Diagnosis and Treatment of Mycoplasma in Urine
Mycoplasma in urine is diagnosed through nucleic acid amplification tests (NAATs) and treated with appropriate antibiotics such as azithromycin, with treatment guided by resistance testing when available.
Diagnostic Approach
Preferred Testing Methods
- Nucleic acid amplification tests (NAATs) are the gold standard for diagnosing urinary mycoplasma infections, particularly for Mycoplasma genitalium 1
- Conventional culture is extremely difficult and impractical for routine clinical use as mycoplasmas are slow-growing and require specialized media 2, 3
- PCR-based methods targeting specific genes (such as MgPa adhesion gene for M. genitalium) offer the highest sensitivity and specificity 1
Specimen Collection
- For men: First-catch urine samples are preferred 4
- For women: Vaginal swabs provide optimal sensitivity 4
- Samples should be processed promptly or refrigerated to prevent degradation of nucleic acids
Testing Considerations
- Testing should include:
- Urine dipstick testing for leukocyte esterase may indicate inflammation but is not specific for mycoplasma 6
Treatment Protocol
First-line Treatment
- Azithromycin 1.5g total (500mg on day 1, followed by 250mg daily for days 2-5) for macrolide-susceptible strains 4
- This extended regimen is preferred over the single 1g dose to reduce risk of resistance development
Alternative Treatments
- Moxifloxacin 400mg daily for 7-14 days for macrolide-resistant strains or treatment failures 4
- Doxycycline has poor efficacy against M. genitalium with only 25% eradication rate 4
Treatment Monitoring
- Test of cure should be performed no earlier than 3-4 weeks after treatment initiation 4
- Earlier testing may yield false negative results due to:
- Temporary suppression of bacterial load below detection threshold
- Day-to-day fluctuations in bacterial shedding, especially with resistant strains 5
Special Considerations
Resistance Management
- Macrolide resistance in M. genitalium is increasing globally 1
- When available, pre-treatment resistance testing should guide antibiotic selection 5
- Patients with treatment failure should be tested for macrolide resistance mutations before switching to second-line therapy 4
Treatment Challenges
- Mycoplasmas lack a cell wall, making them intrinsically resistant to penicillins and other cell wall-targeting antibiotics 2
- Some mycoplasmas may invade eukaryotic cells, making eradication more difficult 2
- Immunosuppressed patients may require longer treatment courses 2
Partner Management
- Sexual partners should be tested and treated to prevent reinfection
- Abstinence is recommended until both patient and partners complete treatment and symptoms resolve
Follow-up Recommendations
- Patients should be monitored for symptom resolution
- Persistent or recurrent symptoms warrant:
- Repeat testing with resistance assessment
- Consideration of alternative diagnoses
- Evaluation for reinfection versus treatment failure
By following this diagnostic and treatment approach, clinicians can effectively manage mycoplasma urinary infections while minimizing the risk of treatment failure and antimicrobial resistance.