26 March 2018
The 2017/18 critical review of the Australian STI Management Guidelines for use in primary care is now complete with a focus on STI and syndrome management. Important changes have been made to the management of urethritis, cervicitis, PID, anorectal syndromes and Mycoplasma Genitalium (MG). Many of the changes have been promoted by a better understanding of MG.
The Guidelines are an online resource for primary care to provide concise information for the prevention, testing, diagnosis, and management of STIs in adults and adolescents and are widely used across Australia and New Zealand with over 16,000 users per month. They were developed and are maintained via yearly review by the Australasian Sexual Health Alliance (ASHA) and is hosted by ASHM. They should be used by clinicians prescribing PrEP and in conjunction with ASHM PrEP prescribing tools.
Update to the treatment of Mycoplasma Genitalium in general practice
MGen: What do primary care providers need to know?
Mycoplasma Genitalium (MG) is a bacterium that infects the urethra, cervix and anus. It is sexually transmitted by unprotected vaginal and anal sex. Clinical manifestations are similar to chlamydia: urethritis, cervicitis, pelvic inflammatory disease (PID), proctitis. Problems arise in general practice because of:
- Increasing drug resistance
- Limited availability of testing and testing for drug resistance
- Rapidly changing guidelines and limited clinical evidence
- Low levels of awareness amongst patients and doctors
- Treatment of drug resistance involves drugs which are expensive and difficult to access
Who does it affect?
Those at risk in Australia are sexually active men and women, particularly those with multiple partners.
Clinical presentation is highly variable:
- Mild symptoms
- Urethritis: dysuria and/or discharge
- Cervicitis: vaginal discomfort and/or discharge
- PID: pain during sex, pelvic pain, deep pain, abdominal pain
- Proctitis: pain
What’s the situation with resistance?
Unfortunately, MG is becoming resistant to its current first line treatment, azithromycin. This is the situation for approximately 50% of heterosexual cases and more than 80% of cases of men who have sex with men. Sexual health experts are now advising caution over the use of azithromycin for treatment of STI syndromes as overuse is contributing to this resistance.
Most laboratories now have a MG NAAT testing available for first pass urine, vaginal, cervical and anal specimens, which can also be tested for gonorrhoea and chlamydia. Some laboratories have access to a MG NAAT test that also detects macrolide (azithromycin) resistance.
Screening of asymptomatic individuals is not recommended. Only test those with symptoms or contacts.
What are the recommendations on treatment?
The Australian STI Management Guidelines for Primary Care, a resource produced by the Australasian Sexual Health Alliance, now recommend:
- initial treatment of MG with doxycycline 100mg/bd for one week
- followed by either azithromycin or a fluoroquinolone (moxifloxacin).
- Doxycycline is now also recommended for initial treatment of syndromes that may be caused by MG including urethritis and cervicitis.
As explained by Tim Read NHMRC Research Fellow, Central Clinical School, Monash University and Sexual Health Physician, Melbourne Sexual Health Centre, “If macrolide-sensitive MG is detected, then this can be treated with azithromycin with greater confidence. We are hopeful, but less certain, that this reduction in bacterial load will also increase the likelihood of success with moxifloxacin treatment.”
To view the full updated guidelines on MG and for other STIs and syndromes, please visit the Australian STI Management Guidelines for use in primary care website
The Australasian Sexual Health Alliance (ASHA) is a group of partner organisations established to improve national and local responses to sexual health issues, via a multidisciplinary support network for the sexual health workforce. It aims to strengthen bonds between specialists, GPs, nurses, researchers and other key contributors to the sexual health sector, through collaboration in sexual health education, training, policy-making and research.
For any general queries, contact:
Sarah Maunsell, ASHA Secretariat
T: +61 2 8204 0700 (Reception)