Abstract
In Japan and Australia, multidrug-resistant Mycoplasma genitalium infections are reported with increasing frequency. Although macrolide-resistant M. genitalium strains are common in Europe and North America, fluoroquinolone-resistant strains are still exceptional. However, an increase of multidrug-resistant M. genitalium in Europe and America is to be expected. The aim of this paper is to increase awareness on the rising number of multidrug-resistant M. genitalium strains. Here, one of the first cases of infection with a genetically proven multidrug-resistant M. genitalium strain in Europe is described. The patient was a native Dutch 47-year-old male patient with urethritis. Mycoplasma genitalium was detected, but treatment failed with azithromycin, doxycycline and moxifloxacin. A urogenital sample was used to determine the sequence of the 23S rRNA, gyrA, gyrB and parC genes. The sample contained an A2059G single nucleotide polymorphism (SNP) in the 23S rRNA gene and an SNP in the parC gene, resulting in an amino acid change of Ser83 → Ile, explaining both azithromycin and moxifloxacin treatment failure. The SNPs associated with resistance were probably generated de novo, as a link with high-prevalence areas was not established. It is, thus, predictable that there is going to be an increase of multidrug-resistant M. genitalium strains in Europe. As treatment options for multidrug-resistant M. genitalium are limited, the treatment of M. genitalium infections needs to be carefully considered in order to limit the rapid increase of resistance to macrolides and fluoroquinolones.
Highlights
Mycoplasma genitalium infects between 1.0 and 3.5% of sexually active people in the general European population [1–3] and is slightly higher in patients from sexually transmitted infection (STI) screenings [4–6]
Multidrug-resistant M. genitalium strains are frequently reported in the Pacific: in Australia, multidrug-resistant M. genitalium strains were identified in 9.8% [14] and in Japan in up to 30.8% of the patients screening for STIs [15]
A single nucleotide polymorphism (SNP) in the parC gene resulting in an amino acid change of Ser83 → Ile was observed, explaining the resistance to moxifloxacin [16]
Summary
Mycoplasma genitalium infects between 1.0 and 3.5% of sexually active people in the general European population [1–3] and is slightly higher (up to 6.0%) in patients from sexually transmitted infection (STI) screenings [4–6]. 40% of the M. genitalium strains are resistant to azithromycin [13]. Multidrug-resistant M. genitalium strains are frequently reported in the Pacific: in Australia, multidrug-resistant M. genitalium strains were identified in 9.8% [14] and in Japan in up to 30.8% of the patients screening for STIs [15]. The first genetically proven fluoroquinolone-resistant strain in Europe was described by Pond et al in the UK [16]. This strain possessed no macrolide resistance-associated mutation, since it could be treated successfully with azithromycin and the patient had no symptoms during the 5-month follow-up period. It is to be expected that an increasing number of the circulating M. genitalium strains in Europe would be resistant to both macrolides and fluoroquinolones. There are almost no peer-reviewed reports on the occurrence of
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