In an asymptomatic male who tests positive for Mycoplasma genitalium and ureaplasma, should treatment be initiated?

Treatment of Asymptomatic Mycoplasma genitalium and Ureaplasma Co-infection in Males

Do not treat asymptomatic Ureaplasma colonization, but you must treat the Mycoplasma genitalium infection regardless of symptoms, along with all sexual partners from the preceding 60 days. 1, 2, 3

Key Decision Points

Mycoplasma genitalium - Requires Treatment

• M. genitalium is an established sexually transmitted infection that requires treatment when detected by nucleic acid amplification testing, even in asymptomatic patients. 1, 2, 3
• The CDC recognizes M. genitalium as a pathogen causing urethritis, cervicitis, and pelvic inflammatory disease with significant morbidity if left untreated. 1
• Asymptomatic M. genitalium infections are frequent but still require treatment to prevent transmission and future complications. 3
• Studies demonstrate that asymptomatic M. genitalium carriers are rare (only 1 in 23 asymptomatic males in one study), suggesting that detection typically indicates true infection requiring intervention. 4

Ureaplasma - Do Not Treat

• Routine testing and treatment of asymptomatic men for Ureaplasma urealyticum and Ureaplasma parvum are not recommended. 5
• Asymptomatic carriage of Ureaplasma is common (40-80% of detected cases likely represent colonization rather than infection), and the majority of individuals do not develop disease. 5
• The European STI Guidelines Editorial Board explicitly states there is no evidence that detecting and treating Ureaplasma colonization does more good than harm. 5
• Even in symptomatic urethritis, U. urealyticum should only be considered for treatment if present in high loads and only after excluding N. gonorrhoeae, C. trachomatis, M. genitalium, and T. vaginalis. 5

Treatment Regimen for M. genitalium

First-Line Therapy

• Azithromycin 500 mg orally on day 1, then 250 mg orally daily on days 2-5. 1, 3
• This extended azithromycin regimen achieves 85-95% cure rates in macrolide-susceptible infections. 1, 3

Second-Line Therapy (if treatment fails or macrolide resistance suspected)

• Moxifloxacin 400 mg orally once daily for 7 days. 2, 3
• Use this regimen if symptoms persist after azithromycin or if macrolide resistance mutations are detected. 3

Essential Partner Management

• All sexual partners within the preceding 60 days must be evaluated and treated simultaneously, regardless of symptoms. 1, 6, 2
• Partners should receive the same M. genitalium treatment regimen (azithromycin extended course). 1
• Both patient and all partners must abstain from sexual intercourse until 7 days after completing therapy to prevent reinfection. 1, 2
• Reinfection rates are high without proper partner management, making this step critical. 1

Additional Testing Requirements

• Ensure concurrent testing for N. gonorrhoeae and C. trachomatis has been completed, as co-infections are common. 1, 2
• Perform syphilis serology and offer HIV testing with counseling, as recommended for all patients with sexually transmitted infections. 1, 2

Follow-Up Protocol

• Instruct the patient to return if any symptoms develop after completing therapy. 1, 6
• Consider repeat testing at 3-6 months due to high reinfection rates, particularly if partner treatment compliance is uncertain. 1, 6
• Test-of-cure is not routinely recommended for asymptomatic patients who received recommended treatment and remain asymptomatic. 6

Critical Pitfalls to Avoid

• Do not treat the Ureaplasma finding - this leads to unnecessary antibiotic exposure, selection of antimicrobial resistance, and substantial economic cost without proven benefit. 5
• Do not skip partner treatment - treating the index patient alone without partner management results in high reinfection rates and ongoing transmission. 1, 2
• Do not use single-dose azithromycin 1g - while effective for chlamydia, the extended 5-day azithromycin regimen is superior for M. genitalium. 1, 3