Do we treat Ureaplasma in urine?

Treatment of Ureaplasma in Urine

Ureaplasma detected in urine without urinary symptoms should NOT be treated, as this represents asymptomatic colonization rather than infection. 1, 2, 3

Key Principle: Distinguish Colonization from Infection

• Asymptomatic bacteriuria, including Ureaplasma, should not be screened for or treated in most patients, according to the European Association of Urology 2024 guidelines 1
• Ureaplasma urealyticum colonizes the lower genitourinary tract in 40-80% of sexually active individuals and is commonly a commensal organism 3
• The presence of Ureaplasma in urine without symptoms represents colonization, not infection requiring treatment 2, 3

When Treatment Is NOT Indicated

Do not treat Ureaplasma in the following scenarios:

• Asymptomatic patients with positive urine cultures - treatment promotes antimicrobial resistance without clinical benefit 1, 2, 3
• Women without urinary tract symptoms, regardless of Ureaplasma detection 1
• Men without urethral symptoms 3
• Patients with well-regulated diabetes mellitus 1
• Elderly institutionalized patients 1
• Postmenopausal women without symptoms 1
• Patients with recurrent UTIs who are currently asymptomatic 1

When to Consider Treatment

Treatment should ONLY be considered in symptomatic patients after excluding other causes:

For Symptomatic Women:

• First exclude traditional STI pathogens (Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium, Trichomonas vaginalis) before considering Ureaplasma as causative 3, 4
• Test for and treat bacterial vaginosis first if present 3
• Consider Ureaplasma testing only in cases of chronic urethritis, sterile pyuria (≥5 WBC/hpf with negative standard cultures), or persistent lower urinary tract symptoms after excluding other causes 1, 5, 4

For Symptomatic Men:

• Only men with high Ureaplasma urealyticum load should be considered for treatment, as low loads likely represent carriage 3
• Quantitative species-specific molecular diagnostic tests should be used 3
• Traditional urethritis pathogens must be excluded first 1, 3

Treatment Regimens (When Indicated)

For symptomatic patients with confirmed Ureaplasma infection:

First-line therapy:

• Azithromycin 1 gram single dose for acute symptoms (<3 weeks duration) 5, 6
• Azithromycin 500 mg once daily for 6 days for chronic symptoms (≥3 weeks duration) - significantly more effective than single-dose for prolonged symptoms 6

Alternative regimens:

• Doxycycline 100 mg twice daily for 7-14 days 1, 7, 5
• Erythromycin 500 mg four times daily for 7-14 days 1
• Ofloxacin (dosing per local protocols) 5

The FDA drug labels confirm that both doxycycline and azithromycin have activity against Ureaplasma urealyticum 7, 8

Critical Pitfalls to Avoid

• Testing asymptomatic patients - this leads to unnecessary treatment and antimicrobial resistance 2, 3
• Using multiplex PCR panels that include Ureaplasma without clinical indication - commercialization of these tests has worsened overtreatment 3
• Treating without excluding other pathogens first - Ureaplasma should be a diagnosis of exclusion 3, 4
• Treating low bacterial loads - only high loads in symptomatic men warrant consideration 3

Special Populations Requiring Treatment

Only two scenarios warrant screening and treatment of asymptomatic bacteriuria (though Ureaplasma-specific data is limited):

• Pregnant women - treat with standard short-course antibiotics or single-dose fosfomycin 1
• Before urological procedures breaching the mucosa 1

Immunosuppressed Patients

• Immunosuppressed patients (e.g., on rituximab, with HIV) have higher colonization rates and increased risk of invasive Ureaplasma infection 9
• Even in immunosuppressed patients, treat only if symptomatic with documented infection, not colonization 9
• Consider Ureaplasma in immunosuppressed patients with culture-negative infections and persistent symptoms 9