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Which azithromycin regimen should be used for treating Mycoplasma genitalium? A meta-analysis
  1. Patrick Horner1,2,3,
  2. Suzanne M Ingle1,3,
  3. Frederick Garrett1,
  4. Karla Blee2,
  5. Fabian Kong4,
  6. Peter Muir3,5,
  7. Harald Moi6
  1. 1 School of Social and Community Medicine, University of Bristol, Bristol, UK
  2. 2 Bristol Sexual Health Services, University Hospitals Bristol NHS Trust, Bristol, UK
  3. 3 National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Evaluation of Interventions in partnership with Public Health England, University of Bristol, Bristol, UK
  4. 4 Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
  5. 5 Public Health Laboratory Bristol, National Infection Service, Public Health England, Bristol, UK
  6. 6 Olafia Clinic, Oslo University Hospital, Institute of Medicine, University of Oslo, Oslo, Norway
  1. Correspondence to Dr Patrick Horner, School of Social and Community Medicine, University of Bristol, Oakfield House, Oakfield Grove, BS8 2BN, UK; paddy.horner{at}


Background There is increasing evidence that azithromycin 1 g is driving the emergence of macrolide resistance in Mycoplasma genitalium worldwide. We undertook a meta-analysis of M. genitalium treatment studies using azithromycin 1 g single dose and azithromycin 500 mg on day 1 then 250 mg daily for 4 days (5-day regimen) to determine rates of treatment failure and resistance in both regimens.

Methods The online databases PubMed and Medline were searched using terms “Mycoplasma genitalium”, “macrolide” or “azithromycin” and “resistance” up to April 2016. Studies were eligible if they: used azithromycin 1 g or 5 days, assessed patients for macrolide resistant genetic mutations prior to treatment and patients who failed were again resistance genotyped. Random effects meta-analysis was used to estimate failure and resistance rates.

Results Eight studies were identified totalling 435 patients of whom 82 (18.9%) had received the 5-day regimen. The random effects pooled rate of treatment failure and development of macrolide antimicrobial resistance mutations with azithromycin 1 g was 13.9% (95% CI 7.7% to 20.1%) and 12.0% (7.1% to 16.9%), respectively. Of individuals treated with the 5-day regimen, with no prior doxycycline treatment, fewer (3.7%; 95% CI 0.8% to 10.3%, p=0.012) failed treatment, all of whom developed resistance (p=0.027).

Conclusion Azithromycin 1 g is associated with high rates of treatment failure and development of macrolide resistance in M. genitalium infection with no pre-existing macrolide mutations. There is moderate but conflicting evidence that the 5-day regimen may be more effective and less likely to cause resistance.

  • Mycoplasma genitalium
  • Azithromycin
  • Meta-analysis
  • Drug resistance
  • Doxycycline
  • Mutation

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  • Contributors PH conceived the study idea. PH, FG and KB undertook the literature searches and FG KB and PH reviewed the records for eligibility. PH and FG extracted the data which was checked by SI. SI undertook the statistical analyses. All authors contributed to the data interpretation. PH wrote the first draft with input from FG, HM and SI and revised subsequent drafts following critical review by all authors.

  • Funding This work was supported by the National Institute of Health Research Health Protection Research Unit (NIHR HPRU) in Evaluation of Interventions at the University of Bristol in partnership with Public Health England (PHE).

  • Disclaimer The views expressed are those of the authors and not necessarily those of the National Health Service, the NIHR HPRU, the Department of Health or PHE.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement There is no unpublished data from this meta-analysis, however, should someone wish to discuss the results in more detail please email the corresponding author.

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