Introduction

Seven mycoplasmal strains have been isolated from the genital tract, of which Mycoplasma hominis and Mycoplasma genitalium are the commonest.

M. genitalium has an unknown incubation period, but symptoms commonly develop within one to three weeks.

There is an estimated 2–2.5-fold increase in the risk of urethritis, cervicitis, pelvic inflammatory disease, infertility and preterm delivery for women infected with M. genitalium.¹

It can be found in the vagina, cervix and endometrium, and usually the infections are asymptomatic. Most studies have the organism in 10–30 per cent of women with clinical cervicitis.

M. genitalium infection is a sexually transmitted infection.

Clinical Presentations

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  Dysuria

  
  
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  Vaginal discharge

  
  
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  Urethral discharge

  
  
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  Pelvic pain

  
  
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  Possibly proctitis

  
  
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  Intermenstrual bleeding

  
  
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  Post-coital bleeding

Complications

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  Pelvic inflammatory disease (PID)

  
  
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  Infertility

  
  
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  Ectopic pregnancy

Effect on Pregnancy

1. 
   

   1. Preterm labour

   
   
2. 
   

   2. Miscarriage

   
   
3. 
   

   3. Chorioamnionitis

   
   
   
   
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     A meta-analysis demonstrated an approximately two-fold increased risk of cervicitis, preterm birth and spontaneous abortion in women infected with M. gentialium. [EL 1]

     
     
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     M. hominis was isolated from blood in approximately 13 per cent of women with postpartum and post-abortion fever.

     
     
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     It was found to be an independent risk factor for preterm delivery after 24 weeks of gestation.²

   
   

Diagnosis

M. genitalium is a slow-growing organism.

1. 
   

   1. Culture can take up to six months, and only a few laboratories in the world are able to recover clinical isolates.

   
   
2. 
   

   2. Nucleic acid amplification test (NAAT) is the preferred method for M. genitalium detection. It is only available in a few large medical centres and commercial laboratories.

Diagnosis is made by NAAT testing of urine, urethral, vaginal and cervical swabs and through endometrial biopsies, typically using in-house polymerase chain reaction (PCR) or assays intended for research use only.³

Treatment

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  M. genitalium lacks a cell wall, and thus antibiotics targeting cell wall biosynthesis (e.g. beta-lactams including penicillins and cephalosporins) are ineffective against this organism.

  
  
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  Due to diagnostic challenges, treatment of most M. genitalium infections occurs in the context of syndromic management for urethritis, cervicitis and PID.⁴

A) First-Line Therapy

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  Single dose of 1 g azithromycin was more effective than doxycycline in two randomised urethritis treatment trials and is the preferred choice. [EL 1]

However, resistance to azithromycin appears to be rapidly growing as median cure rate used to be approximately 85 per cent, but in the most recent trial (278) was found to be in only 40 per cent.

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  Longer course of azithromycin (an initial 500 mg dose followed by 250 mg daily for four days) might be marginally superior. However, in some settings, approximately 50 per cent of all M. genitalium infections are caused by organisms that are already resistant to azithromycin, therefore no regimen has beneficial effect over others.

B) Second-Line Therapy

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  Moxifloxacin, a fourth-generation fluoroquinolone (400 mg daily for 14 days), has been successfully used to treat M. genitalium in men and women with previous treatment failures, with cure rates of 100 per cent in initial reports.

  
  
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  However, it has been used in only a few cases, and the drug has not been tested in clinical trials. Although generally considered effective, studies in Japan, Australia and the United States have reported moxifloxacin treatment failures after the seven-day regimen.⁵

Contact Tracing

1. 
   

   1. In heterosexuals there is a greater risk of PID and reproductive complications, which suggests a greater need to trace, test and treat infected contacts. The time period for contact tracing is unknown.

   
   
2. 
   

   2. Usual testing method: nucleic acid amplification testing on first-pass urine in men (urethral swab less sensitive) and first-pass urine, high vaginal or cervical swab in women.

   
   
3. 
   

   3. It is sexually transmitted, with possible infection due to oral sex.

   
   
4. 
   

   4. Duration of potential infectivity is unknown, but persistent infection occurs in 25 per cent of cases, which may persist to more than 12 months. Infections up to two to three years have been reported.⁸

Fetal Implications

Vertical transmission from mothers to their infants occurs in utero or during delivery.

1. 
   

   1. Early pregnancy loss

   
   
2. 
   

   2. Stillbirth, preterm birth

   
   
3. 
   

   3. Neonatal morbidities

The clinical history of patients with urogenital or extragenital infections because of Ureaplasma species is syndrome-specific, not organism-specific. Usually there are no distinguishing features to indicate the microbiologic aetiology of these infections.⁹

Because of lack of facilities to diagnose Ureaplasma infections in many clinical settings, many clinicians are unfamiliar with aetiologic agents. Identification of these organisms may be achieved only as a last resort, especially if initial treatment with ineffective drugs is unsuccessful.

Signs and Symptoms in Adults

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  Urethritis

  
  
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  Pyelonephritis

  
  
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  Cystitis

  
  
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  Urinary calculi

  
  
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  Endometritis or chorioamnionitis

  
  
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  Infectious arthritis

  
  
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  Surgical and non-surgical wound infections

  
  
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  Bacteraemia

  
  
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  Pneumonia

  
  
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  Meningitis

Neonatal Implications

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  Neonates, particularly if preterm, are especially vulnerable to dissemination of infectious organisms (acquired in utero or at birth) in the bloodstream and, ultimately, the central nervous system.

  
  
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  Usually there are no characteristic signs and symptoms to predict the type of organism present. Subtle manifestations, such as temperature instability, blood pressure fluctuations, heart rate and respiratory efforts, may be the only signs that an infection is present.

  
  
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  Consider Ureaplasma species if signs and symptoms of infection are present; if the neonate does not respond to beta-lactam drugs; and if cultures from blood, the lower respiratory tract and cerebrospinal fluid (CSF) do not reveal a more common microbiological cause.

  
  
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  Radiographic evidence of pneumonitis in the absence of a proven bacterial or viral cause and mononuclear or polymorph nuclear pleocytosis (an abnormal increase in the amount of lymphocytes in the CSF with a negative Gram stain and culture result are consistent with Ureaplasma infection.

  
  
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  Although these organisms have been considered of low virulence, in vitro and in vivo experimental models have provided extra evidence that perinatal morbidities in premature babies (such as bronchopulmonary dysplasia, intraventricular haemorrhage and necrotising enterocolitis) do exist.¹⁰

Diagnosis

Antimicrobial Therapy

1. 
   

   1. Erythromycin ethylsuccinate

   
   

   Dose: oral 800 mg tablets, eight-hourly for seven days

   
   
2. 
   

   2. Clarithromycin

   
   

   (USA only) Dose: suspension, 500 mg oral 12-hourly for 7–14 days

   
   
3. 
   

   3. Azithromycin

   
   

   Dose: 1 g orally in a single dose¹²

Background

Chancroid is a bacterial sexually transmitted disease (STD) caused by Haemophilus ducreyi infection. It is characterised by painful necrotising genital ulcers that may be accompanied by inguinal lymphadenopathy. It is a highly contagious but curable disease.

Clinical manifestations include genital ulcers and inguinal lymphadenopathy.¹³

Chancroid was previously highly prevalent in many areas of the world. Because of collaborative efforts and increasing social awareness, along with subsequent changes in sexual practices, improved diagnosis and treatment options, it has been eradicated as an endemic disease in industrialised countries.¹⁴

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  In 2000, the proportion of chancroid among genital ulcerative diseases decreased from 69 per cent to 15 per cent.

  
  
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  It remains prevalent in certain underdeveloped regions such as Asia, Africa and the Caribbean. In these areas, outbreaks occur in cities among workers in the sex trade.

  
  
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  Individuals travelling to these high-risk areas are at risk of contracting the disease.

  
  
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  In addition, individuals from high-risk areas who travel to other countries to work in the sex industry remain a source of outbreaks in the industrialised world.