What is the recommended treatment for Ureaplasma spp infections in adults, including pregnant women?

Treatment for Ureaplasma spp Infections

For non-pregnant adults with Ureaplasma urethritis, treat with doxycycline 100 mg orally twice daily for 7 days as first-line therapy. 1, 2

Non-Pregnant Adults

First-Line Treatment

• Doxycycline 100 mg orally twice daily for 7 days is the recommended regimen for nongonococcal urethritis (NGU) caused by Ureaplasma urealyticum, which accounts for 20-40% of NGU cases 1
• This regimen has demonstrated effectiveness in alleviating symptoms and achieving microbiologic cure 1
• A single 1 g dose of azithromycin shows similar effectiveness to 7-day doxycycline for U. urealyticum infections 3

Alternative Regimens for Doxycycline Intolerance

• Erythromycin base 500 mg orally 4 times daily for 7 days 1
• Erythromycin ethylsuccinate 800 mg orally 4 times daily for 7 days 1
• For patients unable to tolerate high-dose erythromycin: erythromycin base 250 mg orally 4 times daily for 14 days or erythromycin ethylsuccinate 400 mg orally 4 times daily for 14 days 1

Treatment Failure Management

• If symptoms persist or recur after initial therapy and re-exposure to untreated partners is excluded, retreat with an alternative regimen extended to 14 days (e.g., erythromycin base 500 mg orally 4 times daily for 14 days) 1
• This extended alternative regimen ensures treatment of possible tetracycline-resistant U. urealyticum 1

Pregnant Women

First-Line Treatment Options

• Azithromycin is the preferred macrolide for Ureaplasma infections during pregnancy due to its safety profile and effectiveness 4, 5
• Maternal intravenous azithromycin effectively eradicates macrolide-sensitive Ureaplasma parvum from amniotic fluid 4
• For respiratory colonization in preterm infants, azithromycin 20 mg/kg intravenously for 3 days maintains concentrations above MIC50 for ≥96 hours 6

Alternative Considerations

• Erythromycin-based regimens can be used as alternatives, following the same dosing as non-pregnant adults 1
• Doxycycline should be avoided throughout pregnancy due to effects on fetal bone and teeth development 1

Critical Pregnancy-Specific Concerns

• Intrauterine Ureaplasma infection is strongly associated with preterm birth, chorioamnionitis, and adverse neonatal outcomes including bronchopulmonary dysplasia 4, 5
• Treatment should be initiated promptly when intra-amniotic infection is suspected 5
• Ureaplasma spp. are naturally resistant to β-lactam antibiotics due to lack of a cell wall 5

Important Clinical Pitfalls

Antibiotic Resistance Patterns

• Ureaplasma spp. show low resistance to erythromycin but high resistance to clindamycin and clarithromycin 7
• Macrolide- and fluoroquinolone-resistant isolates have been observed in clinical practice 5
• Tetracycline-resistant U. urealyticum exists, necessitating alternative regimens for treatment failures 1

Partner Management

• Sexual partners must be evaluated and treated to prevent reinfection 1
• Patients should abstain from sexual intercourse until both partners complete therapy 1

Follow-Up Recommendations

• Patients should return for evaluation if symptoms persist or recur after completing therapy 1
• For treatment failures without re-exposure, perform wet mount examination and culture before retreating with extended alternative regimen 1