing to Ensure Accurate Diagnosis:

Follow-up testing, or Test of Cure (TOC), is vital to ensure that the infection has been completely eradicated. Guidelines suggest:

• Timing: Conduct TOC at least three weeks after completing treatment. Testing too soon might detect residual bacterial DNA, leading to false positives.
• Symptomatic Patients: Always perform TOC if symptoms persist after treatment.
• High-Resistance Areas: In regions with high antibiotic resistance, TOC is crucial to confirm the effectiveness of the treatment.

How to Treat Mycoplasma Genitalium: Recommended Protocols

Recommended Antibiotic Regimens Including Azithromycin and Moxifloxacin:

Treating Mycoplasma genitalium infections in Canada involves specific antibiotics:

• Azithromycin: For cases not previously treated with this antibiotic, the regimen starts with 500 mg on the first day, followed by 250 mg daily for the next four days. This multi-day approach is preferred over a single large dose to minimize the risk of antibiotic resistance.
• Moxifloxacin: Used when azithromycin fails or if the strain is known to be resistant. The typical dosage is 400 mg once daily for seven days. This antibiotic is effective but should be reserved for confirmed or suspected resistant cases to maintain its effectiveness.

Protocols for Treating Macrolide-Resistant Strains:

When dealing with macrolide-resistant Mycoplasma genitalium, the treatment protocol changes:

• Macrolide-Resistant Strains: If a patient does not respond to azithromycin, moxifloxacin becomes the next line of treatment. Administer 400 mg of moxifloxacin daily for seven days. This ensures that the resistant strain is effectively targeted.

Special Considerations for Treating Pelvic Inflammatory Disease (PID):

Pelvic Inflammatory Disease (PID) caused by Mycoplasma genitalium requires a more aggressive treatment approach:

• PID Treatment: For suspected or confirmed M. genitalium-related PID, moxifloxacin is prescribed at 400 mg once daily for 14 days. This extended treatment duration helps in thoroughly eradicating the infection from the reproductive organs.
• Combination Therapy: Often, moxifloxacin is used in conjunction with other antibiotics to cover a broad range of potential pathogens, ensuring comprehensive treatment.

Importance of Adhering to Treatment Guidelines to Prevent Resistance:

Following treatment guidelines strictly is essential to prevent antibiotic resistance:

• Complete the Course: Always finish the prescribed antibiotic course, even if symptoms improve before the medication is finished.
• Avoid Self-Medication: Never self-prescribe antibiotics or use leftover medication from previous treatments.
• Regular Follow-Ups: Schedule and attend follow-up appointments to ensure the infection is fully cleared, especially in regions with high resistance rates.

By adhering to these treatment protocols, you can effectively manage and treat Mycoplasma genitalium infections, reducing the risk of complications and antibiotic resistance.

Why Follow-Up is Crucial After Treatment of Mycoplasma Genitalium

Importance of Test of Cure (TOC) at Least Three Weeks Post-Treatment:

Performing a Test of Cure (TOC) three weeks after completing treatment is vital:

• Why Three Weeks? This period allows time for any remaining bacterial DNA to clear from the body. Testing too soon might give false positives due to residual DNA fragments.
• Ensuring Success: A TOC confirms that the antibiotic regimen has effectively eradicated the Mycoplasma genitalium infection.

Managing Patients in Regions with High Antibiotic Resistance:

In areas with high antibiotic resistance, patient management becomes more complex:

• Tailored Approach: Use local resistance data to select the most effective antibiotics. In regions with high macrolide resistance, moxifloxacin might be the first line of treatment.
• Close Monitoring: Patients in these areas should have more frequent follow-ups to catch and address any treatment failures early.

Addressing Persistent Symptoms and Ensuring Complete Eradication:

Persistent symptoms after treatment need immediate attention:

• Symptom Review: If symptoms continue, it's important to reassess and possibly retest for Mycoplasma genitalium and other STIs like chlamydia or gonorrhea.
• Alternative Treatments: If initial treatments fail, alternative antibiotics or combination therapies might be necessary to fully clear the infection.

By implementing these strategies, you can ensure thorough treatment and prevent the development of antibiotic-resistant strains of Mycoplasma genitalium in Canada.

How to Notify and Manage Partners to Prevent Reinfection

Guidelines for Partner Notification and Treatment:

Notifying and treating partners is critical to stopping the spread of Mycoplasma genitalium in Canada:

1. Identify Current and Recent Partners: Ask patients to provide contact information for all sexual partners within the past six months.
2. Confidential Notification: Use anonymous notification services or encourage patients to inform their partners directly.
3. Encourage Testing and Treatment: Urge partners to get tested and treated, even if they show no symptoms, to curb the spread of the infection.

Preventing Reinfection of the Index Case:

Preventing reinfection is essential for effective disease management:

• Simultaneous Treatment: Ensure all identified partners receive treatment simultaneously with the index case to prevent the ping-pong effect of reinfection.
• Abstinence During Treatment: Advise patients and their partners to avoid sexual contact until treatment is complete and a TOC confirms the infection has cleared.

Importance of Treating Current Partners Irrespective of Symptoms:

Treating partners, regardless of whether they show symptoms, is a must:

• Asymptomatic Carriers: Many people may carry the infection without symptoms, unknowingly spreading it to others.
• Complete Eradication: Treating all partners ensures the bacteria are fully eradicated, reducing the risk of persistent or recurrent infections.

At TeleTest, we offer both testing and treatment. Patients can test for just mycoplasma genitalium, utilizing NAAT, or do full STI panel to rule out chlamydia and gonorrhea. By following these guidelines, you can help prevent the spread and recurrence of Mycoplasma genitalium, ensuring better public health outcomes in Canada.

Disclaimer: This blog post is intended for educational purposes only and should not be taken as medical advice. Always consult your healthcare provider for personal health concerns.