Interpretation and Management of Positive Ureaplasma spp. Test
Treatment is only indicated if this patient has documented symptoms or objective signs of urethritis—a positive Ureaplasma test alone in an asymptomatic patient does not warrant treatment. 1
Critical First Step: Assess for Urethritis
Before initiating any treatment, you must document that urethritis is actually present. Ureaplasma exists in a gray zone—it frequently colonizes healthy individuals without causing disease and is not classified as a traditional STD like gonorrhea or chlamydia. 1
Urethritis is confirmed by any of the following:
- Mucopurulent or purulent discharge 2
- Greater than 5 WBCs per oil immersion field on Gram stain of urethral secretions 2
- Positive leukocyte esterase test on first-void urine 2
- Greater than 10 WBCs per high-power field on microscopic examination of first-void urine 2
- Symptoms including dysuria, urethral pruritus, or urethral discharge 1
Treatment Algorithm
If Urethritis IS Present:
First-line treatment: Doxycycline 100 mg orally twice daily for 7 days 3, 1, 4
Alternative regimens (in order of preference):
- Azithromycin 1 g orally as a single dose (particularly useful when compliance with 7-day regimen is questionable) 3, 1, 4
- Erythromycin base 500 mg orally four times daily for 7 days 3, 4
- Erythromycin ethylsuccinate 800 mg orally four times daily for 7 days 4
- Ofloxacin 300 mg orally twice daily for 7 days 4
- Levofloxacin 500 mg orally once daily for 7 days 4
If Urethritis IS NOT Present:
Do not treat. 1 There is no evidence that treating asymptomatic Ureaplasma colonization improves clinical outcomes, even in infertility workups. 1 Defer treatment and consider retesting only if symptoms develop. 2
Partner Management
All sexual partners require evaluation and treatment: 3, 1, 4
- Treat partners with last sexual contact within 30 days of symptom onset for symptomatic patients 3
- Treat partners with last sexual contact within 60 days of diagnosis for asymptomatic patients 3, 4
- Both patient and partners must abstain from sexual intercourse for 7 days after single-dose therapy or until completion of 7-day regimen 3, 1, 4
Follow-Up Recommendations
Test of cure is NOT routinely recommended after completing doxycycline or azithromycin treatment unless symptoms persist or reinfection is suspected. 4
Retest only if:
- Symptoms persist or recur after treatment 4
- Reinfection is suspected 4
- Therapeutic compliance is questionable 4
- Patient was treated with erythromycin (due to lower efficacy) 4
If test of cure is performed, wait at least 3 weeks after completion of therapy. 4
Management of Treatment Failure
If symptoms persist after initial treatment, confirm objective signs of urethritis are still present before retreating. 4
Treatment failure algorithm:
- After doxycycline failure: Consider azithromycin 500 mg orally on day 1, followed by 250 mg daily for 4 days 4
- After azithromycin failure: Consider moxifloxacin 400 mg orally once daily for 7-14 days 4
- If patient was non-compliant or re-exposed to untreated partner: Re-treat with initial regimen 4
Critical Pitfalls to Avoid
Do not routinely screen asymptomatic individuals for Ureaplasma—there is no evidence that treatment improves conception rates or other outcomes, even when organisms are detected. 1
Do not treat based on positive testing alone without documented urethritis symptoms or objective signs of inflammation. 1 This is the most common error in Ureaplasma management.
Do not confuse U. urealyticum with U. parvum—only U. urealyticum is associated with male infertility and has stronger pathogenic evidence. 1 However, most commercial tests report "Ureaplasma spp." without speciation, and this distinction does not change acute management in symptomatic urethritis.
Recognize that resistance patterns matter: Research shows Ureaplasma spp. demonstrate low resistance to erythromycin but high resistance to clindamycin and clarithromycin. 5 This supports the guideline recommendations for doxycycline, azithromycin, and erythromycin as preferred agents.