• genitourinary medicine
• mycoplasma
• ethics
• antibiotic resistance
• public health

The BASHH guideline on the management of Mycoplasma genitalium (2018) contains the following advice:

Current asymptomatic partners (including non-regular partners where there is likely to be further sexual contact and risk of reinfection) of individuals with disease caused by M. genitalium infection should be tested and/or offered epidemiological treatment (using the same antimicrobial regimen as used in the index patient). This is to reduce the risk of re-infection in the index case. 1

European guidelines (2016) are more expansive and recommend treatment ‘On epidemiological grounds for recent sexual contacts (previous 3 months)’.2

Epidemiological treatment has long been a staple of sexual health, but there are increasing reasons to question its appropriateness in this context. For a doctor to treat a person with a course of antibiotics which is unlikely to confer any physical benefit to that individual has always been marginal ethical territory. Without the possibility of feeling better in some way, the scales are significantly more likely to be loaded on the side of harm whether it be the short-term inconvenience of gastrointestinal disturbance or adverse events which are less likely but potentially far more serious.3 Wider concerns for antibiotic governance will significantly add to this discomfiture. Rather than merely for the benefit of the index patient, it is possible that intervention may be justified on the basis of averting the risk of complications such as sexually acquired reactive arthritis, epididymo-orchitis in men or pelvic inflammatory disease in women. We do not yet know the risk of such sequelae arising in individuals with M. genitalium who demonstrate no symptoms, yet the BASHH guidance simultaneously advises that asymptomatic individuals should generally not be tested for the organism. The inference will be drawn that the ONLY reason for treatment of asymptomatic contacts is for the benefit of the index …