What is the best treatment for Mycoplasma and Ureaplasma infections?

Treatment of Mycoplasma and Ureaplasma Infections

Doxycycline 100 mg orally twice daily for 7 days is the first-line treatment for both Mycoplasma and Ureaplasma infections, with azithromycin as an effective alternative. 1, 2, 3

First-Line Treatment Options

For Ureaplasma urealyticum:

• Doxycycline: 100 mg orally twice daily for 7 days 1, 2, 3
• Alternative: Azithromycin 1.0-1.5 g orally as a single dose 1, 2

For Mycoplasma genitalium:

• Azithromycin: 500 mg orally on day 1 1
• Alternative for macrolide resistance: Moxifloxacin 400 mg daily for 7-14 days 1

Treatment Algorithm

1. Initial diagnosis:

   • Confirm infection using nucleic acid amplification tests (NAATs) on first-void urine samples or urethral/cervical swabs 2
   • Do not routinely screen asymptomatic individuals due to high colonization rates 2

2. First-line treatment:

   • Start with doxycycline 100 mg twice daily for 7 days for Ureaplasma 1, 2, 3
   • For Mycoplasma genitalium, start with azithromycin 500 mg on day 1 1

3. For treatment failure:

   • If symptoms persist after doxycycline: Switch to azithromycin 500 mg on day 1, then 250 mg for 4 days 1
   • If symptoms persist after azithromycin: Switch to moxifloxacin 400 mg daily for 7-14 days 1, 4
   • Consider adding metronidazole 400 mg twice daily for 5 days if persistent non-gonococcal urethritis 1

4. Special populations:

   • Pregnant women: Erythromycin is preferred 2
   • Immunocompromised patients: May require more aggressive treatment and follow-up 2

Evidence Quality and Considerations

The European Association of Urology guidelines (2024) provide the most recent and comprehensive recommendations for treating these infections 1. These guidelines are supported by the FDA-approved indications for doxycycline, which specifically lists Ureaplasma urealyticum as an approved indication 3.

Recent research shows that the efficacy of azithromycin for treating Mycoplasma genitalium has decreased over time, from approximately 85% before 2009 to about 67% in more recent studies 5. This supports the guideline recommendation to use moxifloxacin as a second-line treatment for cases with suspected macrolide resistance.

Important Clinical Considerations

• Partner treatment: Concurrent treatment of sexual partners is essential to prevent reinfection 2
• Sexual abstinence: Patients should abstain from sexual intercourse until 7 days after initiating therapy or until resolution of symptoms 2
• Antimicrobial resistance: Resistance to macrolides, tetracyclines, and fluoroquinolones has been reported, so consider local resistance patterns when selecting therapy 2
• Follow-up: Recommended if symptoms persist or recur after treatment 2
• Avoid overdiagnosis: Due to high colonization rates of Ureaplasma in asymptomatic individuals, only test symptomatic patients 2

Potential Pitfalls

• Misdiagnosis: Symptoms may be attributed to other more common urogenital pathogens
• Inadequate treatment duration: Ensure full 7-day course of doxycycline is completed
• Overlooking partners: Failure to treat partners will likely result in reinfection
• Ignoring resistance: Macrolide resistance is increasing, particularly for Mycoplasma genitalium

Remember that treatment success depends on proper diagnosis, appropriate antibiotic selection based on the specific pathogen, and adherence to the complete treatment regimen.