What is the recommended treatment for ureaplasma and mycoplasma infections?

Treatment for Ureaplasma and Mycoplasma Infections

For Ureaplasma urealyticum infections, doxycycline 100 mg orally twice daily for 7 days is the first-line treatment, with azithromycin 1.0-1.5 g as a single dose as an alternative; for Mycoplasma genitalium, azithromycin 500 mg on day 1 followed by 250 mg daily for 4 days is preferred, with moxifloxacin 400 mg daily for 7-14 days reserved for macrolide-resistant cases. 1

Ureaplasma urealyticum Treatment

First-Line Therapy

• Doxycycline 100 mg orally twice daily for 7 days is the recommended first-line treatment for U. urealyticum infections 1, 2
• This regimen is FDA-approved for nongonococcal urethritis caused by U. urealyticum 2

Alternative Regimens

• Azithromycin 1.0-1.5 g orally as a single dose serves as an effective alternative 1
• Research demonstrates that single-dose azithromycin shows similar effectiveness to 7-day doxycycline regimens for U. urealyticum, with comparable cure rates when sexual re-exposure is excluded 3
• Erythromycin base 500 mg orally four times daily for 7 days can be used if doxycycline is contraindicated 1, 4

Important Clinical Considerations

• Testing for U. urealyticum should only be performed after excluding traditional STI pathogens (N. gonorrhoeae, C. trachomatis, M. genitalium, T. vaginalis) 5
• Routine screening of asymptomatic individuals is not recommended, as asymptomatic carriage occurs in 40-80% of detected cases 5
• Only men with high U. urealyticum loads and symptomatic urethritis should be considered for treatment 5
• For persistent urethritis after doxycycline, extended erythromycin therapy (500 mg four times daily for 14 days) addresses possible tetracycline-resistant U. urealyticum 1

Mycoplasma genitalium Treatment

First-Line Therapy

• Azithromycin 500 mg orally on day 1, followed by 250 mg orally daily for 4 days (extended regimen) is the preferred first-line treatment 1
• This extended regimen is superior to single-dose azithromycin, which has declining efficacy 6

Treatment Efficacy Concerns

• Single-dose azithromycin (1 g) efficacy has declined significantly: studies prior to 2009 showed 85.3% cure rates, but studies since 2009 show only 67.0% cure rates 6
• Azithromycin is significantly more effective than doxycycline for M. genitalium: in head-to-head comparison, azithromycin achieved 87% cure rate versus 45% with doxycycline 7
• Doxycycline 100 mg twice daily for 7 days is not recommended as first-line therapy for M. genitalium due to poor efficacy 7

Macrolide-Resistant Infections

• Moxifloxacin 400 mg orally daily for 7-14 days is the treatment of choice for macrolide-resistant M. genitalium 1
• This should be used when macrolide resistance is detected or when azithromycin treatment fails 1

Management of Persistent Urethritis

• After first-line doxycycline failure (if inappropriately used), switch to azithromycin 500 mg on day 1, then 250 mg for 4 days 1
• After first-line azithromycin failure, use moxifloxacin 400 mg daily for 7-14 days 1
• M. genitalium is an important cause of recurrent nongonococcal urethritis after standard CDC-recommended regimens 7

Clinical Relapse Patterns

• Of persistently infected men who appear clinically cured at early follow-up, 47% experience clinical relapse within 2-6 weeks 7
• This underscores the importance of test-of-cure and extended follow-up 7

Special Populations

Pregnancy

• Azithromycin is the first-line treatment for M. genitalium in pregnancy, though dosing schedules vary between guidelines 8
• Moxifloxacin is contraindicated in pregnancy 1, 8
• For U. urealyticum, erythromycin 500 mg orally four times daily for at least 7 days is recommended when tetracyclines are contraindicated 4

Diagnostic Approach

Testing Recommendations

• Perform validated nucleic acid amplification test (NAAT) on first-void urine or urethral swab before empirical treatment 1
• In patients with mild symptoms, delay treatment until NAAT results are available to guide pathogen-directed therapy 1
• Use quantitative species-specific molecular diagnostic tests for U. urealyticum when testing is undertaken 5

Partner Management

• Sexual partners should be treated while maintaining patient confidentiality 1
• Patients should abstain from sexual intercourse until 7 days after therapy initiation 1
• All sex partners within the preceding 60 days should be evaluated and treated 1

Common Pitfalls to Avoid

• Do not routinely test asymptomatic individuals for U. urealyticum, U. parvum, or M. hominis, as this leads to unnecessary treatment and antimicrobial resistance 5
• Do not use doxycycline as first-line therapy for M. genitalium, as it has poor efficacy compared to azithromycin 7
• Do not assume treatment failure at 48 hours when using macrolides for mycoplasma infections, as clinical response may take 2-4 days 9
• Do not use single-dose azithromycin (1 g) for M. genitalium, as the extended regimen is more effective 1, 6