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Original article
Impact of mass drug administration of azithromycin for trachoma elimination on prevalence and azithromycin resistance of genital Mycoplasma genitalium infection
  1. Mark Andrew Harrison1,
  2. Emma Michele Harding-Esch1,2,
  3. Michael Marks3,
  4. Marcus James Pond1,
  5. Robert Butcher3,
  6. Anthony W Solomon3,
  7. Liqing Zhou1,
  8. NgeeKeong Tan4,
  9. Achyuta V Nori1,
  10. Henry Kako5,
  11. Oliver Sokana6,
  12. David C W Mabey3,
  13. Syed Tariq Sadiq1,2
  1. 1 Applied Diagnostic Research and Evaluation Unit, St George's, University of London, London, UK
  2. 2 HIV/STI Department, Public Health England, London, UK
  3. 3 Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
  4. 4 Southwest London Pathology, St George's University Hospitals NHS Foundation Trust, London, UK
  5. 5 Department of STI and HIV Prevention, Ministry of Health and Medical Services, Honiara, Solomon Islands
  6. 6 Eye Health Department, Ministry of Health and Medical Services, Honiara, Solomon Islands
  1. Correspondence to Dr Syed Tariq Sadiq, Applied Diagnostic Research and Evaluation Unit, St George's University of London, London SW17 0RE, UK; ssadiq{at}


Background Mass drug administration (MDA) of 20 mg/kg (maximum 1 g in adults) azithromycin for ocular Chlamydia trachomatis (CT) infection is a key component of the WHO trachoma elimination strategy. However, this dose may be suboptimal in Mycoplasma genitalium infection and may encourage emergence of antimicrobial resistance (AMR) to azithromycin.

Objectives To determine the effect of MDA for trachoma elimination on M. genitalium prevalence, strain type and azithromycin resistance.

Methods A secondary analysis of CT-negative vulvovaginal swabs from three outpatient antenatal clinics (Honiara, Solomon Islands) from patients recruited either pre-MDA, or 10 months post-MDA in two cross-sectional surveys was carried out. Swabs were tested for M. genitalium infection using Fast Track Diagnostics Urethritis Plus nucleic acid amplification assay. M. genitalium-positive samples were subsequently tested for azithromycin resistance by sequencing domain V of the 23S rRNA DNA region of M. genitalium and underwent phylogenetic analysis by dual locus sequence typing.

Results M. genitalium prevalence was 11.9% (28/236) in women pre-MDA and 10.9% (28/256) 10 months post-MDA (p=0.7467). Self-reported receipt of azithromycin as part of MDA was 49.2% in women recruited post-MDA and 17.9% (5/28) in those who tested M. genitalium positive. Of samples sequenced (21/28 pre-MDA, 22/28 post-MDA), all showed a macrolide susceptible genotype. Strain typing showed that sequence types diverged into two lineages, with a suggestion of strain replacement post-MDA.

Conclusion A single round of azithromycin MDA in an island population with high baseline M. genitalium prevalence did not appear to impact on either prevalence or azithromycin resistance, in contrast to reported decreased genital CT prevalence in the same population. This may be due to limitations such as sample size, including CT-negative samples only, and low MDA coverage. Further investigation of the impact of multiple rounds of MDA on M. genitalium azithromycin AMR in antibiotic experienced and naïve populations is warranted.

  • mycoplasma
  • antimicrobial resistance
  • trachoma
  • infection
  • drug resistance
  • Mycoplasma genitalium
  • mass drug administration
  • azithromycin

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  • Handling editor Jonathan Ross

  • Contributors MAH, EMHE, MM, MJP, RB, AWS, AVN, DCWM and STS were involved in study design. Data collection was carried out by MAH, MM, MJP, RB, NKT, HK and OS. Data analysis and interpretation was carried out by MAH, EMHE, MJP, LZ, NKT and STS. Writing of the manuscript was carried out by MAH, EMHE and STS. All authors have reviewed and edited the manuscript.

  • Funding This work was supported by the National Institute for Health Research (NIHR) i4i Programme ( (grant number II-LB-0214-20005), the UK Clinical Research Collaboration (Medical Research Council) ( Translation Infection Research Initiative Consortium (grant number G0901608), a grant from the Royal Society of Tropical Medicine and Hygiene to MM (grant number 522), a grant from the Chadwick Trust, UK, a Wellcome Trust Clinical Research Fellowship (WT 102807) and a Wellcome Trust Intermediate Clinical Fellowship (WT 098521).

  • Disclaimer The funding bodies had no role in the design, performance or analysis of the study.

  • Competing interests MAH, EMHE and STS disclose having received funding outside the submitted work from Atlas Genetics, Alere, Cepheid, SpeeDx, Mologic and Sekisui. MJP discloses having received funding outside the submitted work from Atlas Genetics, Alere, Cepheid and Sekisui. AVN discloses having received funding outside the submitted work from Alere, Cepheid, SpeeDx and Sekisui. EMHE discloses their membership of the Becton Dickinson 'Provision of Sexual Health in the UK' advisory board. All other authors have nothing to disclose.

  • Patient consent for publication Not required.

  • Ethics approval The study was approved by the National Health Research Ethics Committee in the Solomon Islands (HRC 14/15) and the ethics committee of the LSHTM in the UK (6496).

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

  • Data availability statement All data relevant to the study are included in the article or available upon reasonable request to the corresponding author.

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