Ureaplasma – clinical significance?

in this number Describes a complex infection, most likely caused by Ureaplasma urealyticum. The infection started with urinary tract problems and bartolinitis. The patient gradually became seriously ill with abdominal abscess and empyema despite surgical intervention and antibiotic treatment. Repeat cultures were negative, but the bacteria were eventually detected by nucleic acid amplification assay (NAAT). Of particular importance is that the patient at the time of illness was immunosuppressed due to taking rituximab due to MS.

Urethritis in most cases is caused by bacteria chlamydia, gonococcus and mycoplasma genitalium, which are transmitted through sexual contact. We test these three bacteria more or less routinely for urethritis. In addition to urethritis, bacteria can cause cervicitis as well as pelvic inflammatory disease, endometritis, and epididymitis. Then there is a group of patients in which direct microscopic examination of the smears can show signs of infection, but when the samples are negative. We classify this group as nonspecific urethritis/cervicitis. There are other possible sexually transmitted agents, which we don’t usually test for. Trichomonas vaginalis in Sweden is an unusual cause of urethritis but is more common in the genesis of the infection in many other countries, including the United States [1]. Ureaplasma has also been described as a potential agent in urethritis, as well as streptococci, Haemophilus influenzae and enteric pathogens (eg E. coli). Adenoviruses and herpesviruses are potential viral agents [1]. Mycoplasma hominis most often occurs in the normal bacterial flora and is occasionally found in bacterial vaginosis, although this bacteria is not the cause. [2]. Typical symptoms of urethritis are secretions and dysuria. The infection can also be asymptomatic.

Like mycoplasms, Ureaplasma belongs to the species Mollicutes and lacks a cell wall. Bacteria are difficult to grow, which is evident in this tragic patient’s case, and analysis is now usually done with NAAT. Previously, the test could not distinguish between the two types of Ureaplasma we now get when we order NAAT for Ureaplasma: Ureaplasma parvum (formerly Ureaplasma biovar 1) and Ureaplasma urealyticum (Ureaplasma biovar 2). Among Ureaplasma bacteria, Ureaplasma urealyticum is now considered a pathogen, this has been proven in vaccination studies in men, and its association with infections of the lower genitals in men has also been demonstrated. [1]. The number of bacteria may be of great importance [3]. Bacteria are very common, and in 40-80 percent of women, Ureaplasma is found in the genitals [2]. We do not consider urea parfum to be a pathogen in urethritis, and the results of this in men rarely require treatment. [1]. Tetracycline in some cases acts as a urea treatment, but resistance does occur, as is also the case with azithromycin. Clarithromycin is widely used and has the best MIC profile for macrolides [4].

A number of studies have also been conducted on women, especially in the field of obstetrics. The presence of Ureaplasma urealyticum has been described in connection with bacterial vaginosis. However, it is questionable whether Ureaplasma can cause pelvic inflammatory disease [5]. Postoperative wound infection occurs in the urogenital tract, but is probably underreported as Ureaplasma is not detected in normal bacterial culture. The spread of Ureaplasma to the bloodstream has been described in connection with miscarriage and also after birth, as well as colonization of the newborn by vertical transmission. Congenital pneumonia, as well as osteomyelitis and purulent arthritis, have been reported, especially in hypoglycemic individuals. [6]. Several studies have debated whether the presence of Ureaplasma in the mother may play a role in premature ejaculation, miscarriage, and premature birth. In a recently published work, Ureaplasma was the most common bacterium in a cohort of 1,300 women with any of these obstetric complications. [7]. The problem is complex, and may have something to do with individual differences in immune responses, perhaps even greater in immunocompromised states. It is concluded that further studies are needed to increase knowledge and understanding of the role of Ureaplasma in obstetrics and in the implementation of sampling guidelines. The patient’s immune status is likely to be of interest, as the bacteria appear to be completely harmless in most people, while others can have serious complications, as in this patient’s case. A review by a group of urethritis experts does not recommend routine testing for Ureaplasma in asymptomatic men and women. [5]. Another review by Donders et al also does not recommend routine screening during pregnancy [8]But there are different opinions. A balance must be struck between the benefits of screening and the risk of antibiotic resistance, as bacteria are difficult to treat and increased sampling likely risks increasing resistance, similar to the logic of mycoplasma where sampling is recommended primarily for indication. The difference with mycoplasma is also that much of the normal population carries Ureaplasma. Clearly, more research is needed to take a position on targeted screening.

Read the description of the case
Urogenital Ureaplasma in invasive infection caused immunosuppression