What is Ureaplasma in Females and Treatment
Ureaplasma urealyticum is a small bacterium that commonly causes genitourinary infections in women, presenting with symptoms of urethritis, cervicitis, or chronic urinary symptoms, and should be treated with doxycycline 100 mg orally twice daily for 7 days as first-line therapy. 1, 2, 3
Clinical Presentation in Females
Ureaplasma urealyticum infections in women typically manifest as:
- Acute urethral syndrome with dysuria, urinary frequency, and urgency 4
- Cervicitis with confirmed inflammation after excluding Chlamydia trachomatis and Neisseria gonorrhoeae 2
- Chronic voiding symptoms that may mimic interstitial cystitis, with nearly half of women with unexplained chronic urinary symptoms testing positive for U. urealyticum 5
- Tubo-ovarian abscess in severe or immunocompromised cases 6
The infection rate is highest in women aged 21-30 years, followed by those aged 31-40 years 7. U. urealyticum accounts for approximately 76% of positive mycoplasma infections in the female genital tract 7.
First-Line Treatment
Doxycycline 100 mg orally twice daily for 7 days is the recommended first-line treatment for Ureaplasma urealyticum infections in women 1, 8, 2, 3. This regimen demonstrates:
- The lowest MIC90 (0.25 μg/ml) among tested antibiotics 9
- High clinical and bacteriological efficacy when symptoms have been present for less than 3 weeks 4
- Minimal resistance patterns in most populations 9
Alternative Treatment Options
When doxycycline cannot be used due to contraindications or patient preference:
Azithromycin 1 g orally as a single dose is effective, particularly when compliance with a 7-day regimen may be problematic 1, 8, 2
- For symptoms lasting ≥3 weeks, azithromycin 500 mg once daily for 6 days shows superior eradication rates compared to single-dose therapy 4
Erythromycin base 500 mg orally four times daily for 7 days or erythromycin ethylsuccinate 800 mg orally four times daily for 7 days 1, 8, 2
Fluoroquinolones (levofloxacin 500 mg once daily for 7 days or ofloxacin 300 mg twice daily for 7 days) are alternatives, though resistance is a growing concern 1, 8, 7
Critical Treatment Considerations
Antibiotic Resistance Patterns
U. urealyticum shows highest sensitivity to tetracyclines and greatest resistance to quinolones 7. Important resistance considerations include:
- Quinolone resistance (particularly norfloxacin) is a significant concern 7
- Biovar 2 shows higher resistance to sparfloxacin, clarithromycin, josamycin, and doxycycline compared to biovar 1 7
- Regional variation in resistance patterns exists, though resistance remains low in first-time UTI populations 9
Duration of Symptoms Matters
Treatment efficacy varies significantly based on symptom duration 4:
- For symptoms <3 weeks: standard regimens are highly effective
- For symptoms ≥3 weeks: extended azithromycin therapy (500 mg daily for 6 days) achieves significantly higher eradication rates than single-dose therapy 4
Partner Management
Sexual partners must be evaluated and treated concurrently 1, 8, 2:
- Treat partners with last sexual contact within 60 days of diagnosis 1, 2
- Both patient and partner should abstain from sexual intercourse for 7 days after single-dose therapy or until completion of a 7-day regimen 1, 8, 2
- Partner treatment prevents reinfection and treatment failure
Post-Treatment Management
Test of Cure
Routine test of cure is NOT recommended after doxycycline or azithromycin treatment unless specific circumstances exist 1, 2:
- Only retest if symptoms persist or reinfection is suspected 1
- If performed, test of cure should occur no earlier than 3 weeks after completion of therapy 1
- Consider test of cure after erythromycin treatment due to lower efficacy 1
- Test of cure should be considered when therapeutic compliance is questionable 1
Management of Persistent Infections
If symptoms persist or recur after treatment 1:
- Ensure objective signs of infection are present before initiating additional antimicrobial therapy
- Re-treat with initial regimen if patient was non-compliant or re-exposed to untreated partner
- After doxycycline failure: consider azithromycin 500 mg on day 1, followed by 250 mg daily for 4 days
- After azithromycin failure: consider moxifloxacin 400 mg once daily for 7-14 days
Common Pitfalls to Avoid
Do not confuse U. urealyticum infection with recurrent UTI or interstitial cystitis 5:
- Nearly 48% of women with chronic voiding symptoms may have U. urealyticum infection 5
- Standard UTI cultures do not detect Ureaplasma; specific culture is required 5
- Treatment targeting U. urealyticum significantly improves symptom severity scores (2.2 to 0.7) and reduces urinary frequency (9.2 to 6.8 daily) 5
Avoid treating asymptomatic colonization, as U. urealyticum can be part of normal genital flora in some women. Only treat when associated with documented symptoms and positive cultures 2.
In immunocompromised patients (including those on immunosuppressive therapies like ocrelizumab), U. urealyticum can cause severe disseminated infections requiring prolonged combination therapy with doxycycline and moxifloxacin 6.