Treatment of Vaginal Ureaplasma Infection in Women
For symptomatic non-pregnant women with vaginal Ureaplasma infection, doxycycline 100 mg orally twice daily for 7 days is the first-line treatment, with azithromycin 1.0-1.5 g as a single dose serving as the alternative when doxycycline cannot be used. 1, 2, 3
Non-Pregnant Women
When to Treat
- Only treat women with documented urethritis symptoms or objective signs of inflammation 3
- Routine testing and treatment of asymptomatic colonization is not recommended, as Ureaplasma species can be part of normal vaginal flora 4
- U. urealyticum (but not U. parvum) is considered a true etiological agent requiring treatment 1, 3
First-Line Treatment
- Doxycycline 100 mg orally twice daily for 7 days 1, 2, 3, 5
- This regimen is FDA-approved for nongonococcal urethritis caused by U. urealyticum 5
Alternative Regimens
- Azithromycin 1.0-1.5 g orally as a single dose when doxycycline is contraindicated or not tolerated 1, 2, 3
- Erythromycin base 500 mg orally four times daily for 7 days, though macrolide resistance is increasingly common 2, 3
Management of Treatment Failure
If symptoms persist after initial doxycycline therapy:
- Assess treatment compliance and partner re-exposure first 3
- Azithromycin 500 mg orally on day 1, followed by 250 mg daily for 4 days 1, 3
- After azithromycin failure: Moxifloxacin 400 mg orally once daily for 7-14 days 1
- Additional alternatives include levofloxacin 500 mg once daily for 7 days or ofloxacin 300 mg twice daily for 7 days 1, 2
Partner Management
- All sexual partners with last sexual contact within 60 days of diagnosis must be evaluated and treated 1, 2
- Both patients and partners should abstain from sexual intercourse until therapy is completed and symptoms have resolved 1, 2, 3
Pregnant Women
Clinical Context
- Ureaplasma species are the bacteria most often isolated from the amniotic cavity of women with preterm labor or preterm premature rupture of membranes 6
- U. parvum serovar 3 colonization is specifically associated with spontaneous preterm birth at very low (<32 weeks) and extremely low (<28 weeks) gestational age 6
- The combination of U. parvum serovar 3 and bacterial vaginosis or history of preterm birth further increases risk 6
Treatment Considerations
- Symptomatic pregnant women should be treated to relieve symptoms 7
- The evidence provided does not contain specific CDC or FDA guidelines for treating Ureaplasma in pregnancy, though doxycycline is generally contraindicated in pregnancy after the first trimester
- Azithromycin-resistant Ureaplasma infections are increasingly common (9.87% prevalence) and associated with significantly increased adverse pregnancy outcomes including spontaneous abortion, preterm birth, PPROM, and stillbirth 8
- Azithromycin resistance shows cross-resistance to erythromycin, roxithromycin, and clarithromycin 8
Important Caveats
- There is currently a lack of safe and effective drug treatments for azithromycin-resistant mycoplasma infection in pregnancy 8
- Sole presence of Ureaplasma in vaginal flora may be insufficient to cause pathological issues; combination with bacterial vaginosis or cervical incompetence may be needed to induce preterm birth 9
Follow-Up Strategy
- Patients return for evaluation only if symptoms persist or recur after completing therapy 2, 3
- Test-of-cure is not routinely recommended for asymptomatic patients 3
- Re-treatment with the initial regimen is appropriate if the patient failed to comply or was re-exposed to an untreated partner 1
Special Populations
Critical Clinical Pitfall
The most important pitfall is treating asymptomatic colonization. M. hominis was associated with symptoms/signs only in women with bacterial vaginosis, not in women without BV 4. This finding does not support routine testing for M. hominis, U. urealyticum, and U. parvum in nonpregnant women without symptoms 4.