Treatment of Ureaplasma urealyticum in Urine

Doxycycline 100 mg orally twice daily for 7 days is the recommended first-line treatment for Ureaplasma urealyticum detected in urine. 1, 2, 3

First-Line Treatment

Doxycycline 100 mg orally twice daily for 7 days is the primary treatment recommended by both the European Association of Urology and the Centers for Disease Control and Prevention 1, 2
This regimen is FDA-approved specifically for nongonococcal urethritis (NGU) caused by U. urealyticum 3
Clinical cure rates with doxycycline range from 70-79% for U. urealyticum infections 4, 5

When doxycycline cannot be used due to allergy, intolerance, or compliance concerns:

Azithromycin 1 g orally as a single dose is an effective alternative, particularly when adherence to a 7-day regimen is questionable 1, 2
Erythromycin base 500 mg orally four times daily for 7 days is an alternative for patients who cannot tolerate doxycycline 1, 2
Levofloxacin 500 mg orally once daily for 7 days or ofloxacin 300 mg orally twice daily for 7 days are fluoroquinolone alternatives 2

For patients with symptoms lasting ≥3 weeks, azithromycin 500 mg once daily for 6 days achieves significantly higher eradication rates than a single 1 g dose 6
Research demonstrates that doxycycline and josamycin show superior susceptibility (91% and 86% respectively) compared to azithromycin (71%) 7

Only treat U. urealyticum when there are symptoms of urethritis (urethral discharge, dysuria, urethral pruritus) or documented urethritis (≥5 PMNs/HPF on urethral smear) 8
The European Association of Urology notes that the pathogenic role of Ureaplasma species is debated, with recent data suggesting U. urealyticum (but not U. parvum) is an etiological agent in NGU 8
Do not treat asymptomatic bacteriuria unless the patient is undergoing traumatic urinary tract procedures 8

For men, consider extending treatment to 14 days when prostatitis cannot be excluded 8
The FDA label supports 7-day treatment for uncomplicated urethral infections caused by U. urealyticum 3

Persistent detection of U. urealyticum after standard therapy is common:

Confirm objective signs of urethritis (≥5 PMNs/HPF) before retreating, as persistent organism detection does not always correlate with persistent urethritis 4, 5
Clinical cure rates with standard therapies (azithromycin or doxycycline) range from 76-80%, with persistent detection occurring in 25-31% of cases 4, 5
For macrolide-resistant infections or treatment failure, moxifloxacin 400 mg orally once daily for 7-14 days can be considered, though failure rates of 30% have been reported even with this agent 2, 4
Re-treatment with the initial regimen is appropriate if the patient was non-compliant or re-exposed to an untreated partner 1

All sexual partners with contact within 30 days of symptom onset (symptomatic patients) or 60 days of diagnosis (asymptomatic patients) must be evaluated and treated 1, 2
Partners should receive the same treatment regimen as the index patient 1
Both patient and partners must abstain from sexual intercourse for 7 days after single-dose therapy or until completion of a 7-day regimen and resolution of symptoms 1
Failure to treat partners is a common pitfall leading to reinfection 2

Do not treat based on urine culture positivity alone without confirming symptoms or signs of urethritis 2
Do not use fluoroquinolones empirically in patients from urology departments or those who have used fluoroquinolones in the last 6 months due to high resistance rates 8
Ensure adequate fluid intake with doxycycline to reduce risk of esophageal irritation and ulceration 3
If gastric irritation occurs with doxycycline, administer with food or milk, as absorption is not significantly affected 3