What is the recommended treatment for Ureaplasma and Mycoplasma hominis infections?

Treatment of Ureaplasma and Mycoplasma hominis Infections

First-Line Treatment: Doxycycline 100 mg orally twice daily for 7 days

Treat Ureaplasma and Mycoplasma hominis infections only when patients have documented urethritis with objective signs of inflammation—do not treat based on positive testing alone in asymptomatic individuals. 1

When to Treat (Critical Decision Point)

Treatment is indicated ONLY when patients meet these criteria:

• Documented urethritis symptoms: mucopurulent discharge, dysuria, or urethral pruritis 1
• Objective inflammatory signs (at least one required):

  • 5 WBCs per oil immersion field on Gram stain 2, 1

  • Positive leukocyte esterase test on first-void urine 2, 1

  • 10 WBCs per high-power field on first-void urine microscopy 2, 1

Treatment Regimens

First-Line Therapy

• Doxycycline 100 mg orally twice daily for 7 days 1, 3, 4
  • FDA-approved for nongonococcal urethritis caused by Ureaplasma urealyticum 3
  • All Ureaplasma strains show susceptibility to doxycycline in surveillance studies 4
  • Uniformly effective against both M. hominis and U. urealyticum 5

Alternative Therapy (for compliance concerns)

• Azithromycin 1 g orally as single dose 1, 6
  • Use when adherence to 7-day regimen is questionable 1
  • Effective in clinical studies for chronic urinary symptoms 6

Second Alternative

• Erythromycin base 500 mg orally four times daily for 7 days 1
  • Caution: Increasing resistance to erythromycin documented—80% resistance in some Ureaplasma isolates and 97% in mixed infections 7

Partner Management Protocol

• Evaluate and treat all sexual partners 1, 8
• Treatment window for partners:
  • Last sexual contact within 30 days of symptom onset (symptomatic patients) 1
  • Last sexual contact within 60 days of diagnosis (asymptomatic patients) 1
• Sexual abstinence required:
  • 7 days after single-dose therapy completion 1
  • Until completion of entire 7-day regimen 1

Critical Pitfalls to Avoid

Do NOT routinely screen asymptomatic individuals

• Asymptomatic carriage is common (colonizes up to 80% of sexually mature women) 9, 7
• No evidence that treating asymptomatic colonization improves conception rates 1, 8
• The European STI Guidelines Editorial Board explicitly recommends against routine testing and treatment of asymptomatic individuals 9

Do NOT treat based on positive testing alone

• Positive Ureaplasma testing without documented urethritis symptoms or objective inflammatory signs does not warrant treatment 1, 9
• Likely carriage in 40-80% of detected cases without disease 9

Do NOT confuse U. urealyticum with U. parvum

• Only U. urealyticum is associated with male infertility based on European Association of Urology meta-analysis 1, 8
• U. parvum is the predominant species but has weaker pathogenic evidence 7

Do NOT assume treating asymptomatic Ureaplasma improves fertility outcomes

• Randomized controlled trials with live birth as primary outcomes are needed to establish this benefit 1, 8
• No evidence that treatment of genital tract infections without symptoms improves conception rates 8

Special Considerations

Antimicrobial Resistance Patterns

• Doxycycline and josamycin maintain universal susceptibility 4
• Increasing resistance to erythromycin (80% in some studies) and tetracycline (73%) 7
• Moxifloxacin shows 98% susceptibility, but fluoroquinolones are not first-line 7

Pregnancy Context

• Genital mycoplasma colonization may predispose to spontaneous abortion and low birth weight 5
• Doxycycline is contraindicated in pregnancy 7
• Erythromycin is often used in pregnancy, but resistance is increasing 7