What is the recommended treatment for a patient with ureaplasma, gonorrhea, and chlamydia?

Treatment for Ureaplasma, Gonorrhea, and Chlamydia Co-infection

For a patient with ureaplasma, gonorrhea, and chlamydia co-infection, the recommended treatment is ceftriaxone 250 mg IM in a single dose PLUS azithromycin 1 g orally in a single dose.

First-line Treatment Regimen

• Ceftriaxone 250 mg IM in a single dose for gonorrhea 1
• PLUS
• Azithromycin 1 g orally in a single dose for chlamydia and ureaplasma 1, 2

This combination therapy addresses all three infections simultaneously:

• Ceftriaxone is highly effective against gonorrhea 1
• Azithromycin treats both chlamydia (97-98% efficacy) and ureaplasma 2, 3
• Dual therapy helps prevent development of antimicrobial resistance 1

Alternative Treatment Options

If ceftriaxone is unavailable:

• Cefixime 400 mg orally in a single dose PLUS azithromycin 1 g orally in a single dose 1
• A test-of-cure should be performed 1 week after treatment with this alternative regimen 1

For patients with severe cephalosporin allergy:

• Doxycycline 100 mg orally twice daily for 7 days for chlamydia and ureaplasma 2, 3
• PLUS
• Spectinomycin 2 g IM in a single dose for gonorrhea (note: less effective for pharyngeal gonorrhea) 1

Special Considerations

For Ureaplasma Specifically

• While azithromycin 1 g single dose is effective for most ureaplasma infections, persistent infections may require:
  • Doxycycline 100 mg twice daily for 7 days if azithromycin was used initially 4, 3
  • For macrolide-resistant strains, moxifloxacin 400 mg daily for 7-14 days may be necessary 3

For Pregnant Patients

• Azithromycin 1 g orally in a single dose is safe and effective during pregnancy 2
• Ceftriaxone is the preferred treatment for gonorrhea during pregnancy 1
• Doxycycline and fluoroquinolones are contraindicated during pregnancy 2

Partner Management

• All sex partners from the previous 60 days should be evaluated, tested, and treated with the same regimen 5, 1
• If the last sexual contact was more than 60 days before diagnosis, the most recent partner should be treated 5
• Patients should abstain from sexual intercourse until:
  • They complete treatment (7 days after single-dose therapy) 5
  • Their partners complete treatment 5
  • Both patient and partners are asymptomatic 1

Follow-Up Recommendations

• Test-of-cure is not routinely recommended for patients treated with the recommended regimens 2
• Consider retesting approximately 3 months after treatment due to high risk of reinfection 1
• If symptoms persist after treatment:
  • Evaluate for reinfection or treatment failure 1
  • Obtain culture for N. gonorrhoeae and test for antimicrobial susceptibility 1
  • For persistent ureaplasma, consider moxifloxacin 400 mg daily for 7-14 days 3

Common Pitfalls and Caveats

• Azithromycin 1 g alone is insufficient for gonorrhea treatment (only 93% efficacy) 1
• Pharyngeal gonorrhea is more difficult to eradicate than urogenital or anorectal infections 1
• Quinolones are no longer recommended for empiric gonorrhea treatment due to widespread resistance 1
• Erythromycin has lower efficacy for chlamydia and higher gastrointestinal side effects that may reduce compliance 5
• For ureaplasma, increasing macrolide resistance is a concern; test of cure should be considered 3