What is the recommended treatment for ureaplasma infection?

Treatment of Ureaplasma Infection

Doxycycline 100 mg orally twice daily for 7 days is the recommended first-line treatment for Ureaplasma urealyticum infection. 1, 2, 3, 4

First-Line Treatment

• Doxycycline 100 mg orally twice daily for 7 days is the most effective and consistently recommended treatment across all major guidelines (European Association of Urology, American College of Physicians, CDC). 1, 2, 3, 4
• This regimen is specifically indicated for non-gonococcal urethritis caused by U. urealyticum. 5
• Doxycycline can be taken with food or milk if gastric irritation occurs, as absorption is not significantly affected. 5

Alternative First-Line Options

• Azithromycin 1.0-1.5 g orally as a single dose is an effective alternative, particularly when compliance with a 7-day regimen is a concern. 1, 2, 3, 4
• The single-dose regimen improves adherence but may be slightly less reliable than doxycycline. 2

Other Alternative Regimens

• Levofloxacin 500 mg orally once daily for 7 days 2, 3, 4
• Ofloxacin 300 mg orally twice daily for 7 days 2, 4
• Erythromycin base 500 mg orally four times daily for 7 days 2, 4

Critical caveat: Avoid fluoroquinolones empirically in patients from urology departments or those who have used fluoroquinolones in the last 6 months due to high resistance rates. 3

Management of Treatment Failure

After Doxycycline Failure:

• Azithromycin 500 mg orally on day 1, followed by 250 mg daily for 4 days 1, 2, 4
• Before retreating, confirm objective signs of urethritis (≥5 PMNs/HPF on urethral smear) and ensure the patient was compliant with initial therapy and not re-exposed to an untreated partner. 4

After Azithromycin Failure:

• Moxifloxacin 400 mg orally once daily for 7-14 days 1, 2, 4
• This is particularly effective for macrolide-resistant infections. 1, 2

Third-Line Option:

• Pristinamycin 1 g four times daily for 10 days can be used after moxifloxacin failure, with approximately 75% cure rate. 2

When to Treat vs. Not Treat

Only treat when symptomatic or with documented urethritis: 3

• Symptoms include urethral discharge, dysuria, or urethral pruritus. 3
• Objective evidence: ≥5 PMNs/HPF on urethral smear. 3

Do not treat asymptomatic colonization: 3, 6

• Asymptomatic carriage is common (40-80% of detected cases may be simple colonization). 6
• U. urealyticum (not U. parvum) is the pathogenic species in non-gonococcal urethritis. 2, 3
• Routine testing and treatment of asymptomatic individuals is not recommended and may promote antimicrobial resistance. 6

Diagnostic Approach

• Perform nucleic acid amplification test (NAAT) on first-void urine or urethral smear before empirical treatment. 2
• In patients with mild symptoms, delay treatment until NAAT results are available. 2
• Exclude traditional STI pathogens (N. gonorrhoeae, C. trachomatis, M. genitalium, T. vaginalis) before attributing symptoms to Ureaplasma. 6

Partner Management

• Sexual partners with last sexual contact within 60 days of diagnosis should be evaluated and treated. 2, 3, 4
• Patients and partners must abstain from sexual intercourse until therapy is completed and symptoms have resolved. 2, 4
• Maintain patient confidentiality while ensuring partners are treated. 1

Special Considerations

Extended Duration:

• Consider extending treatment to 14 days in men when prostatitis cannot be excluded. 3

HIV-Infected Patients:

• Receive the same treatment regimens as HIV-negative patients. 2, 4

Chronic Urinary Symptoms in Women:

• U. urealyticum may account for chronic voiding symptoms in women; culture and treatment should be considered before pursuing invasive testing for interstitial cystitis. 7
• Treatment with azithromycin 1 g single dose (followed by doxycycline, ofloxacin, or erythromycin for persistent infection) significantly improved symptom severity and urinary frequency. 7

Common Pitfalls to Avoid

• Do not treat based on symptoms alone without confirming Ureaplasma through appropriate testing. 3
• Do not fail to address possible reinfection from untreated partners. 3
• Do not use fluoroquinolones empirically in high-risk populations for resistance. 3
• Do not routinely test or treat asymptomatic individuals, as this promotes resistance and incurs unnecessary costs. 6

Follow-Up

• Patients should return for evaluation if symptoms persist or recur after completing therapy. 2, 4
• Confirm objective signs of urethritis before initiating additional antimicrobial therapy. 2, 4