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Mycoplasma genitalium: Information and guidance for clinicians in British Columbia

Mycoplasma genitalium is an STI that can cause genital symptoms similar to other STIs, including urethritis, cervicitis, and discharge. As it is not a reportable infection, and there is currently no evidence to support routine testing, we do not have good data on prevalence.

The clinical teams at the BC Centre for Disease Control (BCCDC) Sexually Transmitted Infections (STI) Program have been receiving an increasing number of calls for advice around M. genitalium infection.  The majority of these calls have been concerning individuals who are asymptomatic, and in most cases seem to be related to a laboratory universally testing STI samples for this organism regardless of whether or not it was ordered by a clinician. The BCCDC STI Physician Team have developed the guidance summarized below.

  • Routine testing for M. genitalium is not recommended. Testing for this organism should not be performed in anyone who is asymptomatic. This includes those undergoing routine STI screening for chlamydia and gonorrhea.
  • There are specific clinical situations where M. genitalium is known to be of significance and should be tested; for instance, recurrent urethritis and cervicitis. Typically, this would be done once other STIs have been ruled out.
  • Testing (and subsequent treatment) for M. genitalium is generally only appropriate in the context of symptoms (e.g. urethritis, cervicitis, pelvic inflammatory disease) where more likely pathogens like Neisseria gonorrhoeae and Chlamydia trachomatis have either been ruled out or empiric syndromic treatment has failed.
  • Though we acknowledge the paucity of evidence in this area, we generally do not recommend treatment for M. genitalium in those who are asymptomatic. Weighing the risks and benefits, the potential unnecessary overuse of macrolides and fluoroquinolones and risk of antimicrobial resistance is much more of a risk than non-treatment.
  • The decision to test and/or treat for M. genitalium is strictly a clinical decision, and should lie solely with physicians with expertise in this area.

Frequently Asked Questions: Mycoplasma Genitalium Infection

Disclaimer: This information is intended as clinical guidance, and does not replace clinical judgment by clinicians with expertise in this area. As data on M. genitalium continue to emerge, understanding of this organism is evolving, and any recommendations are subject to change.

What is Mycoplasma genitalium?

M. genitalium is a bacterial sexually transmitted infection (STI) that can cause urethritis and cervicitis; it has also been associated with pelvic inflammatory disease (PID). It may cause other syndromes (e.g. proctitis, epididymitis) but there is less data and certainty around these. It is most commonly seen in recurrent/persistent urethritis or cervicitis.

When should someone be tested for M. genitalium?

Until we know more, the general recommendation for testing for this organism is in the context of recurrent or persistent symptoms, typically once other organisms have been ruled out (e.g. chlamydia, gonorrhea). Currently, the BCCDC STI Program recommends against testing for M. genitalium in asymptomatic individuals. All major STI guidelines including the Public Health Agency of Canada (PHAC), US Centres for Disease Control and Prevention, British Association for Sexual Health and HIV, Australia, agree with this approach and advise against asymptomatic testing/screening.

My patient is asymptomatic but has tested positive for M. genitalium. Do I need to treat them?

Only symptomatic individuals should be tested for M. genitalium, and you should only test those you intend to treat. The consequences of asymptomatic M. genitalium infection in both men and women are unknown. Given this, in weighing the risks of potentially unnecessary treatment and its potential to drive antimicrobial resistance (AMR), versus the risk of non-treatment of an organism with questionable significance, we recommend not treating asymptomatic individuals. 

In those with symptomatic M. genitalium who need treatment, what is the best approach?

Treatment for M. genitalium can be challenging, given its often high rates of resistance to one of the commonly-used antibiotics (i.e. azithromycin). Given this, along with the need for a good clinical history in determining a treatment plan, specific treatment recommendations for M. genitalium are outside of the scope of this guidance (see the PHAC STI Guidelines). That said, whenever possible, M. genitalium treatment decisions should always be made using susceptibility testing, a recommendation supported by all major STI guidelines. The BCCDC STI Physicians can also assist with treatment recommendations.

Do I need to treat contacts to diagnosed cases of M. genitalium?

In general, the BCCDC STI Program follows the PHAC STI Guidelines, which recommends treating contacts with the same agent used in the index case. That said, just as we recommend against testing/treating asymptomatic individuals, we recommend against treating contacts of index cases who should not have been tested in the first place (i.e. asymptomatic persons).

I received a positive M. genitalium result on a patient, but I did not order this test. What do I do now?

In general, for the reasons discussed above, this test should only be done when ordered by a clinician, in specific situations where there is a clear intention to treat if it is positive. Again, these testing and treatment decisions need to be made by a clinician with expertise in clinical STI management. Automatic testing of all samples for M. genitalium will inevitably lead to detection of cases of unclear significance, antibiotic overuse, and worsening AMR. Generally, based on what we currently know, the recommendation is not to treat asymptomatic individuals testing positive for M. genitalium. The vast majority of labs in BC do not universally test for M. genitalium. Clinicians should familiarize themselves with the different laboratory options in their area.

This is a controversial area with little data. Why should we listen to you? Are there not different opinions out there?

This guidance follows the PHAC STI Guidelines, as well as other major STI guidelines (United States, Britan, Australia). In the interest of due diligence, prior to putting together this FAQ, the BCCDC STI Physicians Team circulated a few questions on M. genitalium to 14 colleagues* from Canada, the US, and Australia, all of whom are experts in STI clinical care. In response to the question, “Does it make sense to test all STI samples for Mycoplasma genitalium, regardless of symptoms?”, the unanimous response to this question from all respondents was ‘no’.

*In the interest of maintaining respondent confidentiality, we can share aggregate, non-identifiable feedback with those interested.

If you have any questions about Mycoplasma genitalium, please call the BCCDC STI Physician Line.