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

First-Line Treatment

Doxycycline 100 mg orally twice daily for 7 days is the most effective and consistently recommended regimen across European and American guidelines 1, 2, 3, 4
This regimen specifically targets Ureaplasma urealyticum, which is recognized as a true pathogen in non-gonococcal urethritis, unlike U. parvum which is typically a commensal organism 2, 3
The FDA-approved dosing for nongonococcal urethritis caused by U. urealyticum is 100 mg orally twice daily for 7 days 5

When doxycycline is contraindicated or compliance with a 7-day regimen is questionable:

Azithromycin 1.0-1.5 g orally as a single dose provides an effective alternative with improved adherence 1, 2, 3
Levofloxacin 500 mg orally once daily for 7 days 2, 3
Ofloxacin 200 mg orally twice daily for 7 days 1, 2
Erythromycin base 500 mg orally four times daily for 7 days 2, 4

Only treat when symptomatic urethritis is documented or symptoms are present 3, 6:

Confirm urethritis with either urethral discharge, dysuria, urethral pruritus, or ≥5 polymorphonuclear leukocytes per high-power field on urethral smear 3
Perform nucleic acid amplification testing (NAAT) on first-void urine or urethral smear before empirical treatment 2
Do not treat asymptomatic colonization - asymptomatic carriage occurs in 40-80% of detected cases and does not require treatment 6
Rule out Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium, and Trichomonas vaginalis before attributing symptoms to Ureaplasma 6

If symptoms persist after completing initial doxycycline therapy 2, 4:

Confirm objective signs of urethritis are still present before retreating 2, 4
Second-line: Azithromycin 500 mg orally on day 1, then 250 mg daily for 4 days 1, 2, 4
Third-line: Moxifloxacin 400 mg orally once daily for 7-14 days (particularly for macrolide-resistant infections) 1, 2, 3
Fourth-line: Pristinamycin 1 g four times daily for 10 days (approximately 75% cure rate) 2

Consider extending treatment to 14 days when prostatitis cannot be excluded in men with persistent symptoms 3
For acute epididymo-orchitis caused by U. urealyticum, treat for at least 10 days 5

Sexual partners must be evaluated and treated concurrently 1, 2, 4:

Treat partners with last sexual contact within 60 days of diagnosis 2, 4
Patients and partners should abstain from sexual intercourse until therapy is completed and symptoms have resolved 2, 4
Maintain patient confidentiality while ensuring partner treatment 1

Do not use fluoroquinolones empirically in patients from urology departments or those who used fluoroquinolones in the last 6 months due to high resistance rates 3
Avoid treating based on positive cultures alone without symptoms - this leads to unnecessary antibiotic use, promotes resistance, and incurs substantial costs 3, 6
Do not use multiplex PCR panels that detect Ureaplasma alongside traditional STIs without clinical context, as this encourages overtreatment of colonization 6
Distinguish between U. urealyticum (pathogenic) and U. parvum (typically non-pathogenic) - only U. urealyticum is an established cause of non-gonococcal urethritis 2, 3, 6
Ensure treatment failure is not due to reinfection from untreated partners before escalating therapy 3, 4

Patients should return for evaluation if symptoms persist or recur after completing therapy 2, 4
Objective signs of urethritis must be documented before initiating additional antimicrobial therapy 2, 4

HIV-infected patients should receive the same treatment regimens as HIV-negative patients 2, 4
Administer doxycycline with adequate fluids to reduce risk of esophageal irritation; may be given with food or milk if gastric irritation occurs 5