Review Article | Published:

Antimicrobial-resistant sexually transmitted infections: gonorrhoea and Mycoplasma genitalium

Nature Reviews Urology volume 14, pages 139152 (2017) | Download Citation

Abstract

The emergence of antimicrobial resistance (AMR) is a major concern worldwide and already compromises treatment effectiveness and control of several bacterial sexually transmitted infections (STIs). Neisseria gonorrhoeae and Mycoplasma genitalium are evolving into so-called superbugs that can become resistant, both in vitro and clinically, to essentially all antimicrobials available for treatment, causing exceedingly difficult-to-treat or untreatable STIs and threatening global public health. Widespread AMR in these bacteria is likely to persist and even worsen in the future, owing to the high number of infections, widespread and uncontrolled use of antimicrobials, limited surveillance of AMR and clinical failures, as well as the extraordinary capacity of these bacteria to develop AMR. This development would not only result in an increased prevalence of N. gonorrhoeae and M. genitalium infections but also in a considerably increasing number of severe complications affecting reproductive health. To combat this threat, clinicians need to be aware of the current guidelines on diagnostic procedures, recommended treatment regimens, as well as therapeutic options for multidrug-resistant bacteria. AMR testing needs to be more frequently performed, inform treatment decisions and elucidate how AMRs compromise treatment effectiveness, guiding research for effective future therapies.

Key points

  • The burden of Neisseria gonorrhoeae and Mycoplasma genitalium infections and multidrug-resistance in the aetiological agents are major global public health concerns that are poorly surveyed and controlled

  • N. gonorrhoeae and M. genitalium are evolving into so-called superbugs; infections with these bacteria have become exceedingly difficult to treat and they might become untreatable in certain circumstances

  • Current dual antimicrobial therapy for gonorrhoea (ceftriaxone plus azithromycin) should be considered in all settings where regular, local and quality-assured antimicrobial resistance (AMR) data do not support other therapeutic options

  • Dual antimicrobial therapy might also need to be considered for M. genitalium infections

  • Development of novel antimicrobials and treatment algorithms that emphasizes dual antimicrobial therapy and AMR testing is imperative to minimize AMR emergence, enhance AMR surveillance and, ideally, guide personalized treatment

  • Some newly developed antimicrobials, for example the fluoroketolide solithromycin, the spiropyrimidinetrione zoliflodacin and the pleuromutilin lefamulin, need further evaluation in clinical trials as potential future treatments of gonorrhoea and M. genitalium infections

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Acknowledgements

Work at the WHO Collaborating Centre for Gonorrhoea and other STIs is supported by Örebro University Hospital, Department of Laboratory Medicine, the Research Committee of Örebro County and the Örebro University Hospital Foundation, Örebro, Sweden.

Author information

Affiliations

  1. WHO Collaborating Centre for Gonorrhoea and other Sexually Transmitted Infections, National Reference Laboratory for Pathogenic Neisseria, Department of Laboratory Medicine, Clinical Microbiology, Faculty of Medicine and Health, Örebro University, SE-701 85 Örebro, Sweden.

    • Magnus Unemo
  2. Department of Microbiology and Infection Control, Sexually Transmitted Infections, Research and Development, Statens Serum Institut, Artillerivej 5, DK-2300 Copenhagen S, Denmark.

    • Jorgen S. Jensen

Authors

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Contributions

Both authors researched data for the article, made substantial contribution to discussion of its content, wrote and reviewed and/or edited the manuscript before submission.

Competing interests

The authors declare no competing financial interests.

Corresponding author

Correspondence to Magnus Unemo.

Glossary

Homotypic resistance

The whole population of a bacterial strain is genetically or phenotypically resistant to an antimicrobial if all cells contain one or several resistance mutations or according to the measured MIC of the antimicrobial, respectively.

Test-of-cure

(TOC). Test performed at a follow-up visit of patients after treatment to ensure that the infection is eradicated and the patient cured.

Escherichia coli numbering

Number of the nucleotide or amino acid position in the genome of E. coli.

Nucleic acid amplification tests

(NAATs). Molecular diagnostic tests that amplify and subsequently detect nucleic acid (DNA/RNA) specific for the pathogen.

Point-of-care NAATs

Molecular diagnostic tests that amplify and subsequently detect nucleic acid (DNA or RNA) specific for the pathogen and that can be performed on site without laboratory facilities.

Agar dilution

Gold-standard method, using antimicrobial incorporated in the culture media, for determination of antimicrobial susceptibility in N. gonorrhoeae.

Etest

Frequently used method, utilizing antimicrobial gradient strips, for determination of antimicrobial susceptibility in N. gonorrhoeae.

Minimum inhibitory concentration

(MIC). Minimum concentration of an antimicrobial that completely inhibits the growth of bacteria.

Breakpoint

MIC value that distinguishes susceptible or resistant isolates.

M. genitalium numbering

Number of the nucleotide or amino acid position in the genome of M. genitalium.

Pharmacokinetic–pharmacodynamic calculations

Calculations or simulations of the pharmacokinetics (fate of the drug from uptake and metabolism to elimination when administered to humans) and/or pharmacodynamics (biochemical and physiological effects) of a drug.

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DOI

https://doi.org/10.1038/nrurol.2016.268

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