Table 3.

Summary of the laboratory studies on Mycoplasma genitalium antimicrobial susceptibility and genotypic resistance testing in the literature subsequent to the report by Deborah L Couldwell and David A Lewis, 2015

Reference	Study type	Population	MG DNA extracts or isolates examined	Macrolide resistance (MIC data/resistance mutations)	Fluoroquinolone resistance (MIC data/resistance mutations)	Comments
Huerta et al., 2020[120]	Prospective study	95 positive specimens from 89 individuals included 8 vaginal swabs, 20 endocervical swabs, 8 urethral swabs, 25 first-void urine, and 34 rectal swabs	90 DNA extracts	The rate of MRMM in MG among the study population was 41.8%	Not done	The ResistancePlus® MG FleXible a rapid, simple, and accurate cartridge-based assay for simultaneous detection of MG and MRMM in clinical settings
Pitt et al., 2020[121]	Laboratory analysis	Sexually active British general population	66 DNA extracts	Mutations in 23 S rRNA gene were detected in 9/56 (16%) specimens, with the A2058G mutation being most common (n=7), followed by A2059G (n=1) and A2059C (n=1)	parC gene mutations associated with fluoroquinolone resistance were detected in 2/61 (4%)	Specimens with macrolide resistance were more likely to come from participants reporting a history of diagnosed bacterial STIs or recent sexual health clinic attendance
Martens et al., 2019[122]	Retrospe-ctive study	Tested 28,408 samples from 20,537 patients for the presence of STD organisms. Most (n=25,132) samples were provided by general practitioners, 3087 (10.9%) by hospitals, and 189 (0.7%) from other and unknown locations	894 DNA extracts	Single-nucleotide polymorphisms A2058C, A2058G, A2058T, and A2059G in the 23S ribosomal RNA–encoding region of MG, which together account for >95% of the cases of azithromycin resistance	Not done	The rate of MRMM positivity rose from 22.7% in 2014 and 22.3% in 2015 to 44.4% in 2016 but decreased to 39.7% in 2017
Sweeney et al., 2019[123]	Retrospective study	Patients with genital symptoms urine (n=280), cervicovaginal swabs (n=90), urethral swabs (n=10), anal/rectal swabs (n=60), throat swabs (n=1), and samples from unknown sites (n=6)	447 DNA extracts	277/447 (61%) carried strains which harbored MRDR 35/447 (8%) patient samples harbored both MRDR and QRDR mutations	47/447 (11%) samples harbored MG strains with parC or gyrA mutations in QRDR	The levels of antibiotic resistance may differ between populations within the same state, which has implications for clinical management and treatment guidelines
Hokynar et al., 2018[124]	Laboratory analysis	Specimens from heterosexual population included swabs from vagina (n=30), urethra (n=8), rectum (n=1), cervix (n=31) and FVU, (n=233)	17 DNA extracts	4 mutation associated with macrolide resistance A2058/9G and 9 were wild type by sequence	Only one specimen contained a mutation at the QRDR area parC gene leading to fluoroquinolone resistance	Recommend testing for the MG positive samples for mutations leading to macrolide resistance but not for fluoroquinolones to guide in selecting treatment
Mondeja et al., 2018[125]	Retrospe-ctive study	280 MG positive DNA extracts conserved at the Cuban National Reference Laboratory of Mycoplasma Research between 2009 and 2016 from Cuban patients with urogenital syndromes, spontaneous abortion and infertility	280 DNA extracts	52/64 (82%) samples were identified as A2058G/A2059G and 12/64 (19%) as A2058C/T Three new MG isolates confirmed phenotypic resistance to macrolides in a cell-culture assisted susceptibility test	Not done	Rapid emergence and high prevalence of MRMM in MG-infected patients and confirmed the phenotypic resistance in isolates carrying MRMM
Le Roux et al., 2018[126]	Reterospe-ctive study	Vaginal swab samples from 100 and 104 termination of pregnancy attendees at a tertiary hospital in Pretoria, South Africa during 2012 and 2016 respectively	13 clinical isolsates	2 isolates had A2059G mutation in region V of the 23S rRNA gene	One a fluoroquin-olone resistance- associated mutation in the parC gene	Increase in macrolide and fluoroquinolone resistance among local MG strains
Braam et al., 2017[127]	Laboratory analysis	147 women and 73 men (general population)	220 DNA extracts	Mutation at position A2058G (n=18/46), (39%) followed by A2059G (n=16/46), (34%) A2058T (n=10/46) (21%) and A2058C (n=2/46) (5%)	Not done	Molecular methods designed to detect all macrolide resistance-associated mutations, patients infected with proven macrolide-resistant strains can be empirically treated with moxifloxacin
Forslund et al., 2017[128]	Retrospe-ctive study	3167 males and 5636 women who were seeking care at diverse clinics were routinely tested for MG during 2015	271 clinical isolates	Macrolide associated resistance mutations in the 23S rRNA gene 8.8% and 4.2% of the isolates had point mutations of the 23S-gene at position 2072 and 2071, respectively	Not done	Relatively low rate of macrolide-resistant MG
Mondeja et al., 2016[129]	Laboratory analysis	7 strains isolated from endocervical and urethral swab specimens from cuban patients	7 DNA extracts	A2059G transition was detected in the phenotypically macrolide resistant B19 strain	No mutations detected in the QRDR of the parC gene	None
Kristiansen et al., 2016[130]	Laboratory analysis	113 samples were obtained from females (92 cervical swabs, 17 urethral swabs, and 4 urine samples), and 146 were obtained from males (94 urethral swabs and 52 urine samples)	253 DNA extracts	109=Wild type 75=A2058G mutation 65=A2059G mutation 2=A2058T mutation 1=A2058C mutation	Not done	5’nuclease genotyping assay is easily interpretable and allows timely reporting of macrolide resistance in MG The assay can genotype a large proportion of samples and displays a high concordance with sequencing

MRMM=Macrolide-resistance mediating mutations; MG=Mycoplasma genitalium; QRDR=Quinolone resistance-determining regions; MRDR=Macrolide resistance-determining region; STIs=Sexually transmitted infections; STD=Sexually transmitted disease; FVU=First void urine