What is the recommended treatment for Mycoplasma infections during pregnancy?

Treatment of Mycoplasma Infections During Pregnancy

Azithromycin is the first-line treatment for Mycoplasma infections during pregnancy, with specific dosing regimens based on the trimester and type of infection.

First-Line Treatment Options

For Mycoplasma genitalium

• First-line treatment: Azithromycin 1
  • Preferred regimen: 500 mg on day 1, followed by 250 mg daily for 4 days (5-day regimen) 2
  • This extended regimen is associated with lower treatment failure rates (3.7%) compared to single-dose regimens (13.9%) 2
  • Single 1g dose is less effective and more likely to induce antimicrobial resistance 2

For Mycoplasma pneumoniae

• First-line treatment: Azithromycin
  • Standard dosing: 500 mg on day 1, followed by 250 mg daily for 4 days

For Ureaplasma species

• First-line treatment: Azithromycin
  • Note: A single 1g dose has been shown ineffective in reducing lower genital colonization with Ureaplasma urealyticum in pregnant women 3
  • Extended regimen recommended for better efficacy

Treatment Algorithm Based on Trimester

First Trimester

• Consider risks vs. benefits
  • While azithromycin is generally considered safe, some studies have reported conflicting results regarding adverse fetal outcomes 4
  • For severe infections requiring immediate treatment, proceed with azithromycin therapy
  • For mild infections, consider delaying treatment until second trimester if clinically appropriate

Second and Third Trimesters

• Azithromycin is preferred due to:
  • Better safety profile in later pregnancy
  • Good transplacental transfer
  • Effectiveness against Mycoplasma species

Special Considerations

Macrolide-Resistant Infections

• For documented macrolide-resistant Mycoplasma genitalium:
  • Avoid moxifloxacin during pregnancy due to safety concerns 1
  • Consider consultation with infectious disease specialists for alternative regimens

Monitoring and Follow-up

• Test of cure recommended 3-4 weeks after completing treatment
• Monitor for symptoms of treatment failure
• For recurrent or persistent infections, consider extended treatment courses

Safety Profile

• Azithromycin has not been associated with teratogenic effects in the same way as other antibiotics 5
• The American Academy of Pediatrics considers azithromycin compatible with breastfeeding 5
• Benefits of treating Mycoplasma infections during pregnancy generally outweigh potential risks, as untreated infections may lead to adverse pregnancy outcomes

Contraindications and Alternatives

Contraindicated Treatments

• Doxycycline is contraindicated during pregnancy, especially after the first trimester, due to risk of permanent discoloration of developing teeth in the fetus 6
• Fluoroquinolones (including moxifloxacin) should be avoided during pregnancy despite their higher efficacy against Mycoplasma genitalium in non-pregnant individuals 7

Key Pitfalls to Avoid

1. Using single-dose azithromycin regimens - These have higher treatment failure rates and promote antimicrobial resistance
2. Delaying treatment of symptomatic infections - Untreated infections may lead to adverse pregnancy outcomes
3. Failing to test for antimicrobial resistance - When available, resistance testing should guide therapy
4. Not performing test of cure - Essential to confirm eradication, especially for Mycoplasma genitalium

Remember that treatment of Mycoplasma infections during pregnancy requires balancing antimicrobial efficacy with maternal and fetal safety. The 5-day azithromycin regimen offers the best combination of efficacy and safety for most Mycoplasma infections during pregnancy.