P140 Mycoplasma genitalium(Mgen) treatment outcomes amongst a cohort failing macrolide resistance associated mutation (MRAM)-guided treatment across three London sexual health clinics

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Introduction BASHH advises treatment of Mgen infection guided by MRAM assays. There are limited data to inform management when patients fail MRAM-guided treatment. Methods Using lab reports of all positive Mgen results 28/5/2020–5/11/2022, we collected: demographics, indication, MRAM result, treatment and outcomes. Local MRAM-guided treatment is doxycycline + azithromycin with wild type Mgen, and moxifloxacin in complicated infection and/or if MRAMs are detected. Treatment failure was defined as clinical/microbiological failure despite compliance with appropriately prescribed treatment, without re-infection risk. Results We reviewed 441 positive results from 432 individuals, mean age 30 years. Clinical indication: NGU (272; 61.6%), cervicitis (20; 4.5%), PID (17; 3.9%), proctitis (4; 0.9%)), contact (52; 11.8%), other (76; 17.2%). MRAM indeterminable results were excluded (96/441). MRAMs were detected in 187/345 samples (54.2%; 46.8% in women - 77.3% in MSM). Of wild type infections, 144/158 (91.1%) received doxycycline + azithromycin first-line. 43/144 (29.8%) had a positive TOC, all subsequently cured with moxifloxacin, or lost-to-follow-up (LTFU). Of MRAM-detected patients, 74/187 (39.5%) received moxifloxacin initially; 108/187 (57.7%) received doxycycline, of whom 80/108 (74%) switched to moxifloxacin. True treatment failure was seen in 49/154 (31.8%) (see table 1). 28/49 (57.1%) had ongoing symptoms, the remainder were asymptomatic at positive TOC. A variety of regimens were used in the true failure cohort: minocycline, extended doxycycline, pristinamycin, and chloramphenicol. Several received >1 course of moxifloxacin despite previous failure. 16/49 (32.6%) achieved proven microbiological cure; 13/49 (26.5%) remained positive: 3/49 (6.1%) achieved clinical cure only, and 17/49 (34.6%) were LTFU. Due to sequenced and overlapping regimens, we are unable to determine independent effects regarding likelihood of clinical or microbiological cure. Conclusion Treatment failure was identified in 49/432 (11.3%) individuals in this cohort. Management of treatment failure was varied and inconsistent, with no clear treatment rationale identifiable. We will implement a standardised approach to guided treatment failures and re-evaluate.

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