The Population-Level Effect of Screening for Mycoplasma genitalium on Antimicrobial Resistance: A Quasi-Experimental Study

Mycoplasma genitalium molecular typing in men with non-gonococcal urethritis discriminates between phylogenetic clusters based on sexual preference and antibiotic resistance

Introduction. Mycoplasma genitalium is a sexually transmitted bacterium associated with non-gonococcal urethritis (NGU) in men. The rising macrolide and fluoroquinolone resistance in M. genitalium has become a public health concern, requiring close surveillance.Gap statement. MgpB/MG309 typing is commonly used to study genotype distribution and resistance patterns of M. genitalium in men who have sex with men (MSM); however, data for men who have sex with women (MSW) are limited.Aim. The aim of this study was to explore the epidemiology of M. genitalium based on mgpB/MG309 molecular typing in isolates from men diagnosed with NGU, comparing MSM and MSW. Additionally, antibiotic resistance was evaluated to assess associations between the mgpB/MG309 genotypes, antimicrobial resistance profiles, and epidemiological determinants.Methodology. A subset of previously collected M. genitalium isolates from men diagnosed with NGU in Amsterdam, the Netherlands, between May 2018 and November 2019 was analysed. Molecular typing was performed by sequencing relevant regions of the mgpB and MG309 loci. Macrolide resistance was assessed by detecting mutations in the 23S rRNA gene via quantitative polymerase chain reaction, while fluoroquinolone resistance was determined through sequencing parC and gyrA.Results. A total of 62 M. genitalium samples were analysed from 33 MSM and 29 MSW. The overall macrolide and fluoroquinolone resistance was 75.8% and 24.2 %, respectively. At the mgpB locus, 24 sequence types (STs) were identified, with ST4 most prevalent in MSM and ST2 in MSW. The MG309 locus revealed 12 distinct short tandem repeat numbers, with repeat 10 being most common in both groups. Phylogenetic analysis based on mgpB sequences revealed two clusters: cluster A included significantly more MSW, whereas cluster B predominantly comprised MSM (P<0.001). Macrolide and fluoroquinolone resistance was significantly higher in cluster B compared with cluster A (P<0.01 and P<0.05, respectively).Conclusion. Molecular typing of M. genitalium revealed two clusters that differed by sexual preference and antibiotic resistance, highlighting the importance of surveillance of resistance across genotypes. The findings suggest multiclonal spread of resistance through independent mutations. Future studies using next-generation sequencing are needed to further explore the links between sexual transmission and genetic diversity in M. genitalium.

German evidence- and consensus-based guideline on the management of penile urethritis

Urethritis is a common condition predominantly caused by sexually transmitted pathogens such as Chlamydia trachomatis, Neisseria gonorrhoeae, and Mycoplasma genitalium. It is not possible to differentiate with certainty between pathogens on the basis of clinical characteristics alone. However, empirical antibiotic therapy is often initiated in clinical practice. The aim of this clinical practice guideline is to promote an evidence-based syndrome-orientated approach to the management of male adolescents and adults with symptoms of urethritis. Besides recommendations for the diagnosis, classification and choice of treatment, this guideline provides recommendations for the indication to empirically treat patients with penile urethritis. A novel feature compared to existing, pathogen-specific guidelines is the inclusion of a flowchart for the syndrome-orientated practical management. For suspected gonococcal urethritis requiring empirical treatment, ceftriaxone is recommended. Due to the risk of Chlamydia trachomatis co-infection, doxycycline should also be prescribed, unless follow-up for the treatment of possible co-infections is assured. For suspected non-gonococcal urethritis, doxycycline is the recommended empirical treatment. In the empiric treatment of both gonococcal and non-gonococcal penile urethritis, azithromycin is reserved for cases where doxycycline is contraindicated. This guideline also includes detailed recommendations on differential diagnosis, pathogen-specific treatments and specific situations, as well as patient counselling and follow-up.

Mycoplasma genitalium Infections Among Participants in an HIV Pre-exposure Prophylaxis Program in Hanoi, Vietnam

BACKGROUND

Mycoplasma genitalium causes a sexually transmitted infection and is also emerging as an important antimicrobial resistant pathogen. Data on M. genitalium infections among men who have sex with men (MSM) in low-resource settings are sparse.

METHODS

From January to December 2022, participants in an HIV pre-exposure prophylaxis (PrEP) program in Hanoi, Vietnam were enrolled into the study. Demographic, behavioral, and clinical characteristics were collected. Self-collected urine, rectal, and pharyngeal specimens were tested for M. genitalium using the Alinity m STI Assay (Abbott Molecular, USA). Univariate and multivariate logistic regression were performed to assess for factors associated with infections.

RESULTS

Among 477 participants, the median age was 25.3 years (21.7-29.6) and 92.2% (n = 440) identified as MSM; 48.6% had ≥2 sex partners and 38.1% reported condomless anal sex in the prior month. The overall prevalence of M. genitalium infection was 10.9% (52/477); 7.3% (34/464) rectal, 3.2% (15/476) urethral, and 1.9% (9/476) pharyngeal. Infections were asymptomatic in 71.2% (37/52). Among those with M. genitalium , 30.7% (16/52) were co-infected with either Neisseria gonorrhoeae or Chlamydia trachomatis. Among those reporting rectal (n = 51) or urethral (n = 35) symptoms, but without C. trachomatis or N. gonorrhoeae co-infections, five (9.8%) had rectal infections and one (2.9%) had urethral infection. Participants with M. genitalium were more likely to be asymptomatic than participants without M. genitalium (adjusted odds ratio, 1.93; 95% confidence interval, 1.01-3.71).

CONCLUSIONS

Mycoplasma genitalium infections were common among primarily MSM engaged in an HIV PrEP program in Vietnam. The prevalence was highest in rectal specimens and nearly three quarters of M. genitalium infections were asymptomatic. Testing for M. genitalium infections among those with symptoms is important to enable pathogen-directed therapy. Additional research on antimicrobial resistance and treatment strategies for M. genitalium in low-resource settings is needed.

Management of asymptomatic sexually transmitted infections in Europe: towards a differentiated, evidence-based approach

Most sexually transmitted infections (STIs) can be accurately diagnosed and treated during asymptomatic carriage. Widespread screening for these STIs is therefore assumed to be an effective way to reduce their prevalence and associated disease. In this review, we provide evidence that this is the case for HIV and syphilis. However, for other STIs such as Neisseria gonorrhoeae and Chlamydia trachomatis, our review reveals that the evidence that screening reduces infection prevalence and associated disease is weak. There is also growing evidence of harms from screening that might outweigh any benefits. The harms include the increased consumption of antimicrobials that follows frequent screening and increased detection of asymptomatic STIs in key populations, such as men who have sex with men taking HIV pre-exposure prophylaxis, and associated risk of antimicrobial resistance in target and non-target organisms. There may also be psycho-social harm associated with an STI diagnosis. We conclude that in the absence of symptoms, in high STI prevalence populations frequent STI screening should be limited to HIV and syphilis.

Mycoplasma genitalium and Antimicrobial Resistance Among a Cohort of West African Men Who Have Sex With Men Using Preexposure Prophylaxis (CohMSM-PrEP ANRS 12369-Expertise France Study)

BACKGROUND

Antimicrobial resistance to macrolides and fluoroquinolones in Mycoplasma genitalium (MG) among men who have sex with men (MSM) is worryingly high in high-resource countries. Data in Africa are lacking. We aimed to assess the burden of MG including the presence of resistance-associated mutations (RAMs) in MG among MSM using human immunodeficiency virus preexposure prophylaxis in Burkina Faso, Côte d'Ivoire, Mali, and Togo.

METHODS

MSM were included in a prospective cohort study (2017-2021). Molecular detection of MG in urine, anorectal, and pharyngeal samples was performed at baseline and after 6 and 12 months. Detection of RAMs to macrolides and fluoroquinolones was performed by sequencing the 23S ribosomal RNA, parC, and gyrA genes. A sample was found to be possibly resistant to fluoroquinolones if alterations were found in ParC position 83/87.

RESULTS

Of 598 participants, 173 (28.9%) were positive at least once for MG and global point-prevalence was 19.4%. Interestingly, 238 of 250 (95.2%) infections were asymptomatic and 72 of 138 MG infections with follow-up data (52.2%) cleared during the study. Only 1 macrolide RAM was found (0.6%). Prevalence of fluoroquinolones RAMs was 11.3% overall, ranging from 2.4% in Burkina Faso to 17.5% in Mali.

CONCLUSIONS

Although MG was highly prevalent in these MSM, macrolide resistance was almost nonexistent. Nevertheless, >10% of the samples were possibly resistant to fluoroquinolones. Heterogeneity in the prevalence of fluoroquinolone RAMs between countries may be explained by different antimicrobial consumption in humans and animals.

Worryingly high prevalence of resistance-associated mutations to macrolides and fluoroquinolones in Mycoplasma genitalium among men who have sex with men with recurrent sexually transmitted infections

Background

Men who have sex with men (MSM) using pre-exposure prophylaxis (PrEP) recurrently infected with STIs are playing a pivotal role in contemporary Sexually transmitted infections (STI) epidemics. Our aim was to assess whether these individuals had more Mycoplasma genitalium ( M. genitalium) infections and more resistance to macrolides and fluoroquinolones of M. genitalium compared to those who were not recurrently infected with STIs.

Methods

The study was performed on 179 Belgian MSM PrEP users that were followed up for 18 months. STIs including M. genitalium were detected quarterly. Detection of resistance-associated mutations (RAMs) to macrolides and fluoroquinolones was performed via Sanger sequencing of the 23S rRNA gene and parC gene (conferring mutations at position 83/87 in ParC). Differences in M. genitalium positivity rate and presence of RAMs between both groups were assessed using mixed-effects logistic regression.

Results

A total of 91 new M. genitalium infections were detected among 70 participants. MSM experiencing recurrent STIs have significantly more M. genitalium infections compared to those without (11.7% vs. 4.7% OR: 2.69). Importantly, the prevalence of RAMs to macrolides (95.2% vs. 77.4%) and fluoroquinolones (35.7% vs. 12.9%) was much higher among individuals with recurrent STIs. The difference was only statistically significant for macrolides (OR 5.83, p = .036).

Conclusions

MSM recurrently infected with STIs play a central role in the emergence of antimicrobial resistance in M. genitalium. The use of macrolides and fluoroquinolones should preferably be minimized in this population in order to avoid further emergence of multi-resistant M. genitalium.