Mycoplasma genitalium: enhanced management using expanded resistance-guided treatment strategies

Emma L. Sweeney; David M. Whiley; Gerald L. Murray; Catriona S. Bradshaw

doi:10.1071/SH22012

REVIEW (Open Access)

Previous Next Contents Vol 19(4)

Mycoplasma genitalium: enhanced management using expanded resistance-guided treatment strategies

Emma L. Sweeney

^A ^* , David M. Whiley ^A ^B , Gerald L. Murray ^C ^D ^E and Catriona S. Bradshaw ^F ^G

+ Author Affiliations

- Author Affiliations

^A Faculty of Medicine, The University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Qld, Australia.

^B Pathology Queensland Central Laboratory, Brisbane, Qld, Australia.

^C Murdoch Children’s Research Institute, Parkville, Vic., Australia.

^D Women’s Centre for Infectious Diseases, The Royal Women’s Hospital, Parkville, Vic., Australia.

^E Department of Obstetrics and Gynaecology, The University of Melbourne, Parkville, Vic., Australia.

^F Melbourne Sexual Health Centre, Alfred Hospital, Carlton, Vic., Australia.

^G Central Clinical School, Monash University, Melbourne, Vic., Australia.

^* Correspondence to: e.l.sweeney@uq.edu.au

Handling Editor: Jane Hocking

Sexual Health - https://doi.org/10.1071/SH22012
Submitted: 19 January 2022 Accepted: 18 March 2022 Published online: 27 May 2022

© 2022 The Author(s) (or their employer(s)). Published by CSIRO Publishing. This is an open access article distributed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND)

Abstract

Mycoplasma genitalium is an emerging sexually transmitted bacterium that is gaining attention because of the impact escalating antimicrobial resistance (AMR) is having on patient management. Of additional concern is that increased availability of testing appears to be resulting in screening practices that are not supported by clinical guidelines. This results in increasing numbers of asymptomatic M. genitalium infections being identified, which when combined with AMR issues, creates significant challenges for patients and clinicians. Rapidly rising levels of AMR, coupled with limited alternative treatment options, means patients can enter cycles of complex antimicrobial regimens that may cause more harm than the infection itself. In this review, we discuss the emergence of AMR and the implication for treatment practices, highlight the recommendations for testing but not screening for M. genitalium, and discuss expansion of individualised treatment strategies, to curb the emergence of resistance and improve outcomes for patients. We also provide suggestions for future research on the transmission and spread of resistance, to enhance global surveillance of this antimicrobial resistant pathogen and inform the revision of local and international treatment strategies.

Keywords: antimicrobials, antimicrobial resistance, enhanced patient management, individualised treatment, mycoplasma genitalium, resistance-guided treatment, STIs, treatment failure.

References

[1] The Kirby Institute. HIV, viral hepatitis and sexually transmissible infections in Australia: Annual Surveillance Report 2018. 2018. Available at https://kirby.unsw.edu.au/report/asr2018

[2] Chow EPF, Hocking JS, Ong JJ, Phillips TR, Fairley CK. Sexually transmitted infection diagnoses and access to a sexual health service before and after the national lockdown for COVID-19 in Melbourne, Australia. Open Forum Infect Dis 2021; 8 ofaa536
| Sexually transmitted infection diagnoses and access to a sexual health service before and after the national lockdown for COVID-19 in Melbourne, Australia.Crossref | GoogleScholarGoogle Scholar | 33506064PubMed |

[3] Taylor-Robinson D, Jensen JS.. Mycoplasma genitalium: from Chrysalis to multicolored butterfly. Clin Microbiol Rev 2011; 24 498–514.
| Mycoplasma genitalium: from Chrysalis to multicolored butterfly.Crossref | GoogleScholarGoogle Scholar | 21734246PubMed |

[4] Machalek DA, Tao Y, Shilling H, et al. Prevalence of mutations associated with resistance to macrolides and fluoroquinolones in Mycoplasma genitalium: a systematic review and meta-analysis. Lancet Infect Dis 2020; 20 1302–14.
| Prevalence of mutations associated with resistance to macrolides and fluoroquinolones in Mycoplasma genitalium: a systematic review and meta-analysis.Crossref | GoogleScholarGoogle Scholar | 32622378PubMed |

[5] Chua TP, Bodiyabadu K, Machalek DA, et al. Prevalence of Mycoplasma genitalium fluoroquinolone-resistance markers, and dual-class-resistance markers, in asymptomatic men who have sex with men. J Med Microbiol 2021; 70 001429
| Prevalence of Mycoplasma genitalium fluoroquinolone-resistance markers, and dual-class-resistance markers, in asymptomatic men who have sex with men.Crossref | GoogleScholarGoogle Scholar |

[6] Ke W, Li D, Tso LS, et al. Macrolide and fluoroquinolone associated mutations in Mycoplasma genitalium in a retrospective study of male and female patients seeking care at a STI Clinic in Guangzhou, China, 2016–2018. BMC Infect Dis 2020; 20 950
| Macrolide and fluoroquinolone associated mutations in Mycoplasma genitalium in a retrospective study of male and female patients seeking care at a STI Clinic in Guangzhou, China, 2016–2018.Crossref | GoogleScholarGoogle Scholar | 33308173PubMed |

[7] Li Y, Su X, Le W, et al. Mycoplasma genitalium in symptomatic male urethritis: macrolide use is associated with increased resistance. Clin Infect Dis 2020; 70 805–10.
| Mycoplasma genitalium in symptomatic male urethritis: macrolide use is associated with increased resistance.Crossref | GoogleScholarGoogle Scholar | 30972419PubMed |

[8] Ando N, Mizushima D, Takano M, et al. High prevalence of circulating dual-class resistant Mycoplasma genitalium in asymptomatic MSM in Tokyo, Japan. JAC Antimicrob Resist 2021; 3 dlab091
| High prevalence of circulating dual-class resistant Mycoplasma genitalium in asymptomatic MSM in Tokyo, Japan.Crossref | GoogleScholarGoogle Scholar | 34223146PubMed |

[9] Kenyon C, Laumen J, Van Dijck C.. Could intensive screening for gonorrhea/chlamydia in preexposure prophylaxis cohorts select for resistance? Historical lessons from a mass treatment campaign in Greenland. Sex Trans Dis 2020; 47 24–7.
| Could intensive screening for gonorrhea/chlamydia in preexposure prophylaxis cohorts select for resistance? Historical lessons from a mass treatment campaign in Greenland.Crossref | GoogleScholarGoogle Scholar |

[10] Kenyon C.. Does intense sexually transmitted infection screening cause or prevent antimicrobial resistance in sexually transmitted infections? It depends on one’s underlying epistemology. A viewpoint. Sex Trans Dis 2020; 47 506–10.
| Does intense sexually transmitted infection screening cause or prevent antimicrobial resistance in sexually transmitted infections? It depends on one’s underlying epistemology. A viewpoint.Crossref | GoogleScholarGoogle Scholar |

[11] Kenyon C.. To what extent should we rely on antibiotics to reduce high gonococcal prevalence? Historical insights from mass-meningococcal campaigns. Pathogens 2020; 9 134
| To what extent should we rely on antibiotics to reduce high gonococcal prevalence? Historical insights from mass-meningococcal campaigns.Crossref | GoogleScholarGoogle Scholar |

[12] Kenyon C.. We need to consider collateral damage to resistomes when we decide how frequently to screen for chlamydia/gonorrhoea in preexposure prophylaxis cohorts. AIDS 2019; 33 155–7.
| We need to consider collateral damage to resistomes when we decide how frequently to screen for chlamydia/gonorrhoea in preexposure prophylaxis cohorts.Crossref | GoogleScholarGoogle Scholar | 30234609PubMed |

[13] Kenyon CR, Schwartz IS.. Effects of sexual network connectivity and antimicrobial drug use on antimicrobial resistance in Neisseria gonorrhoeae. Emerg Infect Dis 2018; 24 1195–203.
| Effects of sexual network connectivity and antimicrobial drug use on antimicrobial resistance in Neisseria gonorrhoeae.Crossref | GoogleScholarGoogle Scholar | 29912682PubMed |

[14] Kenyon C, Manoharan-Basil SS.. Macrolide consumption and resistance in Mycoplasma genitalium. Lancet Infect Dis 2020; 20 1235–6.
| Macrolide consumption and resistance in Mycoplasma genitalium.Crossref | GoogleScholarGoogle Scholar | 33098774PubMed |

[15] Kenyon C, Manoharan-Basil SS, Van Dijck C.. Is there a resistance threshold for macrolide consumption? Positive evidence from an ecological analysis of resistance data from Streptococcus pneumoniae, Treponema pallidum, and Mycoplasma genitalium. Microb Drug Resist (Larchmont, NY) 2021; 27 1079–86.
| Is there a resistance threshold for macrolide consumption? Positive evidence from an ecological analysis of resistance data from Streptococcus pneumoniae, Treponema pallidum, and Mycoplasma genitalium.Crossref | GoogleScholarGoogle Scholar |

[16] Bradshaw CS, Jensen JS, Tabrizi SN, et al. Azithromycin failure in Mycoplasma genitalium urethritis. Emerg Infect Dis 2006; 12 1149–52.
| Azithromycin failure in Mycoplasma genitalium urethritis.Crossref | GoogleScholarGoogle Scholar | 16836839PubMed |

[17] Jensen JS, Bradshaw CS, Tabrizi SN, Fairley CK, Hamasuna R.. Azithromycin treatment failure in Mycoplasma genitalium-positive patients with nongonococcal urethritis is associated with induced macrolide resistance. Clin Infect Dis 2008; 47 1546–53.
| Azithromycin treatment failure in Mycoplasma genitalium-positive patients with nongonococcal urethritis is associated with induced macrolide resistance.Crossref | GoogleScholarGoogle Scholar | 18990060PubMed |

[18] Read TRH, Fairley CK, Tabrizi SN, et al. Azithromycin 1.5 g over 5 days compared to 1 g single dose in urethral Mycoplasma genitalium: impact on treatment outcome and resistance. Clin Infect Dis 2017; 64 250–6.
| Azithromycin 1.5 g over 5 days compared to 1 g single dose in urethral Mycoplasma genitalium: impact on treatment outcome and resistance.Crossref | GoogleScholarGoogle Scholar |

[19] Horner P, Ingle SM, Garrett F, et al. Which azithromycin regimen should be used for treating Mycoplasma genitalium? A meta-analysis. Sex Trans Infect 2018; 94 14–20.
| Which azithromycin regimen should be used for treating Mycoplasma genitalium? A meta-analysis.Crossref | GoogleScholarGoogle Scholar |

[20] Workowski KA, Bolan GA. Workowski KA, Bolan GA. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep 2015; 64 1–137.
| 26042815PubMed |

[21] Lau A, Bradshaw CS, Lewis D, et al. The efficacy of azithromycin for the treatment of genital Mycoplasma genitalium: a systematic review and meta-analysis. Clin Infect Dis 2015; 61 1389–99.
| The efficacy of azithromycin for the treatment of genital Mycoplasma genitalium: a systematic review and meta-analysis.Crossref | GoogleScholarGoogle Scholar | 26240201PubMed |

[22] Li Y, Le W-J, Li S, Cao Y-P, Su X-H.. Meta-analysis of the efficacy of moxifloxacin in treating Mycoplasma genitalium infection. Int J STD AIDS 2017; 28 1106–14.
| Meta-analysis of the efficacy of moxifloxacin in treating Mycoplasma genitalium infection.Crossref | GoogleScholarGoogle Scholar | 28118803PubMed |

[23] Tabrizi SN, Su J, Bradshaw CS, et al. Prospective evaluation of ResistancePlus MG, a new multiplex quantitative PCR assay for detection of Mycoplasma genitalium and macrolide resistance. J Clin Microbiol 2017; 55 1915–9.
| Prospective evaluation of ResistancePlus MG, a new multiplex quantitative PCR assay for detection of Mycoplasma genitalium and macrolide resistance.Crossref | GoogleScholarGoogle Scholar | 28381611PubMed |

[24] Tabrizi SN, Tan LY, Walker S, et al. Multiplex assay for simultaneous detection of Mycoplasma genitalium and macrolide resistance using PlexZyme and PlexPrime technology. PLoS ONE 2016; 11 e0156740
| Multiplex assay for simultaneous detection of Mycoplasma genitalium and macrolide resistance using PlexZyme and PlexPrime technology.Crossref | GoogleScholarGoogle Scholar | 27271704PubMed |

[25] Rumyantseva T, Golparian D, Nilsson CS, et al. Evaluation of the new AmpliSens multiplex real-time PCR assay for simultaneous detection of Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium, and Trichomonas vaginalis. APMIS 2015; 123 879–86.
| Evaluation of the new AmpliSens multiplex real-time PCR assay for simultaneous detection of Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium, and Trichomonas vaginalis.Crossref | GoogleScholarGoogle Scholar | 26299582PubMed |

[26] Goldstein E, Martinez-García L, Obermeier M, et al. Simultaneous identification of Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium, and Trichomonas vaginalis – multicenter evaluation of the Alinity m STI assay. J Lab Med 2021; 45 213–23.
| Simultaneous identification of Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium, and Trichomonas vaginalis – multicenter evaluation of the Alinity m STI assay.Crossref | GoogleScholarGoogle Scholar |

[27] Pillay J, Wingert A, MacGregor T, Gates M, Vandermeer B, Hartling L.. Screening for chlamydia and/or gonorrhea in primary health care: systematic reviews on effectiveness and patient preferences. Syst Rev 2021; 10 118
| Screening for chlamydia and/or gonorrhea in primary health care: systematic reviews on effectiveness and patient preferences.Crossref | GoogleScholarGoogle Scholar | 33879251PubMed |

[28] Peel J, Aung E, Bond S, Bradshaw C.. Recent advances in understanding and combatting Mycoplasma genitalium. Fac Rev 2020; 9 3
| Recent advances in understanding and combatting Mycoplasma genitalium.Crossref | GoogleScholarGoogle Scholar | 33659935PubMed |

[29] Cina M, Baumann L, Egli-Gany D, et al. Mycoplasma genitalium incidence, persistence, concordance between partners and progression: systematic review and meta-analysis. Sex Trans Infect 2019; 95 328–35.
| Mycoplasma genitalium incidence, persistence, concordance between partners and progression: systematic review and meta-analysis.Crossref | GoogleScholarGoogle Scholar |

[30] Baggio D, Ananda-Rajah MR.. Fluoroquinolone antibiotics and adverse events. Aust Prescr 2021; 44 161–4.
| Fluoroquinolone antibiotics and adverse events.Crossref | GoogleScholarGoogle Scholar | 34728881PubMed |

[31] Bjartling C, Osser S, Persson K.. Mycoplasma genitalium in cervicitis and pelvic inflammatory disease among women at a gynecologic outpatient service. Am J Obstet Gynecol 2012; 206 476.e1–8.
| Mycoplasma genitalium in cervicitis and pelvic inflammatory disease among women at a gynecologic outpatient service.Crossref | GoogleScholarGoogle Scholar |

[32] Latimer RL, Vodstrcil LA, Plummer EL, et al. The clinical indications for testing women for Mycoplasma genitalium. Sex Trans Infect 2021;
| The clinical indications for testing women for Mycoplasma genitalium.Crossref | GoogleScholarGoogle Scholar |

[33] Lis R, Rowhani-Rahbar A, Manhart LE.. Mycoplasma genitalium infection and female reproductive tract disease: a meta-analysis. Clin Infect Dis 2015; 61 418–26.
| Mycoplasma genitalium infection and female reproductive tract disease: a meta-analysis.Crossref | GoogleScholarGoogle Scholar | 25900174PubMed |

[34] Lewis J, Horner PJ, White PJ.. Incidence of pelvic inflammatory disease associated with Mycoplasma genitalium infection: evidence synthesis of cohort study data. Clin Infect Dis 2020; 71 2719–22.
| Incidence of pelvic inflammatory disease associated with Mycoplasma genitalium infection: evidence synthesis of cohort study data.Crossref | GoogleScholarGoogle Scholar | 32701123PubMed |

[35] ASHM. Australian STI management guidelines: Mycoplasma genitalium [database on the Internet]. 2019. Available at https://sti.guidelines.org.au/sexually-transmissible-infections/mycoplasma-genitalium/

[36] Soni S, Horner P, Rayment M. British Association for Sexual Health and HIV national guideline for the management of infection with Mycoplasma genitalium (2018). Int J STD AIDS 2019; 30 938–50.
| British Association for Sexual Health and HIV national guideline for the management of infection with Mycoplasma genitalium (2018).Crossref | GoogleScholarGoogle Scholar | 31280688PubMed |

[37] Workowski KA, Bachmann LH, Chan PA. Sexually transmitted infections treatment guidelines, 2021. MMWR 2021; 70 1–187.
| Sexually transmitted infections treatment guidelines, 2021.Crossref | GoogleScholarGoogle Scholar | 34292926PubMed |

[38] Read TRH, Fairley CK, Murray GL, et al. Outcomes of resistance-guided sequential treatment of Mycoplasma genitalium infections: a prospective evaluation. Clin Infect Dis 2019; 68 554–60.
| Outcomes of resistance-guided sequential treatment of Mycoplasma genitalium infections: a prospective evaluation.Crossref | GoogleScholarGoogle Scholar | 29873691PubMed |

[39] Vodstrcil L, Doyle M, Plummer EL. A trial of combination therapy for Mycoplasma genitalium, and new insights into the utility of parC mutant detection to improve first-line cure. Clin Infect Dis 2022; –ciab1058.
| A trial of combination therapy for Mycoplasma genitalium, and new insights into the utility of parC mutant detection to improve first-line cure.Crossref | GoogleScholarGoogle Scholar | 34984438PubMed |

[40] Manhart LE, Jensen JS.. Quinolone resistance-associated mutations in Mycoplasma genitalium: not ready for prime time. Sex Trans Dis 2020; 47 199–201.
| Quinolone resistance-associated mutations in Mycoplasma genitalium: not ready for prime time.Crossref | GoogleScholarGoogle Scholar |

[41] Murray GL, Bradshaw CS, Bissessor M, et al. Increasing macrolide and fluoroquinolone resistance in Mycoplasma genitalium. Emerg Infect Dis 2017; 23 809–12.
| Increasing macrolide and fluoroquinolone resistance in Mycoplasma genitalium.Crossref | GoogleScholarGoogle Scholar | 28418319PubMed |

[42] Murray GL, Bodiyabadu K, Danielewski J, et al. Moxifloxacin and sitafloxacin treatment failure in Mycoplasma genitalium infection: association with parC mutation G248T (S83I) and concurrent gyrA mutations. J Infect Dis 2020; 221 1017–24.
| Moxifloxacin and sitafloxacin treatment failure in Mycoplasma genitalium infection: association with parC mutation G248T (S83I) and concurrent gyrA mutations.Crossref | GoogleScholarGoogle Scholar | 32031634PubMed |

[43] Sweeney EL, Bradshaw CS, Murray GL, Whiley DM.. Individualised treatment of Mycoplasma genitalium infection – incorporation of fluoroquinolone resistance testing into clinical care. Lancet Infect Dis 2022;
| Individualised treatment of Mycoplasma genitalium infection – incorporation of fluoroquinolone resistance testing into clinical care.Crossref | GoogleScholarGoogle Scholar | 35325618PubMed |

[44] Doyle M, Vodstrcil LA, Plummer EL, Aguirre I, Fairley CK, Bradshaw CS.. Nonquinolone options for the treatment of Mycoplasma genitalium in the era of increased resistance. Open Forum Infect Dis 2020; 7 ofaa291
| Nonquinolone options for the treatment of Mycoplasma genitalium in the era of increased resistance.Crossref | GoogleScholarGoogle Scholar | 32782911PubMed |

[45] Read TRH, Jensen JS, Fairley CK, et al. Use of pristinamycin for macrolide-resistant Mycoplasma genitalium infection. Emerg Infect Dis 2018; 24 328–35.
| Use of pristinamycin for macrolide-resistant Mycoplasma genitalium infection.Crossref | GoogleScholarGoogle Scholar | 29350154PubMed |

[46] Murray GL, Doyle M, Bodiyabadu K, et al. Evaluation of ResistancePlus MG FleXible, a ‘near-patient’ test for the detection of Mycoplasma genitalium and macrolide resistance mutations, using freshly collected clinical samples. J Med Microbiol 2021; 70 001271
| Evaluation of ResistancePlus MG FleXible, a ‘near-patient’ test for the detection of Mycoplasma genitalium and macrolide resistance mutations, using freshly collected clinical samples.Crossref | GoogleScholarGoogle Scholar |

[47] Sweeney EL, Mhango LP, Ebeyan S, et al. Evaluation of the ResistancePlus MG FleXible cartridge for near-point-of-care testing of Mycoplasma genitalium and associated macrolide resistance mutations. J Clin Microbiol 2020; 58 e01897-19
| Evaluation of the ResistancePlus MG FleXible cartridge for near-point-of-care testing of Mycoplasma genitalium and associated macrolide resistance mutations.Crossref | GoogleScholarGoogle Scholar | 31896664PubMed |

[48] Bissessor M, Tabrizi SN, Twin J, et al. Macrolide resistance and azithromycin failure in a Mycoplasma genitalium-infected cohort and response of azithromycin failures to alternative antibiotic regimens. Clin Infect Dis 2015; 60 1228–36.
| Macrolide resistance and azithromycin failure in a Mycoplasma genitalium-infected cohort and response of azithromycin failures to alternative antibiotic regimens.Crossref | GoogleScholarGoogle Scholar | 25537875PubMed |

[49] Durukan D, Read TRH, Murray G, et al. Resistance-guided antimicrobial therapy using doxycycline-moxifloxacin and doxycycline-2.5 g azithromycin for the treatment of Mycoplasma genitalium infection: efficacy and tolerability. Clin Infect Dis 2020; 71 1461–8.
| Resistance-guided antimicrobial therapy using doxycycline-moxifloxacin and doxycycline-2.5 g azithromycin for the treatment of Mycoplasma genitalium infection: efficacy and tolerability.Crossref | GoogleScholarGoogle Scholar | 31629365PubMed |

[50] Deguchi T, Ito S, Yasuda M. Emergence of Mycoplasma genitalium with clinically significant fluoroquinolone resistance conferred by amino acid changes both in GyrA and ParC in Japan. J Infect Chemother 2017; 23 648–50.
| Emergence of Mycoplasma genitalium with clinically significant fluoroquinolone resistance conferred by amino acid changes both in GyrA and ParC in Japan.Crossref | GoogleScholarGoogle Scholar | 28462860PubMed |

[51] Deguchi T, Ito S, Yasuda M, et al. Surveillance of the prevalence of macrolide and/or fluoroquinolone resistance-associated mutations in Mycoplasma genitalium in Japan. J Infect Chemother 2018; 24 861–7.
| Surveillance of the prevalence of macrolide and/or fluoroquinolone resistance-associated mutations in Mycoplasma genitalium in Japan.Crossref | GoogleScholarGoogle Scholar | 30190106PubMed |

[52] Kikuchi M, Ito S, Yasuda M, et al. Remarkable increase in fluoroquinolone-resistant Mycoplasma genitalium in Japan. J Antimicrob Chemother 2014; 69 2376–82.
| Remarkable increase in fluoroquinolone-resistant Mycoplasma genitalium in Japan.Crossref | GoogleScholarGoogle Scholar | 24894419PubMed |

[53] Murray G, Bodiyabadu K, Vodstrcil L. parC variants in Mycoplasma genitalium: trends over time and association with moxifloxacin failure. Antimicrob Agents Chemother 2022; 66 –e00278-22.
| parC variants in Mycoplasma genitalium: trends over time and association with moxifloxacin failure.Crossref | GoogleScholarGoogle Scholar | 35475636PubMed |

[54] Sweeney EL, Tickner J, Bletchly C, Nimmo GR, Whiley DM.. Genotyping of Mycoplasma genitalium suggests de novo acquisition of antimicrobial resistance in Queensland, Australia. J Clinical Microbiol 2020; 58 e00641–20.
| Genotyping of Mycoplasma genitalium suggests de novo acquisition of antimicrobial resistance in Queensland, Australia.Crossref | GoogleScholarGoogle Scholar |

[55] Dumke R, Rust M, Glaunsinger T.. MgpB types among Mycoplasma genitalium strains from men who have sex with men in Berlin, Germany, 2016–2018. Pathogens (Basel, Switzerland) 2019; 9 12
| MgpB types among Mycoplasma genitalium strains from men who have sex with men in Berlin, Germany, 2016–2018.Crossref | GoogleScholarGoogle Scholar |

[56] Chen SC, Han Y, Yuan LF, Zhu XY, Yin YP.. Identification of internationally disseminated ceftriaxone-resistant Neisseria gonorrhoeae strain FC428, China. Emerg Infect Dis 2019; 25 1427–9.
| Identification of internationally disseminated ceftriaxone-resistant Neisseria gonorrhoeae strain FC428, China.Crossref | GoogleScholarGoogle Scholar | 30900979PubMed |

[57] Lahra MM, Martin I, Demczuk W, et al. Cooperative recognition of internationally disseminated ceftriaxone-resistant Neisseria gonorrhoeae strain. Emerg Infect Dis 2018; 24 735–40.
| Cooperative recognition of internationally disseminated ceftriaxone-resistant Neisseria gonorrhoeae strain.Crossref | GoogleScholarGoogle Scholar |

[58] Shimuta K, Watanabe Y, Nakayama S, et al. Emergence and evolution of internationally disseminated cephalosporin-resistant Neisseria gonorrhoeae clones from 1995 to 2005 in Japan. BMC Infect Dis 2015; 15 378
| Emergence and evolution of internationally disseminated cephalosporin-resistant Neisseria gonorrhoeae clones from 1995 to 2005 in Japan.Crossref | GoogleScholarGoogle Scholar | 26381611PubMed |