What is the recommended treatment for a patient with a confirmed Ureaplasma (a type of bacteria) infection in the urine?

Treatment of Ureaplasma in Urine

Ureaplasma detected in urine should only be treated if the patient has symptomatic urethritis (dysuria, urethral discharge, or urethral pruritus); asymptomatic Ureaplasma bacteriuria should not be treated except in pregnant women or before endoscopic urologic procedures with mucosal trauma. 1

Clinical Context Determines Management

The critical distinction is between asymptomatic colonization and symptomatic infection:

• Asymptomatic bacteriuria with Ureaplasma should not be treated in most clinical scenarios, as recommended by the American College of Physicians and Infectious Diseases Society of America 1
• Only U. urealyticum (not U. parvum) is definitively recognized as pathogenic in non-gonococcal urethritis, causing 20-40% of cases 1
• Treatment is indicated only when patients have urethritis symptoms: dysuria, urethral discharge, or urethral pruritus 1

Exceptions Requiring Treatment of Asymptomatic Ureaplasma

Two specific situations warrant treatment even without symptoms:

• Pregnant women with asymptomatic Ureaplasma bacteriuria should be screened and treated 1
• Before endoscopic urologic procedures that breach the mucosa (e.g., transurethral resection of the prostate), asymptomatic bacteriuria should be treated 1

First-Line Treatment for Symptomatic Urethritis

Doxycycline 100 mg orally twice daily for 7 days is the recommended first-line treatment for symptomatic urethritis caused by Ureaplasma 2, 1

This regimen is supported by:

• Centers for Disease Control and Prevention recommendations 1
• European Association of Urology guidelines for U. urealyticum urethritis 2
• Clinical evidence showing successful eradication and symptom resolution 3, 4

Alternative Regimens

If doxycycline cannot be used (contraindication, intolerance, or pregnancy):

• Erythromycin base 500 mg orally four times daily for 7 days 1, 5
• Azithromycin 1.0-1.5 g orally as a single dose 2

The FDA label specifically indicates erythromycin 500 mg four times daily for at least 7 days for nongonococcal urethritis caused by U. urealyticum when tetracycline is contraindicated 5

Treatment of Sexual Partners

All at-risk sexual partners should be evaluated and treated with the same regimen, even if asymptomatic, to prevent reinfection 2, 1. This is critical because:

• Ureaplasma is sexually transmitted 6
• Reinfection from untreated partners is a common cause of treatment failure 4
• Patient confidentiality must be maintained during partner notification 2

Monitoring Treatment Response

After completing antibiotic therapy:

• Symptoms should resolve within days to weeks of appropriate treatment 3
• In one study, mean symptom severity improved from 2.2 to 0.7 (on a 0-3 scale) and urinary frequency decreased from 9.2 to 6.8 voids daily after treatment 3
• Persistent symptoms after treatment warrant re-evaluation for other causes (detrusor instability, interstitial cystitis) or treatment failure 3

Common Pitfalls to Avoid

Do not treat Ureaplasma found incidentally on urine culture without corresponding symptoms 1. This is a critical error that leads to:

• Unnecessary antibiotic exposure and resistance development 7
• Eradication of potentially protective commensal organisms 2
• Failure to identify the true cause of symptoms if present 3

Do not confuse U. urealyticum with U. parvum - only U. urealyticum is definitively pathogenic in urethritis 1. U. parvum colonization does not require treatment.

Do not assume negative routine bacterial cultures exclude Ureaplasma - specialized culture techniques or nucleic acid amplification testing (NAAT) are required for detection 2, 6. Standard urine cultures will miss these fastidious organisms.

Resistant or Persistent Infections

If symptoms persist after initial doxycycline therapy:

• Consider azithromycin 500 mg on day 1, then 250 mg daily for 4 days as second-line treatment 2
• For macrolide-resistant strains, moxifloxacin 400 mg daily for 7-14 days may be used 2
• Resistance to tetracyclines, macrolides, and fluoroquinolones has been reported, with varying patterns between biovars 7
• Some patients may require multiple treatment courses, though pregnancies occurred only in those who became Ureaplasma-negative after doxycycline 4