MYCOPLASMA GENITALIUM IN SCOTLAND

KATE TEMPLETON

ROYAL INFIRMARY EDINBURGH

DIRECTOR SCOTTISH STI REFERENCE LAB

MYCOPLASMA GENITALIUM

First discovered in 1980s

1990s – sexually transmitted – epidemiology studies indicated MG infection in

people who had unprotected sex and people who never had sex had no infection

SYMPTOMS

Men – non-gonocoocal urethritis (NGU)

Women - less clear, cervicitis, pelvic inflammatory disease

PREVALENCE

Unclear - not part of routine STI health screen in UK

Published data tend to be from small scale studies

Opportunistic screening of general population ~1-2%

Patients attending sexual health clinics 3-17%

TREATMENT

Sensitive to macrolides, tetracyclines, and fluoroquinolones

Treatment with tetracycline not recommended – high rates of clinical failure

First line – macrolides – protein synthesis inhibitors

Second line – fluoroquinolones – inhibits DNA synthesis

Azithromycin 500 mg single dose, then 250 mg daily for 4 days, or 1 g single dose orally

Doxycyline100 mg twice daily or 200 mg once daily orally for seven days

M. genitalium macrolide-resistant strains should be treated with moxifloxacin 400 mg

once daily for 7(-10) days

Suggested best approach is start with Doxycyline – reduces load and if not resistant switch

to Azithromycin if resistance switch to Moxifloxacin

RESISTANCE

Treatment failure associated with azithromycin resistance

Resistance increased -prescribe azithromycin patients with Chlamydia

MG detection has increased as a results of treatment failure

Macrolide resistance – mutations in 23S rRNA gene

Fluoroquinolone resistance – mutations in gyrA and parC genes

Macrolide resistance rates 14.2%1 to 82%2

Fluoroquinolone resistance rates 5%3 -15%4

1 France 2 England 3 England 4 Australia

Public health

concern as limited

alternative

antimicrobial

treatments

SAMPLES TESTED BY PHE COLINDALE

44 samples

Approx cost £4,000

STUDY

To determine the frequency of Mycoplasma genitalium presence

and its resistance to macrolides

within the NHS Lothian and NHS GGC sexual health services

STUDY DESIGN

Anonymised residual swab elute samples from women and urine samples from men attending sexual & reproductive health clinics within the Lothian Health Board that have

been identified as high-risk for Mycoplasma genitalium

Inclusion criteria:

1) Males with urethritis

2) Females ( Lothian only) who are:

a) Aged <25 years

b) Diagnosed with presumed cervicitis, endometritis or

pelvic inflammatory disease

Exclusion criteria:

1) Genital chlamydia/gonorrhoea test not

requested

2) Inadequate sample

METHOD

1. Samples collected

and anonymised

(Feb 17- Nov17)

2. Automated extraction of

nucleic acids from clinical

specimen 3. Real-time PCR

RESULTS

57-80% resistance

Samples M genitalium resistant CT GC

Lothian 146 11 9 50 10

Glasgow 199 17 10 0 0

0

20

40

60

80

100

120

140

160

180

200

Axis

Tit

le

RESISTANCE – MACROLIDE AND QUINOLONE

Male Female Total

A2059G 6 1 7

A2059C 1 0 1

A2058G 5 0 5

A2058T 1 0 1

AIM TO START TESTING WITHIN SCOTLAND HOW TO COST NEW SERVICE

PLAN AND GO LIVE

Went live in Jan 2018.

Assessed as part of UKAS visit

Charge £40/test – done by NHS Lothian not part of SBSTIRL.

Testing is currently limited to 400 samples /per anum in Lothian

Other health boards will follow in due course. ( we hope)

SBSTIRL ( NSS funded) validating Resistance testing.

Request that all M.gen positive cases are sent to SBSTIRL for resistance determination

If samples sent to PHE local board who have to pay rather than NSS

WHO TO TEST - NO GUIDELINES IN 2017

Recurrent or persistent NGU (whether Chlamydia positive or negative)

Recurrent or persistent epididymoorchitis

Contacts of patients treated for mycoplasma genitalium

Women:

PID with symptoms persisting after 2 weeks of treatment

Contacts of patients treated for mycoplasma genitalium

SINCE GO LIVE – 8 JAN 2018

104 samples

20 positive ( 19%)

13 resistance (65%)

Cost to lab £1,500

Saving of £10,400

RESISTANCE – MACROLIDE AND QUINOLONE - TREATMENT

Aim to test for M genitalium and test directly for macrolide resistance

Treatment – Moxifloxacin

So far Quinolone resistance rare – 1 case so far

Options see if treatment given is successful at TOC ( 4-5 weeks )

If still symptomatic

3rd line Doxycycline – followed by pristinamycin

Only to test current partner – not one of contacts

BASHH GUIDELINES – M GENITALIUM IMPACT FOR SCOTLAND

BASHH GUIDELINES - PROPOSED

All Men with urethritis

All women with PID

Contacts of positives

TOC - > 6-8 weeks

Rapid determination of azithromycin resistance prior to treatment

Estimated number – lothian – around 5,000/ year

Compare to CT – 70,000 per year

? INCREASE IN AZITHROMYCIN GC

20

2012 2013 2014 2015 2016 2017

Total number of GC

episodes 1905 1597 1820 2257 2193 1741*

Number of episodes

with culture 958 803 936 1101 1101 930*

Number of Hi-L AziR

GC 0 0 3 3 2 21

LINK TREATMENT AND TESTING

Treatment Treatment

Tests and Results Tests and Results

LINK TREATMENT AND TESTING

Treatment

Tests and Results

USE CIPRO FOR GC

23

70% of

Scottish GC is

susceptible to

Cipro

AST – too

slow

NEXT STEPS

ACKNOWLEDGEMENTS

Microbiology labs - RIE

Rebecca Dewar

Ewan Olson

Jill Shepherd

Lynne Renwick

Diane Ghahouo

Lauren Reid

Terry Sunderland

GUM department

Dan Clutterbuck

Nori Achyuta

Carlos Oroz

Jackie Paterson

Imali Fernando

Glasgow

Rory Gunson

Amanda Bradley Stewart

Rebecca Gilson