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Mycoplasma genitalium

Heavey, Elizabeth PhD, RN, CNM

doi: 10.1097/01.NURSE.0000520524.30192.07
Department: COMBATING INFECTION
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Elizabeth Heavey is a certified nurse midwife, epidemiologist, and professor of nursing at SUNY Brockport in Brockport, N.Y. She also serves as an editorial board member for Nursing2017.

The author has disclosed no financial relationships related to this article.

ALTHOUGH IT WAS FIRST identified in the 1980s, Mycoplasma genitalium (MG) is still a little-known sexually transmitted infection (STI). This article reviews the epidemiology, signs and symptoms, treatment, and nurse's role in prevention of MG.

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Epidemiology

MG is caused by a bacterium from the mollicute class that can colonize the reproductive tract in men and women.1 MG infection is associated with nongonococcal urethritis (NGU) in men and cervicitis, pelvic inflammatory disease (PID), and tubal factor infertility in women.2,3

MG infection is currently estimated to be prevalent in 1% to 3.3% of people in the U.S. and Europe.

MG infection during pregnancy is associated with preterm birth and may be implicated in early pregnancy loss and neonatal infection.4 It can occur concurrently with Chlamydia trachomatis and other STIs, so discerning the independent effect of MG infection is difficult.1

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MG and HIV

MG infection impacts HIV susceptibility as well as HIV transmission rates among those concurrently infected. MG infection triggers inflammation and the release of cytokines; if exposed to HIV, this increases the patient's susceptibility to actual HIV infection. In addition, MG impacts the integrity of the epithelial barrier, which also facilitates HIV infection. Patients infected with MG and HIV shed larger amounts of HIV, potentially increasing HIV transmission rates during unprotected sexual activity.2

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Detection

MG grows poorly and slowly in a traditional culture medium. MG can be accurately detected by nucleic acid amplification tests (NAATs), including polymerase chain reaction and transcription-mediated amplification tests, which are currently available only for research purposes in a limited number of medical centers and commercial labs.1,5 If NAATs are available, patients with persistent NGU, cervicitis, or PID should be tested for MG infection and treated accordingly (see Suspicious signs and symptoms).2 NAATs may be performed on vaginal and cervical/urethral swabs and on endometrial biopsy specimens for women; and on urethral swabs, semen, prostatic secretions, or urine for men.1 Vaginal swabs for women and first-void urine samples for men appear to provide the best results when testing for MG.5 If NAATs aren't available, MG should be suspected and treated presumptively in cases of persistent or recurrent urethritis, cervicitis, and PID.1

Currently no FDA-approved diagnostic tests are available in the United States, and current CDC guidelines don't recommend screening asymptomatic patients for MG.1

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Treatment

Urethritis and cervicitis treatment guidelines currently include a single dose of azithromycin or a 5-day dosing schedule. The 5-day dosing schedule is preferred for pregnant patients and may have a slightly higher cure rate than the single dose of azithromycin, but adherence may be a concern.6

In some settings, 40% of MG infections are resistant to azithromycin.5 Moxifloxacin has been used (for 7-10 days) successfully to treat MG with encouraging data available from other countries, but it hasn't been tested in clinical trials and only limited data are available to date.1 Because of high levels of azithromycin resistance, repeated clinical evaluation in 3 to 4 weeks is recommended by some providers.7 Treatment with moxifloxacin is recommended if azithromycin treatment fails.7

Current CDC guidelines for the treatment of PID don't include treatment for MG, but the guidelines do recommend treating patients who don't respond to standard PID treatment for MG infection.8 Providers may consider MG testing, when available. Infected sexual partners should follow the management guidelines for sexual partners of patients with NGU, cervicitis, and PID.1

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Prevention

Though we currently lack a viable population-based screening mechanism for MG, we do need to do our best to monitor and contain this emerging STI. Teaching our patients about safer sexual practices is essential to prevent MG as well as other STIs. Many patients aren't aware of how having one STI can impact their risk of acquiring or transmitting another STI.

Nurses can provide this critical patient information to help promote safer sexual behavior and disease containment. Encouraging regular sexual health visits among all our sexually active patients is critical. Some STIs are asymptomatic and may be detected during routine screening and exams. As always, keeping an open line of communication with our patients helps facilitate the best possible outcomes.

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SUSPICIOUS SIGNS AND SYMPTOMS5

Patients with MG infection may present with any of the following:

Cervicitis

  • frequently asymptomatic
  • vaginal discharge
  • vaginal pruritus
  • dysuria
  • pelvic discomfort
  • irregular bleeding, particularly after sexual activity and between menstrual periods
  • pain with intercourse

Pelvic inflammatory disease

  • abdominal pain
  • pelvic pain
  • abnormal vaginal discharge/bleeding
  • fever
  • cervical motion tenderness

Urethritis

  • dysuria
  • urethral pruritus
  • mucopurulent urethral discharge.
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REFERENCES

1. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. Morbidity and Mortality Weekly Report. 2015;64(RR3):1–137.
2. Davies N. Mycoplasma genitalium: the need for testing and emerging diagnostic options. MLO Med Lab Obs. 2015;47(12):8.
3. Jensen JS, Bradshaw C. Management of mycoplasma genitalium infections - can we hit a moving target. BMC Infect Dis. 2015;15:343.
4. Lis R, Rowhani-Rahbar A, Manhart LE. Mycoplasma genitalium infection and female reproductive tract disease: a meta-analysis. Clin Infect Dis. 2015;61(3):418–426.
5. Mobley V, Sena AC. Mycoplasma genitalium infection in men and women. 2017. UpToDate.com.
6. Jensen JS, Cusini M, Gomberg M. 2016 European guideline on Mycoplasma genitalium infections. 2016. http://www.iusti.org/regions/europe/pdf/2016/2016EuropeanMycoplasmaGuidelines.pdf.
7. Manhart LE, Broad JM, Golden MR. Mycoplasma genitalium: should we treat and how. Clin Infect Dis. 2011;53(suppl 3):S129–S142.
8. Ona S, Molina RL, Diouf K. Mycoplasma genitalium: an overlooked sexually transmitted pathogen in women? Infect Dis Obstet Gynecol. [e-pub Apr. 24, 2016].
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