Abstract
Dear Editor,
We present here a case of clinical treatment failure to cure Mycoplasma genitalium (MG) urethritis with 1 g of azithromycin and discuss some issues in managing sexually transmitted infections in Lebanon.
Case
We report here a case of a 32-year-old man who presented with urethral discharge for two months. Discharge had occurred ten days following an episode of unprotected insertive oral sex with a female sex worker. A detailed history failed to detect any other sexual contact up to six months previous to this incident. His last HIV, hepatitis B and C and syphilis tests were all negative (six months before his presentation).
He had initially presented to his general physician who administered 1 g of ceftriaxone with 500 mg daily of oral ciprofloxacin for ten days and fluconazole 300 mg/week for three weeks without improvement. Two weeks later, he was given four tablets of azithromycin 250 mg without improvement. Four weeks later, he presented to our clinic with persistent urethral discharge.
A first-passed urine was sampled for Gram stain examination and polymerase chain reaction (PCR) assay (Real-TM, Sacace Biotechnologies, Como, Italy). Gram stain contained 16 polymorphonuclear leucocytes and the sample tested positive for MG and negative for Neisseria gonorrhoeae (NG), Chlamydia trachomatis (CT) and Ureaplasma urealyticum (UU).
He was prescribed moxifloxacin 400 mg/day for ten days. Four weeks later, the patient was reassessed; his symptoms had disappeared in one week. A test of cure based on urine PCR analysis was negative for MG.
Comment
In a country where no data exist concerning MG prevalence, and in a troubled region like the Middle East and North Africa (MENA), this short report aims to suggest that the apparent treatment failure in this patient might represent macrolide resistance.
In Lebanon, such infections are often treated by general physicians or pharmacists and recommended antibiotics or regimens might not be evidence based. This might explain the initial treatments prescribed for the patient.
In this patient, there was only one unprotected oral sex exposure with a sex worker and this exposure seemed the likely source of infection. Although oral-urethral transmission of MG has not been proven, this case raises questions about this route of infection.1,2
In the present case, we propose that the apparent treatment failure might represent macrolide resistance in this patient. 3 Moreover, this might be present in the local population in Lebanon but further work with a large series of patients is warranted to investigate MG prevalence and resistance rate estimation.