What is the recommended treatment for Ureaplasma genitalium infection?

Treatment for Ureaplasma genitalium Infection

Critical Clarification: Organism Identification Error

You are asking about "Ureaplasma genitalium," but this organism does not exist—you likely mean either Ureaplasma urealyticum or Mycoplasma genitalium, which are distinct pathogens requiring different treatment approaches. 1, 2

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If You Mean Ureaplasma urealyticum (or Ureaplasma species):

First-Line Treatment

Doxycycline 100 mg orally twice daily for 7 days is the recommended first-line treatment for Ureaplasma urethritis. 1, 3, 4, 5

• This regimen achieves 91% susceptibility rates and remains the most reliable option 6
• The FDA-approved dosing is 200 mg on day 1 (100 mg every 12 hours), followed by 100 mg twice daily for maintenance 5
• Treatment should only be initiated when urethritis is documented (≥5 WBCs per oil immersion field on Gram stain or mucopurulent discharge) 1

Alternative Regimens (When Doxycycline Cannot Be Used)

• Azithromycin 1 g orally as a single dose is preferred when compliance with 7-day therapy is questionable 3, 4

  • Achieves 71% susceptibility but offers convenience advantage 6

• Erythromycin base 500 mg orally four times daily for 7 days or erythromycin ethylsuccinate 800 mg orally four times daily for 7 days 1, 3, 4

  • Consider test-of-cure at 3 weeks due to lower efficacy 4

• Fluoroquinolones (ofloxacin 300 mg twice daily for 7 days or levofloxacin 500 mg once daily for 7 days) are additional alternatives 3, 4

  • Ofloxacin achieves 77% susceptibility 6

Management of Treatment Failure

For persistent symptoms after doxycycline, re-treat with the initial regimen if non-compliance or partner re-exposure occurred. 1, 3, 4

• After documented doxycycline failure: azithromycin 500 mg on day 1, then 250 mg daily for 4 days 4, 7
• After azithromycin failure: moxifloxacin 400 mg once daily for 7-14 days 4, 7
• Do not re-treat based on symptoms alone without objective signs of urethritis 1, 4

Partner Management

All sexual partners with contact within 60 days of diagnosis must be evaluated and treated. 3, 4, 7

• For symptomatic patients: treat partners with contact within 30 days of symptom onset 3, 7
• Both patient and partners must abstain from sexual intercourse for 7 days after single-dose therapy or until completion of 7-day regimen 3, 4, 7

Follow-Up Strategy

Test-of-cure is NOT routinely recommended after doxycycline or azithromycin unless symptoms persist or reinfection is suspected. 4

• If performed, test no earlier than 3 weeks after treatment completion 4
• Return only if symptoms persist or recur 3, 4

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If You Mean Mycoplasma genitalium:

First-Line Treatment (Different from Ureaplasma)

For M. genitalium without macrolide resistance: azithromycin 500 mg on day 1, then 250 mg daily on days 2-5. 2

• Doxycycline alone has only 30-40% cure rate for M. genitalium 2
• Macrolide resistance testing is mandatory before treatment 2

Second-Line Treatment

Moxifloxacin 400 mg once daily for 7 days for uncomplicated macrolide-resistant M. genitalium infection. 2

• For complicated infections (PID, epididymitis): extend moxifloxacin to 14 days 2

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Critical Clinical Pitfalls

• Do NOT treat asymptomatic Ureaplasma colonization—40-80% of detected cases represent carriage, not infection 8
• Ureaplasma parvum should generally NOT be treated, as its pathogenic role is questionable 1, 8
• Only U. urealyticum (not U. parvum) is considered a true urethritis pathogen 1
• Quantitative testing is preferred—only high bacterial loads warrant treatment 8
• Always exclude Chlamydia trachomatis, Neisseria gonorrhoeae, and M. genitalium before attributing urethritis to Ureaplasma 1, 8