Do you need to treat Ureaplasma infections?

Treatment of Ureaplasma Species

Treatment is generally not recommended for Ureaplasma parvum, but may be warranted for Ureaplasma urealyticum in specific clinical contexts with confirmed infection and symptoms. 1

Key Distinction Between Species

The critical first step is understanding that U. urealyticum and U. parvum are distinct organisms with different clinical significance:

• U. urealyticum causes 20-40% of nongonococcal urethritis (NGU) cases and is considered a true pathogen 2
• U. parvum is commonly detected but its role as a causative agent in urethritis is debated, with current evidence suggesting it is more likely a commensal organism 3, 1
• Asymptomatic carriage of these bacteria is common (40-80% of detected cases may represent colonization rather than infection) 1

When NOT to Treat (Most Important)

Routine testing and treatment of asymptomatic men and women for M. hominis, U. urealyticum and U. parvum are not recommended 1. This includes:

• Asymptomatic individuals with positive cultures or PCR results 1
• Patients with mild, non-specific urinary symptoms without confirmed urethritis 1
• Routine screening in any population 1

The extensive testing and treatment of these bacteria may result in antimicrobial resistance selection and substantial economic costs without proven benefit 1.

When to Consider Treatment

Treatment should only be considered in the following specific scenarios:

For Confirmed U. urealyticum (NOT U. parvum):

• Men with symptomatic urethritis (mucoid or purulent urethral discharge, or ≥5 polymorphonuclear leukocytes per oil immersion field on urethral smear) 2
• After excluding N. gonorrhoeae, C. trachomatis, M. genitalium, and T. vaginalis 1
• Only if high bacterial load is present on quantitative species-specific molecular diagnostic tests 1
• Persistent or recurrent urethritis after initial treatment failure with doxycycline 2

For Women:

• Bacterial vaginosis should always be tested for and treated first if detected 1
• Treatment may be considered for acute urethral syndrome with confirmed U. urealyticum infection and negative cultures for other pathogens 4, 5

Treatment Regimens

First-Line Treatment for U. urealyticum:

Doxycycline 100 mg orally twice daily for 7 days 2, 3, 6

This is the recommended regimen for NGU caused by U. urealyticum 2, 6. The FDA label confirms this indication and dosing 6.

Alternative Regimens:

Azithromycin 1.0 g orally as a single dose 3, 7, 8, 9

• Clinical cure rates comparable to doxycycline (81% vs 77%) 9
• However, microbiological cure rates for U. urealyticum are lower (45% for azithromycin vs 47% for doxycycline) 9
• Single-dose convenience may improve compliance 8

Azithromycin 500 mg once daily for 6 days 4

• Superior to single-dose azithromycin for patients with symptoms lasting ≥3 weeks (p < 0.001) 4

Erythromycin-based regimens (if patient cannot tolerate doxycycline):

• Erythromycin base 500 mg orally 4 times daily for 7 days, OR 2
• Erythromycin ethylsuccinate 800 mg orally 4 times daily for 7 days 2

For Persistent or Recurrent Infection:

Extended erythromycin regimen for 14 days 2

• Erythromycin base 500 mg orally 4 times daily for 14 days 2
• This ensures treatment of possible tetracycline-resistant U. urealyticum 2

Moxifloxacin 400 mg daily for 7-14 days may be considered as second-line 3

Critical Management Steps

Partner Evaluation:

Sexual partners should be evaluated and treated while maintaining patient confidentiality 2, 3. This is crucial to prevent reinfection 3.

Follow-Up Protocol:

• Patients should return for evaluation if symptoms persist or recur after completion of therapy 2
• For persistent/recurrent urethritis, re-treat with initial regimen if non-compliance or re-exposure to untreated partner occurred 2
• If compliance was adequate and no re-exposure: perform wet mount and culture for T. vaginalis; if negative, use alternative 14-day regimen 2

Timing of Treatment:

For patients with mild symptoms, delay treatment until nucleic acid amplification test (NAAT) results are available to guide treatment choice 2, 3. This prevents unnecessary antibiotic use for colonization rather than true infection.

Common Pitfalls to Avoid

1. Do not treat U. parvum routinely - it is likely a commensal organism in most cases 3, 1

2. Do not use multiplex PCR results alone to justify treatment - the commercialization of multiplex assays detecting these organisms has led to overtreatment 1

3. Do not treat based on positive test results without clinical symptoms - asymptomatic carriage is extremely common 1

4. Do not skip testing for traditional STI pathogens first - C. trachomatis, N. gonorrhoeae, M. genitalium, and T. vaginalis must be excluded before attributing symptoms to Ureaplasma 1

5. Do not use single-dose azithromycin for chronic symptoms (≥3 weeks duration) - extended regimens are more effective 4

6. Do not forget to assess for re-exposure - treatment failure is often due to untreated partners rather than antibiotic resistance 2, 3