What is the recommended treatment for a patient with detected Ureaplasma parvum and Ureaplasma urealyticum DNA, and negative results for Mycoplasma hominis, Mycoplasma genitalium, and other relevant tests?

Management of Detected Ureaplasma parvum and Ureaplasma urealyticum

Do NOT Treat This Patient Based on Testing Alone

You should not treat this patient unless they have documented symptoms of urethritis (mucopurulent discharge, dysuria, urethral pruritus) or objective signs of inflammation (>5 WBCs per oil immersion field on Gram stain, positive leukocyte esterase, or >10 WBCs per high-power field on first-void urine). 1, 2, 3

Critical Decision Algorithm

Step 1: Assess for Symptoms and Signs

• Ask specifically about: mucopurulent or purulent urethral discharge, dysuria (burning with urination), or urethral pruritus 4
• If symptomatic, document objective evidence of urethritis with:
  • Gram stain showing >5 WBCs per oil immersion field 4
  • Positive leukocyte esterase test on first-void urine 4
  • Microscopic examination showing >10 WBCs per high-power field on first-void urine 4

Step 2: Rule Out Traditional STIs First

• Before attributing any symptoms to Ureaplasma, you must exclude Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium, and Trichomonas vaginalis 5
• Your patient's results show M. genitalium was cancelled and M. hominis is negative, which is appropriate 1

Step 3: Understand the Pathogenic Difference

• U. urealyticum (detected in your patient) has evidence as a urethritis pathogen 4, 3
• U. parvum (also detected in your patient) has questionable pathogenic role and should generally NOT be treated 3, 6
• Asymptomatic colonization occurs in 40-80% of sexually active individuals 5, 7

If Patient is Asymptomatic: No Treatment

Do not treat asymptomatic Ureaplasma detection—this represents colonization, not infection. 1, 5 The European STI Guidelines Editorial Board explicitly states that routine testing and treatment of asymptomatic individuals for U. urealyticum and U. parvum are not recommended, as we have no evidence that treatment does more good than harm 5.

Asymptomatic carriage is common, and the majority of individuals do not develop disease 5, 7. Even in infertility workups, there is no evidence that treating asymptomatic Ureaplasma improves conception rates or pregnancy outcomes 1.

If Patient is Symptomatic with Documented Urethritis: Treatment Protocol

First-Line Treatment

Doxycycline 100 mg orally twice daily for 7 days 1, 2, 3, 8

• This achieves 91% susceptibility rates 3
• FDA-approved dosing for nongonococcal urethritis caused by U. urealyticum 8

Alternative Regimens (for compliance concerns or contraindications)

• Azithromycin 1 g orally as single dose 1, 2, 9
  • Preferred when compliance with 7-day therapy is questionable 3
  • Achieves 71% susceptibility rates 3
• Erythromycin base 500 mg orally four times daily for 7 days 1, 2, 3

Management of Treatment Failure

• After doxycycline failure: Azithromycin 500 mg on day 1, then 250 mg daily for 4 days 2, 3
• After azithromycin failure: Moxifloxacin 400 mg orally once daily for 7-14 days 2

Partner Management (Only if Patient is Treated)

• All sexual partners with contact within 60 days of diagnosis must be evaluated and treated 1, 3
• For symptomatic patients: treat partners with last sexual contact within 30 days of symptom onset 1, 2
• Both patient and partners must abstain from sexual intercourse for 7 days after single-dose therapy or until completion of 7-day regimen 1, 3

Follow-Up Strategy

• Test-of-cure is NOT routinely recommended after treatment unless symptoms persist or reinfection is suspected 2, 3
• Patients should return for evaluation only if symptoms persist or recur after completing therapy 2, 3
• Do not retreat based on persistent symptoms alone without documented objective signs of urethritis 2, 3
• If test-of-cure is performed, wait at least 3 weeks after treatment completion 3

Critical Pitfalls to Avoid

• Do not treat based on positive testing alone without symptoms or signs 1, 5—this is the most common error and leads to unnecessary antibiotic exposure, selection of antimicrobial resistance, and substantial economic cost 5
• Do not assume U. parvum is pathogenic—only U. urealyticum has stronger evidence as a urethritis pathogen 4, 3
• Do not confuse colonization with infection—40-80% of sexually active individuals carry these organisms asymptomatically 5, 7
• Do not use multiplex PCR results as justification for treatment without clinical correlation 5—the commercialization of these assays has worsened inappropriate testing and treatment