Why Ureaplasma Is Not Commonly Screened For
Ureaplasma should not be routinely screened for because it is primarily a commensal organism with high asymptomatic colonization rates, and there is insufficient evidence that detection and treatment of Ureaplasma improves clinical outcomes in most populations. 1, 2
Reasons for Not Screening
High Prevalence of Asymptomatic Colonization
- Ureaplasma species frequently colonize the genital tract of asymptomatic individuals, with studies showing colonization rates of 40-80% in detected cases 2
- Asymptomatic carriage is common, and the majority of individuals do not develop any disease related to this colonization 2
- In a study of asymptomatic patients, 14% were found to be infected with Ureaplasma urealyticum without any symptoms 3
Limited Clinical Significance
- Current guidelines do not recommend routine testing for Ureaplasma urealyticum in asymptomatic individuals 1
- The 2018 Infectious Diseases Society of America guidelines specifically state that "culture or NAATs for Ureaplasma is not recommended because of the high prevalence of colonization in asymptomatic, sexually active people" 1
- While Ureaplasma urealyticum has been associated with urethritis in men, it is probably not causal in most cases unless a high bacterial load is present 2
Antimicrobial Stewardship Concerns
- Extensive testing and subsequent treatment may result in selection of antimicrobial resistance, not only in these bacteria but also in true STI agents and the general microbiota 2
- Treating asymptomatic bacteriuria (including Ureaplasma) is generally not recommended due to concerns about antibiotic resistance 1
- Unnecessary antibiotic use contributes to the pressing concerns of antibiotic resistance and contradicts principles of antibiotic stewardship 1
Diagnostic Challenges
- Traditional STI urethritis agents such as Neisseria gonorrhoeae and Chlamydia trachomatis should be excluded prior to Ureaplasma testing 2
- If testing is performed, quantitative species-specific molecular diagnostic tests should be used rather than just detecting presence/absence 2
- The commercialization of multiplex PCR assays that detect traditional STIs alongside Ureaplasma has led to overdetection and overtreatment 2
Specific Clinical Contexts
Non-gonococcal Urethritis (NGU)
- While Ureaplasma urealyticum is implicated in 20-40% of NGU cases, Chlamydia trachomatis remains the most frequent cause (23-55% of cases) and is the primary target for screening 1
- The etiology of many cases of NGU remains unknown, and routine testing for Ureaplasma in this context is not recommended without first ruling out other pathogens 1
Asymptomatic Individuals
- In asymptomatic individuals with neurogenic lower urinary tract dysfunction, guidelines explicitly recommend against surveillance/screening urine testing, including cultures that might detect Ureaplasma 1
- European STI Guidelines Editorial Board has issued a position statement against routine screening of asymptomatic men and women for Ureaplasma species 2
Exceptions Where Testing May Be Considered
Specific Clinical Scenarios
- In men with symptomatic urethritis where other pathogens have been excluded, testing for Ureaplasma urealyticum with quantitative methods may be considered 2
- In cases of infertility with asymptomatic leukocytospermia, some evidence suggests screening and treating Ureaplasma may improve sperm quality 4
- Immunocompromised patients, particularly those with humoral immunodeficiencies (either congenital or iatrogenic, such as from rituximab treatment), may be at higher risk for invasive Ureaplasma infections 5
Conclusion
The current medical consensus does not support routine screening for Ureaplasma species in either symptomatic or asymptomatic individuals due to high colonization rates, limited clinical significance in most cases, and concerns about antimicrobial stewardship. Testing should be limited to specific clinical scenarios after excluding other more established pathogens.