Is Ureaplasma a normal component of the urogenital flora and should I be treated with antibiotics?

Is Ureaplasma Part of Normal Flora and Should It Be Treated?

Ureaplasma is commonly found as commensal colonization in the urogenital tract of sexually active individuals, and you should NOT treat it unless the patient has documented symptoms of urethritis with objective evidence of inflammation. 1, 2

Key Distinction: Colonization vs. Infection

• Ureaplasma species colonize up to 80% of sexually active, asymptomatic individuals, making routine testing and treatment inappropriate in the absence of symptoms 1, 3
• The Infectious Diseases Society of America explicitly states that culture or NAATs for Ureaplasma is not recommended because of the high prevalence of colonization in asymptomatic, sexually active people 1
• Only Ureaplasma urealyticum (not U. parvum) is considered a true urethritis pathogen, while U. parvum's pathogenic role remains questionable 4, 2

When to Treat: Symptomatic Urethritis Only

You should only treat Ureaplasma when BOTH of the following criteria are met:

1. Documented Symptoms 2, 5

• Mucopurulent or purulent urethral discharge
• Dysuria
• Urethral pruritus

2. Objective Evidence of Urethritis 5

• Gram stain showing ≥5 polymorphonuclear leukocytes per high-power field on urethral smear 2
• Positive leukocyte esterase test on first-void urine 5
• Microscopic examination showing ≥10 WBCs per high-power field on first-void urine 5

Treatment Regimen (When Indicated)

First-line treatment: Doxycycline 100 mg orally twice daily for 7 days (91% susceptibility rate) 1, 4, 2

Alternative regimens:

• Azithromycin 1.0-1.5 g orally as a single dose (71% susceptibility rate) 1, 4, 2
• Levofloxacin 500 mg orally once daily for 7 days 2
• Ofloxacin 200 mg orally twice daily for 7 days 2

Treatment duration modifications:

• Standard urethritis: 7 days 2
• If prostatitis cannot be excluded: extend to 14 days 2

Critical Pitfalls to Avoid

• Do NOT treat asymptomatic Ureaplasma detection, as this represents colonization and may select for antimicrobial resistance 1, 2
• Do NOT treat U. parvum specifically, as it is the predominant species (92.6% of isolates) but has questionable pathogenic significance 4, 2, 6
• Always exclude Chlamydia trachomatis, Neisseria gonorrhoeae, and Mycoplasma genitalium first before attributing urethritis to Ureaplasma 4
• Avoid fluoroquinolones in patients who used them in the last 6 months or from urology departments where resistance rates are higher 4, 2

Partner Management (Only for Symptomatic Cases)

• All sexual partners with contact within 60 days of diagnosis must be evaluated and treated while maintaining patient confidentiality 1, 2, 5
• Both patient and partners must abstain from sexual intercourse for 7 days after single-dose therapy or until completion of 7-day regimen 4, 5

Follow-Up Strategy

• Test-of-cure is NOT routinely recommended after doxycycline or azithromycin unless symptoms persist or reinfection is suspected 4, 2, 5
• If performed, test no earlier than 3 weeks after treatment completion 4

Special Populations

Pregnancy: While Ureaplasma colonizes up to 80% of pregnant women, there is insufficient evidence that treating asymptomatic colonization prevents preterm birth 3, 7. Treatment should still be reserved for symptomatic cases only, though antibiotic choice must be modified (avoid tetracyclines and fluoroquinolones) 3.