What is the recommended treatment for a patient positive for Mycoplasma genitalium and Ureaplasma?

Treatment for Mycoplasma genitalium and Ureaplasma Infections

For patients positive for both Mycoplasma genitalium and Ureaplasma, doxycycline 100 mg orally twice daily for 7 days is the recommended first-line treatment. 1

First-Line Treatment

• Doxycycline 100 mg orally twice daily for 7 days 1
  • This regimen is effective against both Mycoplasma genitalium and Ureaplasma species
  • Doxycycline has a cure rate of approximately 30-40% for M. genitalium but is more effective for Ureaplasma 2

Alternative Regimens (if doxycycline cannot be tolerated)

• Erythromycin base 500 mg orally four times a day for 7 days 1
• OR
• Erythromycin ethylsuccinate 800 mg orally four times a day for 7 days 1

For Patients Who Cannot Tolerate High-Dose Erythromycin

• Erythromycin base 250 mg orally four times a day for 14 days 1
• OR
• Erythromycin ethylsuccinate 400 mg orally four times a day for 14 days 1

For Persistent M. genitalium Infection After Initial Treatment

For patients with persistent symptoms after initial therapy and confirmed M. genitalium infection:

• Extended azithromycin regimen: 500 mg on day one, then 250 mg on days 2-5 (for macrolide-susceptible strains) 2
• Moxifloxacin 400 mg once daily for 7 days (for macrolide-resistant strains) 2

Management of Sex Partners

• Sex partners should be referred for evaluation and treatment 1
• For symptomatic patients: treat partners with last sexual contact within 30 days of symptom onset 1
• For asymptomatic patients: treat partners with last sexual contact within 60 days of diagnosis 1
• Patients and partners should abstain from sexual intercourse until therapy is completed and symptoms have resolved 1

Follow-Up Recommendations

• Patients should return for evaluation if symptoms persist or recur after completing therapy 1
• For persistent or recurrent urethritis:
  • Re-treat with initial regimen if non-compliant with treatment or re-exposed to untreated partner 1
  • If compliant and not re-exposed, consider alternative regimen for 14 days (e.g., erythromycin base 500 mg orally four times daily for 14 days) 1
• Test of cure for M. genitalium should not be performed earlier than 3-4 weeks after treatment due to potential delayed emergence of resistance 3

Important Clinical Considerations

• Ureaplasma is often a commensal organism and may not require treatment in asymptomatic individuals 4
• M. genitalium is increasingly recognized as a significant pathogen causing urethritis, cervicitis, and pelvic inflammatory disease 2
• Antimicrobial resistance in M. genitalium is increasing, particularly to macrolides 2, 5
• Single-dose azithromycin (1g) should be avoided for M. genitalium due to high rates of treatment failure and development of resistance 5

Special Situations

• For complicated infections (PID, epididymitis) caused by M. genitalium: consider moxifloxacin 400 mg once daily for 14 days 2
• For HIV-infected patients: use the same treatment regimens as for HIV-negative patients 1

Treatment Failures

For patients who fail multiple treatment regimens for M. genitalium:

• Consider high-dose tinidazole (2g daily for 7 days) as a salvage therapy option 6
• Consult with infectious disease specialists for management of multi-drug resistant infections 2