What is the recommended management for Ureaplasma (a type of bacteria) in urine?

Management of Ureaplasma in Urine

Do not treat asymptomatic Ureaplasma detected in urine, as asymptomatic bacteriuria should not be treated in most clinical scenarios. 1

Clinical Context Determines Management

The management of Ureaplasma in urine depends entirely on whether the patient is symptomatic and the clinical presentation:

Asymptomatic Bacteriuria (No Treatment Indicated)

• Do not screen for or treat asymptomatic bacteriuria in general populations 1
• The only exceptions where asymptomatic bacteriuria requires treatment are:
  • Pregnant women 1
  • Before endoscopic urologic procedures with mucosal trauma (e.g., TURP, ureteroscopy) 1
• Ureaplasma detected incidentally in urine without symptoms does not warrant antimicrobial therapy 1

Symptomatic Urethritis (Treatment Indicated)

If the patient has urethritis symptoms (dysuria, urethral discharge, urethral pruritus), treat with doxycycline 100 mg orally twice daily for 7 days. 1, 2

• The 2024 European Association of Urology guidelines recognize U. urealyticum (but not U. parvum) as a causative agent of non-gonococcal urethritis 1
• Ureaplasma urealyticum causes 20-40% of non-gonococcal urethritis cases 1
• Doxycycline is the recommended first-line regimen for non-gonococcal urethritis, which covers Ureaplasma 1, 2

Alternative regimens if doxycycline cannot be used:

• Erythromycin base 500 mg orally 4 times daily for 7 days 1
• Azithromycin 1 g single dose (though less evidence for Ureaplasma specifically) 3

Chronic Urinary Symptoms

• If a patient has chronic voiding symptoms (frequency, urgency, dysuria) with positive Ureaplasma culture and negative standard bacterial cultures, consider treatment 3
• One study showed 48% of women with chronic urinary symptoms had U. urealyticum, and treatment with azithromycin 1 g followed by doxycycline if needed resulted in significant symptom improvement 3
• Treat with azithromycin 1 g as initial therapy; if infection persists, use doxycycline 100 mg twice daily for 7 days 3

Important Antibiotic Resistance Considerations

Fluoroquinolone Resistance is Rising

• Avoid fluoroquinolones (ciprofloxacin, levofloxacin, ofloxacin) as first-line therapy for Ureaplasma 4, 5
• Ciprofloxacin resistance in Ureaplasma is approximately 60%, making it unreliable 5
• Levofloxacin resistance is lower (5.3%) but increasing over time 5
• Fluoroquinolone-resistant Ureaplasma has been documented causing disseminated disease in immunocompromised patients 4

Tetracyclines Remain Most Effective

• Doxycycline has the lowest MIC90 (0.25 μg/ml) among tested antibiotics for Ureaplasma 6
• Tetracycline resistance exists but remains relatively uncommon in first-time infections (approximately 3% in one U.S. study) 6
• All Ureaplasma isolates in recent studies remained sensitive to doxycycline 6

Special Populations

Immunocompromised Patients

• In immunocompromised patients (transplant recipients, etc.) with systemic symptoms and Ureaplasma infection, use combination therapy with azithromycin plus doxycycline 4
• Monitor serum ammonia levels, as Ureaplasma can cause hyperammonemia syndrome through urea hydrolysis 4
• Consider susceptibility testing given higher risk of antimicrobial resistance 4

Partner Management

• Evaluate and treat all at-risk sexual partners when treating urethritis 1
• Partners should receive the same treatment regimen even if asymptomatic 1

Common Pitfalls to Avoid

• Do not treat Ureaplasma found incidentally on urine culture without corresponding symptoms 1
• Do not use ciprofloxacin empirically for suspected Ureaplasma urethritis due to high resistance rates 5
• Do not confuse U. urealyticum with U. parvum—only U. urealyticum is definitively pathogenic in urethritis 1
• Do not use single-dose azithromycin alone for confirmed Ureaplasma; 7-day doxycycline is preferred 1, 2
• Do not order routine post-treatment cultures if the patient is asymptomatic 1