Are mycoplasma and ureaplasma treated the same?

Treatment of Mycoplasma and Ureaplasma: Key Differences

Mycoplasma and Ureaplasma are NOT treated the same—the decision to treat depends critically on which specific species is identified and the clinical context, with Mycoplasma genitalium and Ureaplasma urealyticum warranting treatment in symptomatic cases, while Ureaplasma parvum and asymptomatic colonization should generally not be treated. 1, 2

Species-Specific Treatment Recommendations

Mycoplasma Species

• Mycoplasma genitalium is a recognized pathogen in nongonococcal urethritis (15-25% of cases) and cervicitis/PID in females, and should be treated when detected in symptomatic patients. 1

• Mycoplasma hominis has been associated with male infertility and may warrant treatment in specific fertility contexts, though routine testing is not recommended. 1

• Mycoplasma pneumoniae requires macrolide antibiotics as first-line treatment in respiratory infections, particularly in children aged 5 and above. 1

Ureaplasma Species

• Ureaplasma urealyticum is associated with male infertility and nongonococcal urethritis (20-40% of NGU cases), and treatment may be considered in symptomatic patients with documented urethritis. 1, 3, 2

• Ureaplasma parvum is NOT associated with male infertility or urethritis and should not be treated, as it represents normal colonization. 1, 4

• The Infectious Diseases Society of America explicitly recommends against routine testing for Ureaplasma in asymptomatic individuals due to high colonization rates (40-80% carriage in sexually active people). 1, 5, 2

Antibiotic Selection When Treatment Is Indicated

First-Line Agents

• Doxycycline is the most effective antibiotic against both Mycoplasma and Ureaplasma species when treatment is warranted. 3, 6

• Macrolides (azithromycin, erythromycin, clarithromycin) are effective alternatives, particularly for Mycoplasma genitalium and Mycoplasma pneumoniae. 1, 7

• Fluoroquinolones can be used as second-line agents, though resistance is increasing. 8, 9

FDA-Approved Coverage

• Azithromycin has documented activity against Ureaplasma urealyticum and Mycoplasma pneumoniae. 7

• Doxycycline is active against Mycoplasma pneumoniae, Ureaplasma urealyticum, and Chlamydia trachomatis. 3

Critical Clinical Pitfalls to Avoid

Do NOT Treat Asymptomatic Colonization

• Treating asymptomatic bacteriuria (including Ureaplasma) contributes to antibiotic resistance and contradicts antimicrobial stewardship principles. 5

• Asymptomatic carriage is common, and the majority of individuals do not develop disease. 2

• Recent molecular testing studies show that Ureaplasma/Mycoplasma detection correlates negatively with irritative lower urinary tract symptoms, suggesting no diagnostic benefit in chronic urinary complaints. 10

Require Objective Evidence Before Treatment

• For urethritis, document ≥5 polymorphonuclear leukocytes per high-power field on urethral smear before treating. 4

• Exclude traditional STI agents (Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis) before attributing symptoms to Ureaplasma. 1, 2

• Use quantitative species-specific molecular diagnostic tests when available, as only high bacterial loads of U. urealyticum should be considered for treatment. 2

Distinguish Between Species

• Multiplex PCR assays that detect M. hominis, U. parvum, and U. urealyticum together have worsened inappropriate testing and treatment. 2

• The European STI Guidelines Editorial Board states we have no evidence that detecting and treating M. hominis, U. parvum, and U. urealyticum does more good than harm. 2

Special Clinical Contexts

Male Infertility

• Meta-analysis data show U. urealyticum and M. hominis (but NOT U. parvum or M. genitalium) are associated with male infertility. 1

• Treatment may improve sperm parameters in documented infections, though evidence for improved conception rates is lacking. 1

Female Reproductive Health

• In symptomatic women, always test for and treat bacterial vaginosis first before considering Ureaplasma/Mycoplasma treatment. 2

• The prevalence of these organisms is only slightly higher in women with fertility problems compared to fertile controls, and their negative effect on reproduction is not clearly established. 6

Post-Transplant Infections

• M. hominis and U. urealyticum infections after lung transplantation are donor-derived, carry high morbidity, and require aggressive treatment with tetracyclines, macrolides, or fluoroquinolones. 8