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Original research
Antimicrobial resistance in Mycoplasma genitalium sampled from the British general population
  1. Rachel Pitt1,
  2. Magnus Unemo2,
  3. Pam Sonnenberg3,
  4. Sarah Alexander1,
  5. Simon Beddows1,
  6. Michelle Jayne Cole1,
  7. Soazig Clifton3,
  8. Catherine H Mercer3,
  9. Anne M Johnson4,
  10. Catherine A Ison1,
  11. Nigel Field4
  1. 1 National Infection Service, Public Health England, London, United Kingdom
  2. 2 WHO Collaborating Centre for Gonorrhoea and Other STIs, National Reference Laboratory for STIs, Department of Laboratory Medicine, Microbiology, Faculty of Medicine and Health, Örebro University, Orebro, Sweden
  3. 3 Centre for Population Research in Sexual Health and HIV, Institute for Global Health, UCL, London, United Kingdom
  4. 4 Centre for Molecular Epidemiology and Translational Research, Institute for Global Health, UCL, London, United Kingdom
  1. Correspondence to Dr Nigel Field, Centre for Molecular Epidemiology and Translational Research, Institute for Global Health, UCL, London WC1E 6JB, UK; nigel.field{at}


Background Mycoplasma genitalium is a common sexually transmitted infection. Treatment guidelines focus on those with symptoms and sexual contacts, generally with regimens including doxycycline and/or azithromycin as first-line and moxifloxacin as second-line treatment. We investigated the prevalence of antimicrobial resistance (AMR)-conferring mutations in M. genitalium among the sexually-active British general population.

Methods The third national survey of sexual attitudes and lifestyles (Natsal-3) is a probability sample survey of 15 162 men and women aged 16–74 years in Britain conducted during 2010–12. Urine test results for M. genitalium were available for 4507 participants aged 16–44 years reporting >1 lifetime sexual partner. In this study, we sequenced regions of the 23S rRNA and parC genes to detect known genotypic determinants for resistance to macrolides and fluoroquinolones respectively.

Results 94% (66/70) of specimens were re-confirmed as M. genitalium positive, with successful sequencing in 85% (56/66) for 23S rRNA and 92% (61/66) for parC genes. Mutations in 23S rRNA gene (position A2058/A2059) were detected in 16.1% (95%CI: 8.6% to 27.8%) and in parC (encoding ParC D87N/D87Y) in 3.3% (0.9%–11.2%). Macrolide resistance was more likely in participants reporting STI diagnoses (past 5 years) (44.4% (18.9%–73.3%) vs 10.6% (4.6%–22.6%); p=0.029) or sexual health clinic attendance (past year) (43.8% (23.1%–66.8%) vs 5.0% (1.4%–16.5%); p=0.001). All 11 participants with AMR-conferring mutations had attended sexual health clinics (past 5 years), but none reported recent symptoms.

Conclusions This study highlights challenges in M. genitalium management and control. Macrolide resistance was present in one in six specimens from the general population in 2010–2012, but no participants with AMR M. genitalium reported symptoms. Given anticipated increases in diagnostic testing, new strategies including novel antimicrobials, AMR-guided therapy, and surveillance of AMR and treatment failure are recommended.

  • mycoplasma
  • antibiotic resistance
  • molecular epidemiology
  • public health
  • Mycoplasma genitalium

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  • Handling editor Nicola Low

  • Twitter @sarah1alexander, @soazigclifton, @fienige

  • Contributors RP, PS, CI, and NF conceived this article. RP wrote the first draft with further contributions from all authors. RP did the statistical analysis. PS, CM, AJ, and CI were initial applicants on Natsal-3, wrote the study protocol and obtained funding. PS, SC, CM, AJ, CI, and NF designed the Natsal-3 questionnaire, applied for ethics approval and undertook piloting of the questionnaire. RP, SC, and CM managed data. RP, SA, SB, MC, and CI were responsible for laboratory testing. All authors interpreted data, reviewed successive drafts and approved the final version of the article.

  • Funding The study was supported by grants from the Medical Research Council (G0701757) and the Wellcome Trust (084840), with contributions from the Economic and Social Research Council and Department of Health.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval We obtained ethical approval from Oxfordshire Research Ethics Committee A (09/H0604/27). Participants gave written informed consent to anonymised testing, without the return of results, the ethical rationale for which has been previously described.

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

  • Data availability statement An anonymised Natsal-3 data set has been deposited with the UK Data Service, persistent identified: 10.5255/UKDA-SN-7799-1. Researchers are also directed to the Natsal website for further information (

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