[Question #4240] Concern about Mycoplasma Genitalium's resistance to antibiotics treatment

31 months ago

Dear doctors,


I am a 26 year-old male living in Hong Kong.  I have been recently diagnosed with Myco. Genitalium and was prescribed an antibiotics treatment.


Today is Day 10 of treatment, my symptoms have improved: itchiness/pain during urination is at minimal; very mild testicular pain, whitish penile discharge is about 10% to 20% as much as before.


May I ask how likely it is MG is resistant to my treatment given I still experience symptoms on Day 9?  Thanks!


June 21:

-two unprotected vaginal intercourses (15 min each) with a unfamiliar girl (allegedly aged 22)


June 22 to late July:

-gradual increase in itchiness around my foreskin and head of penis

-2 visits to GP; prescribed me topical cream for fungal infection and allergy


July 28 - Urologist visit #1:

-itchy feeling at the tip of my urethra, around head of penis and foreskin

-slight pain during urination

-occasional mild pain in my right testicle (swollen)

-urologist ordered 2 tests for me: urine culture, semen culture

-prescription: Amoxicillin Clavulanate and Levofloxacin for 2 weeks


Aug 11 -  Ur. visit #2 :

-symptoms have largely subsided, still a little pain in right testicle

-test results: Streptococcus faecalis

-Prescribed another week of Amoxicillin and Levofloxacin


Aug 15 to Aug 20:

-virtually no symptoms


Aug 21 to Aug 26:

-itchiness at tip of urethra again; began noticing whitish penile discharge in my underwear.  


Aug 27 -  Ur. visit #3 :

-Undertook a comprehensive STD test


Aug 31 -  Ur. visit #4 :

Test results:

1) Mycoplasma Genitalium  - Positive

2) Urine & semen cultures -  Streptococcus faecalis


-Prescription: 2 weeks of Amoxicillin, Levofloxacin, Doxycycline, Azithromycin (1g first day, 250 mg next 4 days).

Edward W. Hook M.D.
Edward W. Hook M.D.
31 months ago
Welcome to our Forum.  I believe you may have asked questions of us before but I cannot be sure and due to a problem with our software, I cannot access prior posts.  If we have interacted, please let me know the numbers of our interactions to provide additional context for my responses.  In the meantime, I will make some preliminary comments related to your questions.

You have had positive tests for both M. genitalium (Mg) and Step. faecalis.  In my opinion, either of these pathogens could be causing your problems but both of these organisms may also be present in the urinary tract without any symptoms at all and the right way to assess your response is with follow-up tests for both organisms..  When infections get tot he prostate and cause testicular pain they can be more difficult to treat and sometimes need prolonged courses of therapy.  If you have been off antibiotics for at least a week, the results of repeat testing will provide much useful information. 

As part of the therapy you have had, you have taken at least three drugs which sometimes have activity against Mg- levofloxacin, doxycycline, and azithromycin although the dose of azithromycin you took was a bit lower than what is typically recommended for Mg.  Thus your therapy may have eliminated one or both of the pathogens.  Knowing this will be helpful in determining how to address your continuing symptoms (please provide more information on your current symptoms - what are they, how severe are they, do they come and go, etc.).

I hope this is helpful.  EWH
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31 months ago
Dear Dr. Hook,

Thanks a lot for your response!  My current treatment will end this Friday, which is when I will visit my urologist again, so may I ask a few more questions to help me navigate my conversation with him?  Thank you very much!

First a little clarification - I have been tested with Strep. faecalis two times - once as of July 28 and once as of Aug 27. I already had a course of Amoxicillin and Levofloxacin for 3 weeks from July 28 to Aug 17 (Amox. 875 mg + Levo. 250 mg twice daily). I am now on 2 more weeks of the same treatment from Sep 1 to Sep 14 because of results from the 2nd test.

Questions:

1) Since I still got Strep. faecalis (as of Aug 27) in my urine and semen after 3 weeks of Amox. + Levo. , does that mean the bacteria didn't respond well to treatment? Is that enough justification for a prolonged treatment as you mentioned?
2) For a prolonged treatment, what kind of time frame, dosage, and antibiotics should my Dr. and I be thinking about? Is it good practice to switch antibiotics given I will have had 5 weeks combined of Amox. + Levo. already?
3) My STD test only included the screening of the following, could it have missed anything else that could be causing my symptoms?

HIV AB + p24; T. Pallidum; Syph. VDRL; Herpes 2 IgG; Trichromonas; Candida; Chamydia; Gonorrhea; Urea. Urealyticum; Urea. Parvum; Myco. Gen.; Myco. Hom.; G. vaginalis


P.S. I have never asked questions here before.

Edward W. Hook M.D.
Edward W. Hook M.D.
31 months ago

1)   Since I still got Strep. faecalis (as of Aug 27) in my urine and semen after 3 weeks of Amox. + Levo. , does that mean the bacteria didn't respond well to treatment?  Is that enough justification for a prolonged treatment as you mentioned?
The repeated positive cultures may indicate that you are colonized and that the bacteria present are not causing a problem or they may suggest a need for a longer duration of therapy.  I favor the former interpretation of your results.

2)   For a prolonged treatment, what kind of time frame, dosage, and antibiotics should my Dr. and I be thinking about?  Is it good practice to switch antibiotics given I will have had 5 weeks combined of Amox. + Levo. already?
Prolonged therapy, if it is likely going to eradicate infection, is typically about 6 weeks in duration.

3) My STD test only included the screening of the following, could it have missed anything else that could be causing my symptoms?
No.  There is no evidence of an STI from your test results.

EWH

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31 months ago
Dear Dr. Hook,

Once again, thank you very much for your professional insight!  Just have a few final questions before I catch up with my doctor on Friday.  

1) For the 2 infections I have been diagnosed with -  Strep. Faecalis and Myco. Genitalium - may I ask how long do I have to wait after the last dose of my antibiotics treatment before I could undertake a test-of-cure?  Would an early test increase the risk of a false-negative, a false-positive or both?(Urine culture test for Strep. Faecalis; Nucleic acid test for Myco. Gen.)

2) Given that my symptoms have not gone away 100% (a very mild burning sensation toward the end of and after urination; occasional mild pain in my right testicle), is there any merit in asking my doctor to prescribe me an additional 2-week course of Moxifloxacin right after my Doxycycline treatment is finished to treat my M. Gen, or shall I wait for the results of the next test before taking action?

3) In the unfortunate case where this will turn out to be a repeat of what happened last time - symptoms going back to 100% about a week after the end of the antibiotics treatment, what would be your suggestion for the next course of action?

Thank you very much for your kind help and patience!

Edward W. Hook M.D.
Edward W. Hook M.D.
31 months ago
1.  Testing a week after completion of antibiotics will be accurate.  The exception is azithromycin which can take longer to clear from the body and, as a result, I would wait for at least two weeks after completion of azithromycin to test.  Because of the types of tests used, early testing increases risk for false positive tests for M. genitalium, false negative for S. faecalis.

2.  Moxifloxacin is currently the most active antibiotic for M. genitalium infection.  Taking it after the other therapy does increase the likelihood of cure. 

3.  A longer course of moxifloxacin.

This is my third response to your questions.  As per Forum guidelines, the thread will be closed later this morning.  Take care.  EWH
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