There is a lot of confusion amongst not only just you ladies but also amongst health care providers regarding these little bugs. So, we decided to break it down for you. Here is the scoop of what really is/ are mycoplasma and ureaplasma….
What are mycoplasma and ureaplasma?
The term “mycoplasma” is widely used to refer to any organism within the class Mollicutes, which is composed of eight genera (including Mycoplasma, Ureaplasma, Acholeplasma, Anaeroplasma, and Asteroloplasma).
The mycoplasma include:
- Mycoplasma hominis
- Mycoplasma genitalium
- Mycoplasma fermentans(incognitus strain)
- M. pneumoniae
The ureaplasma include:
- Ureaplasma parvum
- Ureaplasma urealyticum
What are they? Are they bacteria or viruses?
Mycoplasma and ureaplasma are the smallest free-living organisms. They lack a cell wall, therefore neither mycoplasma nor ureaplasma can be visualized by routine gram stain microscopy. It is hard to diagnose their presence because of difficulty in growing or culturing them in the lab. In order to culture these organisms, specialized media and very strict conditions are required.
Do Mycoplasma and ureaplasma live in normal genital tract?
Yes, Many healthy asymptomatic adults have genitourinary colonization with Mycoplasma and Ureaplasma spp. The percentage of women with vaginal colonization by M. hominis, M. genitalium, and Ureaplasma spp increases after puberty in proportion to the number of lifetime sexual partners. It has been seen to vary from 0% in never active women to upto 70% in sexually active women
Does this mean these women are infected and contagious?
This does not mean that these women are “infected”, if these are not creating any symptoms, then these mycoplasmas and ureaplasma are considered normal inhabitants of the genital tract.
How is M. Genitalum different from other Mycoplasmas and Ureaplasma?
M. genitalium was first described in 1981 after being isolated from the urethral specimens of two men diagnosed with non gonococcal urethritis (NGU). Studies have suggested a strong causative link between M. genitaliuminfection and urethritis in men and an association with cervicitis and pelvic inflammatory disease (PID) in women.
When can Mycoplasma and Ureaplasma spp cause infections?
Mycoplasma and Ureaplasma spp normally stay attached to mucosal epithelial cells (lining) of the respiratory or urogenital tracts. However, they can spread to other sites and cause infection when there is a break in the lining and/or an underlying defect in host defenses, such as in the developing fetus, premature infant, or immunosuppressed adults.
M. genitalum in addition to above evades the immune system and alters the host’s immune system, which allows it to survive in the host’s body.
How common is M. Genitalum?
In studies from the United States, M. genitalium is present in approximately 1 percent among young adults in the general population. In comparison, the prevalence of gonorrhea is 0.4% and Chlamydia is 2.3%. Amongst STI clinics and in population with multiple STI risk factors, prevalence may range from 4 to 38 percent.
What are the risk factors for these infections?
Young age (e.g., <20 to 22 years old), smoking, recent sexual intercourse, and an increasing number of sexual partners are some risk factors.
In which conditions have the mycoplasma and ureaplasma infections been implicated?
Infections that have been linked to various types of mycoplasma and ureaplasma include:
M. hominis
- Pelvic inflammatory disease (PID) – not proven
- Chorioamnionitis
- Postpartum and postabortal fever
- Pyelonephritis
- Central nervous system infections
- Septicemia
- Wound infections, especially postoperative wounds
- Joint infections
- Upper and lower respiratory tract infections
- Endocarditis
- Neonatal bacteremia and meningitis
- Neonatal abscesses
Ureaplasma spp
- Chorioamnionitis
- Postpartum and postabortal fever
- Congenital pneumonia
- Neonatal bacteremia
- Neonatal abscesses
- Non gonococcal Urethritis in males – not proven
- UTI
M Genitalum.
- Non gonococcal urethritis (men)
- Cervicitis
- PID
- UTI in men and women
- Preterm birth and abortion – not proven
Is M. genitalum an STD and is transmitted sexually?
Sexual transmissibility of M. genitalium is supported by both clinical and molecular epidemiologic evidence. As above, M. genitalium is detected more frequently among sexually-experienced
Furthermore, in DNA-typing studies, sexual partners often harbor identical bacterial genomic strains.
Can there be other infections that co-exist with Mycoplasma Genitalum?
Chlamydia trachomatis is the most commonly reported co-infecting organism.
How does M. genitalum present in Men?
M. genitalium infection accounts for 15 to 20 percent of NGU cases reported per year among men in the United States. M. genitaliumdetection is more frequent in men with persistent or recurrent urethritis. It may also be associated with balanitis (inflammation of the glans penis) and posthitis (inflammation of the foreskin).
How does M.genitalum affect women?
M. genitalium can ascend from the lower to upper genital tract after sexual transmission
Cervicitis
Cervical inflammation is the most common manifestation of M. genitalium infection in women and is usually described as mucopurulent cervicitis (MPC).
Pelvic inflammatory disease
Several studies have observed associations between detection of the organism and clinical signs and symptoms of PID.
Clinical presentation of M. genitalium-associated pelvic inflammatory disease (PID) may include mild to severe pelvic pain, abdominal pain, abnormal vaginal discharge, and/or bleeding, similar to PID due to C. trachomatis.
Which specimen is most accurate for men and women?
Among men, the diagnostic performance of first-void urine specimens in detecting M. genitalium is higher than that of urethral smear specimens
Among women, vaginal specimens are more diagnostic. In one study of 400 women the relative sensitivity of PCR for M. genitalium was 86 percent with vaginal swabs as compared to 61 percent with first-void urine.
When to test for M. Genitalum?
If a sexually active person presents with evidence of urethritis, cervicitis, or pelvic inflammatory disease, it is recommended to test for M. genitalium also in addition to other STI’s. If women or men continue to have symptoms of these conditions despite completion of appropriate therapy, regardless of initial cause, then testing for M. genitalium is also recommended.
How are Mycoplasma and Ureaplasma infections diagnosed?
They are diagnosed by testing vaginal swabs or urine specimens. For women, vaginal swabs are more accurate.
There are either culture based or RNA based tests for detection of these organisms called NAAT based tests.
Culture based methods are difficult to implement because of reasons described above. Most hospital microbiology laboratories are not prepared to culture them.
RNA based or PCR-based assays are becoming increasingly available in multiplex kits for the diagnosis of respiratory and genitourinary tract pathogens. The only drawback is that we cannot test for sensitivity to drugs through RNA based tests.
A DNA chip assay is capable of identifying 13 targeted urinary tract pathogens including M. hominis and U. urealyticum, with relatively high sensitivity and specificity compared to PCR tests. It is not currently commercially in use in the US.
Which drugs are effective in treatment of Mycoplasma spp and Ureaplasma spp?
Most mycoplasmas and ureaplasma are susceptible in vitro to macrolides (e.g. Azithromycin), tetracyclines, (e.g. Doxycycline) and fluoroquinolones (e.g. Ciprofloxacin). Azithromycin is active against Mycoplasma genitalum (considered an STD).An exception is M. hominis, which is not susceptible to macrolides.
Which antibiotic is the best for which species?
M. GENITALUM
Azithromycin – is the first line treatment. It is 100-fold more active against this organism than the tetracyclines or most fluoroquinolones. However, resistance is increasing. In certain regions, the estimated rate of azithromycin resistance in isolated M. genitalium strains has been as high as 40 percent. Suggested treatment dose is Azithromycin 1g orally.
Failed or recurrent infection with M. genitalum
Moxifloxacin– If Azithromycin failed and there is documented persistence or recurrence then next choice is Moxifloxacin. There is also increasing evidence of resistance to fluorquinolones.
MYCOPLASMA HOMINIS
Doxycycline – is recommended for non pregnant adults with disease caused by M. hominis
Clindamycin: is recommended for infants with disease caused by M. hominis,
Fluroquinolones have been found to be effective, however there is increasing development of resistance seen in mycoplasmas.
UREAPLASMA SPP.
Doxycycline – is recommended for non pregnant adults with disease caused by Ureaplasma spp
Clarithromycin, Azithromycin and Ofloxacin (fluoroquinolones) are also effective for ureaplasma spp.
Clindamycin is not active against Ureaplasma
Azithromycin or Clarithromycin: is recommended for infants with disease caused by Ureaplasma spp,
Which symptoms could suggest clinical disease warrantying treatment in Women?
- Recurrent Vaginal infections not responsive or resistant to routine treatments of BV.
- Recurring infections after sexual intercourse.
- Persistent vaginal burning, malodorous discharge with negative cultures for routine culprits – Candida and Gardnella etc with negative Gonorrhea/ Chlamydia and Trichomonas.
Please remember that these are presumptive associations and linkages. We still need robust trials and larger studies to prove these organisms as primary causative agents of vaginal infections.
Do partners need to be treated for M. genitalum infection?
Although there are no guidelines for partner referral and treatment, it is reasonable to screen all sexual partners of laboratory-confirmed cases of M. genitalium and treat if positive. If screening of sexual partners of index patients with confirmed M. genitalium is not possible, it is reasonable to empirically treat for M. genitalium given the evidence of sexual transmission of this organism.
How long does M. genitalum take to grow and infect someone?
Although the incubation period of this pathogen remains undefined, screening should target sexual partners in the past 60 days. Treatment for partners of patients with confirmed M. genitalium infection is the same as for patients.
When should we treat Mycoplasma or Ureaplasma?
If patients have clinical signs and symptoms, caused by a Mycoplasma or Ureaplasma spp, then they should be treated. In contrast, patients who just have these organisms in their genital tract with no symptoms, do not require treatment.
Treatment paradigm for Mycoplasma and Ureaplasma
M. hominis
Non-pregnant
Doxycycline: 100mg PO BID x 7 days
If allergy
Moxifloxacin: 400mg PO daily x 10 days
Or
Pregnant
*Clindamycin: 600mg PO every 8hrs x 7 days
Ureaplasma
Doxycycline: 100mg PO BID X 10 days (14d if PID)
Or
Azithromycin: 1g PO single dose
*Clindamycin not effective against ureaplasma
M. genitalum
Azithromycin: 1g PO single dose
If resistant or recurrent infection
Moxifloxacin: 400mg PO daily x 10-14d
Rest assured, we are here to help you navigate this difficult issue at Walk IN GYN Care
Well wishes
Dr. Adeeti Gupta