Research J. Pharm. and Tech.

12(12): December 2019

ISSN 0974-3618 (Print) www.rjptonline.org

0974-360X (Online)

RESEARCH ARTICLE

Antimicrobial Susceptibility Patterns of Genital Mycoplasma Infections in

Pregnancy and Spontaneous Abortion
Hussein O. Al-Dahmoshi1, Mourouge S. Alwash2*, Sura I. Chabuck3, Noor S. Al-Khafaji4,
Susan I. Jabuk5
1,2,3,4
Department of Biology, College of Science, University of Babylon, Iraq
5
Al Hilla Teaching Hospital, Babylon Health Directorate, Iraq
*Corresponding Author E-mail: murooj_saadi2000@yahoo.com

ABSTRACT:
Genital mycoplasmas are opportunistic pathogens that may cause complications during pregnancy. The
resistance of mycoplasmas to routine antimicrobials is widespread and increasing. We aimed to investigate the
antimicrobial susceptibility patterns of mycoplasmas and to detect a possible link between the diagnosis of
mycoplasmas and the cessation of pregnancy. The detection and antimicrobial susceptibilities of Mycoplasma
hominis and Ureaplasma urealyticum were evaluated using the Mycoplasma IES Plus Kit. This study was
performed with 56 patients who had abnormal vaginal discharge and who attended an antenatal clinic at the Al
Hilla General Teaching Hospital in Babylon Province, Iraq. The groups were divided as follows: 35 patients had
a spontaneous abortion, and 21 patients had a pregnancy that went to full-term. Mycoplasmas were detected in
89.3% (50/56) of patients. Of these women infected with M. hominis and/or U. urealyticum, 62.5% (35/56) had a
spontaneous abortion, and 26.8% (15/56) delivered a live foetus. The susceptibility rates of M. hominis and U.
urealyticum to clindamycin were 20% and 13%, respectively. Mixed isolates (M. hominis and U. urealyticum)
had a higher resistance to most of the antibacterial agents in comparison to the resistance of either M. hominis or
U. urealyticum alone. To prevent complications during pregnancy, the data on local antimicrobial susceptibility
patterns needs to be updated; this will assist the decision-making groups in choosing the best treatment strategies
for patients with these infections.

KEYWORDS: Antimicrobial susceptibilities, Genital Mycoplasma, Pregnancy complications, Spontaneous

abortion.

INTRODUCTION: Thus, macrolides are often used empirically by

M. hominis and U. urealyticum are common commensals
found in the genital microbiota of up to 80% of sexually
active women.[1-3] Vaginal colonisation with
mycoplasmas has been associated with endometritis,
pyelonephritis, preterm birth, bacterial vaginosis,
cervicitis, pelvic inflammatory disease, postpartum
septicaemia, chorioamnionitis, non-chlamydial diseases,
non-gonococcal urethritis, spontaneous abortion, and
preterm labour.[4-6] Such aggravating conditions require
the therapeutic use of antimicrobial agents. Because
genital mycoplasmas lack a cell wall, they exhibit
inherent resistance to β-lactams and glycopeptides.[7]
obstetricians[8] because tetracyclines and
fluoroquinolones are contraindicated during
pregnancy.[9] Although macrolides are often considered
the drug of choice for the management of these
infections, M. hominis is intrinsically resistant to
macrolides (erythromycin and clarithromycin).[10]
Resistance to macrolides is associated with mutations in
the 23S rRNA gene.[11,12] The tetracycline resistance of
M. hominis is due to the presence of the moveable tetM
genes [13,14], while resistance to quinolones is developed
as a result of mutations in the gyrA and parC genes and,
to a lesser extent, in the gyrB and parE genes of the
DNA gyrase/topoisomerase IV complex.[15]

Received on 27.06.2019 Modified on 11.08.2019 As far we know, data on the occurrence and
Accepted on 03.09.2019 © RJPT All right reserved antimicrobial susceptibility of genital mycoplasmas in
Research J. Pharm. and Tech. 2019; 12(12):6198-6202.
DOI: 10.5958/0974-360X.2019.01076.X
Babylon Province, Iraq are completely non-existent.
More importantly, information concerning the

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 Research J. Pharm. and Tech. 12(12): December 2019
association of these mycoplasmas with pregnancy
complications and their antimicrobial susceptibilities is
urgently needed. The purpose of this study was to
investigate the occurrence and the antimicrobial
susceptibility patterns of genital mycoplasmas in
pregnant, outpatient women and to correlate pathogen
detection with the complications of pregnancy and their
outcomes.
SUBJECTS AND METHODS:
Measurement principle:
The presence and antimicrobial susceptibility patterns of
genital mycoplasmas were detected using the
Mycoplasma IES Plus Kit (Autobio Diagnostics, China)
as indicated by the manufacturer’s instructions. The kit
contains strips that give information on the presence or
absence of U. urealyticum and M. hominis based on
hydrolysis of urea and arginine; urea is decomposed by
the urease enzyme produced by U. urealyticum and NH3
is released, while arginine is decomposed by the arginase
enzyme produced by M. hominis with the release of
NH3. Thereafter, NH3 increases the pH of the liquid
medium, and the corresponding colour change of the
indicator was used to judge the results. The strip (30
wells) is divided into 3 sections: i) identification (wells
numbered 1, 2, and 5); ii) enumeration (wells numbered
3 and 4); and iii) antimicrobial susceptibility (wells
numbered 6-30) (Figure 1).
Figure 1 Mycoplasma IES Plus Kit
Measurement procedure:
This study included 56 patients (pregnant and women
who had spontaneous abortions) who were attending the
Al Hilla General Teaching Hospital in Babylon
Province, Iraq from September 2017 to May 2018. A
detailed medical history questionnaire was completed for
each woman to obtain general information on sexual
history, symptoms, and other obstetric and gynaecologic
disorders. Patients who had received antibiotic treatment
during the last 3 months were excluded from this study.
The gestational age was calculated based on an
ultrasound during the first trimester of pregnancy. The
patient groups experienced symptoms of abnormal
vaginal discharge, vaginitis, and burning in the genital
area. Before the commencement of the study, the women
gave their verbal, informed consent. The experiments
were conducted at the Department of Biology of the
College of Science at the University of Babylon.
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Vaginal swabs were obtained and tested for the presence
of genital mycoplasmas. Mycoplasma hominis and
Ureaplasma urealyticum were identified and
enumerated, and the antimicrobial susceptibility patterns
were determined with the Mycoplasma IES Plus Kit as
recommended by the manufacturer. The swab was used
to inoculate the UTM transport medium. Each inoculated
UTM transport medium was mixed with a vial of freeze-
dried powder. Approximately 500 μl of the inoculated
medium was incubated at 37°C for 24 h. A change in
colour from yellow to red or light brown marked the
presence of genital mycoplasmas. One hundred
microliters of the combined medium was dispensed into
all wells, followed by the addition of one drop of sterile
mineral oil to each well. The strip was covered and then
incubated at 37°C for 24-48 h. After 24 h of incubation,
the presence or absence of a colour change on the
relevant part of the strip provides an indication of the
resistance or susceptibility to each antimicrobial agent,
which corresponds to the Clinical and Laboratory
Standards Institute (CLSI) guidelines.[16] Antimicrobial
susceptibility test results were interpreted based on the
criteria set by the Mycoplasma IES Plus Kit. The
following interpretative criteria were provided as
proposed by CLSI [16]: pristinamycin (PRI), sensitive ≤ 2
µg/ml, and resistant (not available); minocycline (MIN),
sensitive ≤ 2 µg/ml, and resistant ≥ 8 µg/ml; josamycin
(JOS), sensitive ≤ 2 µg/ml, and resistant ≥ 8 µg/ml;
erythromycin (ERY), sensitive ≤ 8 µg/ml, and resistant ≥
16 µg/ml; roxithromycin (ROX), sensitive ≤ 1 µg/ml,
and resistant ≥ 4 µg/ml; clindamycin (CLI), sensitive ≤
0.25 µg/ml, and resistant ≥ 0.5 µg/ml; ofloxacin (OFL),
sensitive ≤ 1 µg/ml, and resistant ≥ 4 µg/ml;
ciprofloxacin (CIP), sensitive ≤ 1 µg/ml, and resistant ≥
2 µg/ml; clarithromycin (CLA), sensitive ≤ 1 µg/ml, and
resistant ≥ 4 µg/ml; tetracycline (TETUu), sensitive ≤ 1
µg/ml, and resistant ≥ 2 µg/ml; levofloxacin (LEV Uu),
sensitive ≤ 2 µg/ml, and resistant ≥ 4 µg/ml; tetracycline
(TETMh), sensitive ≤ 4 µg/ml, and resistant ≥ 8 µg/ml;
and levofloxacin (LEVMh), sensitive ≤ 1 µg/ml, and
resistant ≥ 2 µg/ml.
The results are reported as percentages. Differences in
the presence of genital mycoplasmas between the
pregnant and spontaneous abortion groups were
determined by the Chi-square test (SPSS Inc., Chicago,
IL, USA). p-values of <0.05 were considered statistically
significant.
RESULTS
The present study included 56 female patients aged
between 26 and 45 years old. Of the 56 specimens tested,
89.3% (50/56) were positive for M. hominis and/or U.
urealyticum (Table 1). Among these, 62.5% (35/56) of
the women were in the spontaneous abortion group, and
 Research J. Pharm. and Tech. 12(12): December 2019

26.8% (15/56) were in the full-term pregnancy group.
Ureaplasma urealyticum was the most predominant
pathogen in the spontaneous abortion group (43%),
followed by M. hominis (17%). With regard to the full-
term pregnancy group, M. hominis and U. urealyticum
were found in 38% and 19% of the patient women,
respectively. U. urealyticum isolates were found more
often in combination with M. hominis in the spontaneous
abortion group (40%) than in the full-term pregnancy
group (14%).

Table 1 The occurrence of Mycoplasma hominis and Ureaplasma urealyticum among pregnant women.
Group a M. hominis U. urealyticum M. hominis+ U. urealyticum Negatives Total
No (%) No (%) No (%) No (%)
Spontaneous abortion N = 35 6 (17) 15 (43) 14 (40) 0 35 (62.5)
Full term Pregnancy N = 21 4 (19) 8 (38) 3 (14) 6 (29) 15 (26.8)
Total (N = 56) 10 (18) 23 (41) 17 (30) 6 (11) 56
Results are No. (%).; a p < 0.05.

The distribution of genital mycoplasmas in the two age Table 3 Distribution of M. hominis and U. urealyticum by the
groups is shown in Table 2. Mycoplasma hominis and U. gestation time in weeks
Gestation age (Weeks) M. hominis U. urealyticum
urealyticum were found most often in patients aged No (%) No (%)
between 26 and 35 years old. ≤ 12 Week (First Trimester) 6 (60) 12 (52.2)
> 12 Week (Second 0 4 (17.4)
Table 2 Distribution of Mycoplasma hominis and Ureaplasma Trimester)
urealyticum in the different age groups ≥ 36 Weeks (Third Trimester) 4 (40) 7 (30.4)
Age Group M. hominis U. urealyticum M. hominis + Total 10 (100) 23 (100)
(years) No (%) No (%) U. urealyticum
No (%) The susceptibility patterns of genital mycoplasmas at
26-30 5 (50) 5 (22) 5 (28) various breakpoints of antimicrobial agents are shown
31-35 2 (20) 10 (43) 4 (24)
36-40 1 (10) 6 (26) 4 (24)
in Tables 4 and 5. Full resistance rates (100%) (23/23)
41-45 2 (20) 2 (9) 4 (24) in the U. urealyticum isolates were found for
Total 10 23 17 pristinamycin and josamycin. One hundred percent
Cases (10/10) of M. hominis isolates were fully resistant to
pristinamycin and minocycline, whereas 90% (9/10) of
Table 3 shows the distribution of genital mycoplasmas M. hominis isolates had multi-drug resistance to
by the gestation time in weeks. Of the 33 mycoplasmas, josamycin, tetracycline, and ofloxacin. The presence of
66.7% (22/33) of the women in the patient group had a both Ureaplasma urealyticum and M. hominis in a
spontaneous abortion (≤ 20 weeks). Among these, 48.5% single specimen was noted as a mixed isolate. Greater
(16/33) of the cases were colonised with U. urealyticum, resistance was observed for mixed isolates against
and 18.2% (6/33) of the cases were colonised with M. pristinamycin, josamycin, clarithromycin, minocycline,
hominis. The colonisation rate of mycoplasmas was less ciprofloxacin, and levofloxacin [100% (17)].
prominent in the full-term pregnancy group (≥ 36 weeks
of gestation), where 21.2% (7/33) of the cases were
colonised with U. urealyticum and 12.1% (4/33) of the
cases were colonised with M. hominis (Table 3).
Table 4: Antimicrobial susceptibility patterns (%) of M. hominis and U. urealyticum positive specimens as single or mixed isolates
at different breakpoints of antimicrobial agents (n = 50)
M. hominis U. urealyticum M. hominis+ U. urealyticum
N=10 (%) N=23 (%) N=17 (%)
Group Antimicrobial Agent S I R S I R S I R
Macrolid Pristinamycin (PRI) 10 (100) 23 (100) 17 (100)
es
Josamycin (JOS) 1 (10) 9 (90) 23 (100) 17 (100)
Erythromycin (ERY) 1 (10) 1 (10) 8 (80) 2 (9) 1 (4) 20 (87) 1 (6) 16 (94)
Roxithromycin (ROX) 2 (20) 8 (80) 2 (9) 7 (30) 14 (61) 1 (6) 5 (29) 11 (65)
Clarithromycin (CLA) 3 (30) 7 (70) 2 (9) 21 (91) 17 (100)
Tetracyc Minocycline (MIN) 10 (100) 1 (4) 22 (96) 17 (100)
lines
Tetracycline (TET) 1 (10) 9 (90) 1 (4) 2 (9) 20 (87) 2 (12) 15 (88)
Lincosa Clindamycin (CLI) 2 (20) 2 (20) 6 (60) 3 (13) 20 (87) 2 (12) 15 (88)
mides
Ofloxacin (OFL) 1 (10) 9 (90) 1 (4) 22 (96) 3 (18) 14 (82)
Quinolo Ciprofloxacin (CIP) 1 (10) 1 (10) 8 (80) 2 (9) 21 (91) 17 (100)
nes
Levofloxacin (LEV) 3 (30) 7 (70) 1 (4) 22 (96) 17 (100)

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Table 5: Antimicrobial resistance patterns (%) of the total mycoplasma to various antimicrobial agents
Group Antimicrobial Agent Susceptible Intermediate Resistant
Macrolides Pristinamycin (PRI) 33 (100)
Josamycin (JOS) 1 (3) 49 (98)
Erythromycin (ERY) 4 (8) 2 (4) 44 (88)
Roxithromycin (ROX) 3 (6) 14 (28) 33 (66)
Clarithromycin (CLA) 5 (10) 45 (90)
Tetracyclines Minocycline (MIN) 1 (2) 49 (98)
Tetracycline (TET) 2 (4) 4 (8) 44 (88)
Lincosamides Clindamycin (CLI) 5 (10) 4 (8) 41 (82)
Ofloxacin (OFL) 1 (2) 4 (8) 45 (90)
Quinolones Ciprofloxacin (CIP) 1 (2) 3 (6) 46 (92)
Levofloxacin (LEV) 3 (6) 1 (2) 46 (92)

DISCUSSION: Regarding antibacterial susceptibility patterns, only

Genital mycoplasmas (M. hominis and U. urealyticum) clindamycin retained its low activity against M. hominis
have received increased attention in recent years because (20%) and U. urealyticum (13%), while macrolides and
of their risk of causing the development of certain quinolones showed poor activities against both species.
pathologic conditions during pregnancy, such as Mycoplasma hominis is known to be naturally resistant
spontaneous abortion, urogenital infections, preterm to macrolides, whereas U. urealyticum is moderately
labour, and low birth weight.[17,18] The detection rate of susceptible to macrolides but is resistant to quinolones. [2]
genital mycoplasmas observed in the age group ≤ 34 The erythromycin resistance of U. urealyticum in this
years was higher than that in the elderly group ≥ 36 study (87%) is comparable to that documented by
years. This concurs with the study results of Bayraktar et Kechagia et al. [10] (83%), but it is in contrast to that
al. [2], which revealed that the highest frequency of documented by Koh et al. (17.2%).[8] Genital
genital mycoplasmas was observed in pregnant women mycoplasma isolates displayed full resistance rates
in the 18- to 34-year-old age group. (100%) to the more recently developed macrolide
(pristinamycin). The lowest susceptibility rate of U.
When assessing correlations between the mycoplasma
urealyticum in this study (4%) to tetracycline is fairly
loads in the spontaneous abortion and full-term
consistent with that of the study conducted in Pretoria,
pregnancy groups, a significant correlation between the
South Africa (27%) [9] but is distinctly different from
two species with a mean load > 0.05 was detected. These
those in the previously published data from Turkey
findings provide evidence that maternal colonisation
(100%) [2], Greece (87.4%) [10], and South Korea
with U. urealyticum and/or M. hominis was associated
(81%).[8] The resistance of mixed isolates to most of the
with a significantly higher risk of pregnancy loss.
antibacterial agents tested was higher when compared to
In this study, 62.5% (35/56) of women with M. hominis that of M. hominis or U. urealyticum single pathogens
and/or U. urealyticum infections showed an increased and may suggest their role in higher pathogenicity.
risk of pregnancy loss at < 24 gestational weeks. The
The resistance of U. urealyticum to quinolones, such as
colonization rate with mycoplasmas in the spontaneous
ofloxacin and levofloxacin, was higher (96%) when
abortion group (62.5%) was nearly twice the rate of the
compared to that reported by Zhu et al. [22], who reported
full-term pregnancy group (26.8%), which underlines the
ofloxacin (32.96%) and levofloxacin (20.09%) resistance
impact of mycoplasma infections on the loss of
rates in U. urealyticum isolates from Chinese women.
pregnancy. Our findings correspond to the previous
The resistance rates of quinolones are realistic because
results that genital mycoplasmas play causative roles in
these antibiotics, similar to other antibiotics in Iraq, can
spontaneous abortion and early pregnancy loss (< 37
be purchased easily over-the-counter and are
gestational weeks).[19] In the present study, vaginal
accompanied by their massive use in the community (for
colonisation with U. urealyticum seemed to be an
respiratory and urinary tract infections); this contributes
independent risk factor for early pregnancy loss. The
to the increase of selective pressures that may confer the
detection rate of U. urealyticum was 43% (15/35) of
rise of antibacterial resistance.[23,24] Therefore, the
women from the spontaneous abortion group compared
antimicrobial susceptibilities of genital mycoplasmas
to 19% (4/21) of women from the full-term pregnancy
vary geographically due to various antimicrobial
group. This concurs with the study results of Olomu et
therapies.[8] The unexpected findings in the resistance
al. [20], which revealed that the presence of Ureaplasma
rates found in the present work and in studies from
in the placental parenchyma before 28 gestational weeks
various countries may be the consequence of diverse
was associated with a higher risk of preterm labour and
antimicrobial prescribing guidelines and their
delivery.[18] Robertson and colleagues claimed in 1986
availabilities, which can frequently promote the spread
that the presence of vaginal U. urealyticum in placental
of antimicrobial resistance.[10] Furthermore,
tissue was associated with a higher risk of spontaneous
inconsistencies in resistance rates among the
abortion.[21]
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aforementioned studies may be due to the use of
different kits, the populations studied, or the study
period.[9,25]
Resistance within the bacterial population persists and is
expanding due to the misuse of antibacterial agents that
cause the selective pressure. Strategies are required to
minimise antibacterial resistance. These strategies may
include the development of (i) new antibacterial agents
and nonantibiotic therapies and (ii) newer derivatives of
currently used antibacterial agents.[26] Therefore, the
frequent monitoring of the antibacterial susceptibility
patterns of genital mycoplasmas and the formulation of
an antibacterial policy may be useful to decrease the
occurrence of mycoplasma infections.
The present study may have some limitations with the
putative link of M. hominis and U. urealyticum with
newborns with a very low birth weight (< 2.500 g) and
the uncertainty of the gestational age (+/- 2 weeks).
Another limitation may be the inability of the authors to
test for other Mycoplasma spp. because no approved,
commercially available diagnostic assay exists for the
detection of all Mycoplasma spp. More studies in
broader populations, such as non-pregnant women, are
required to assert the high resistance rates of genital
mycoplasmas; this must be followed by the
characterisation of mobile genetic elements, which carry
a variety of resistance associated-genes, and of their
possible spread via intra- and interspecific transfer.
In conclusion, the present study emphasises the
importance of routine monitoring to ensure the efficacy
of treatment and helps to fill the lack of local data
regarding the antimicrobial susceptibility patterns of the
mycoplasmas responsible for pregnancy complications;
this indicates a higher occurrence of genital
mycoplasma-resistant isolates in comparison to those of
other regions. Furthermore, the findings may assure the
usefulness of the mycoplasma kit for the phenotypic
detection of mycoplasmas.
ACKNOWLEDGMENT:
The authors are greatly thankful to the staff members at
Department of Biology-College of Science-University of
Babylon, Iraq.
CONFLICTS OF INTEREST:
The authors declare no conflicts of interest.
REFERENCES:
1. Abdel Rahman SM, Hassan RA, Sakna NA. Antimicrobial susceptibility
pattern of genital Mycoplasmas among a group of pregnant women.
Alexandria Journal of Medicine. 2016;52(4):353-8.
2. Bayraktar MR, Ozerol IH, Gucluer N, Celik O. Prevalence and antibiotic
susceptibility of Mycoplasma hominis and Ureaplasma urealyticum in
pregnant women. Int J Infect Dis. 2010;14(2):e90-5.
3. Taylor BD, Darville T, Haggerty CL. Does bacterial vaginosis cause
pelvic inflammatory disease? Sex Transm Dis. 2013;40(2):117-22.
4. Skiljevic D, Mirkov D, Vukicevic J. Prevalence and antibiotic
susceptibility of Mycoplasma hominis and Ureaplasma urealyticum in
genital samples collected over 6 years at a Serbian university hospital.
Indian J Dermatol Venereol Leprol. 2016;82(1):37-41.
6202
5. Yoon BH, Romero R, Lim JH, Shim SS, Hong JS, Shim JY, et al. The
clinical significance of detecting Ureaplasma urealyticum by the
polymerase chain reaction in the amniotic fluid of patients with preterm
labor. Am J Obstet Gynecol. 2003;189(4):919-24.
6. Zdrodowska-Stefanow B, Klosowska WM, Ostaszewska-Puchalska I,
Bulhak-Koziol V, Kotowicz B. Ureaplasma urealyticum and Mycoplasma
hominis infection in women with urogenital diseases. Adv Med Sci.
2006;51:250-3.
7. Waites KB, Katz B, Schelonka RL. Mycoplasmas and ureaplasmas as
neonatal pathogens. Clin Microbiol Rev. 2005;18(4):757-89.
8. Eunha Koh SK, In-Suk Kim, Kook-Young Maeng, Soon-Ae Lee.
Antimicrobial Susceptibilities of Ureaplasma urealyticum and
Mycoplasma hominis in Pregnant Women. Korean Journal of Clinical
Microbiology Vol 12, No 4, December, 2009. 2009;12(4):159-62.
9. Redelinghuys MJ, Ehlers MM, Dreyer AW, Lombaard HA, Kock MM.
Antimicrobial susceptibility patterns of Ureaplasma species and
Mycoplasma hominis in pregnant women. BMC Infect Dis. 2014;14:171.
10. Kechagia N, Bersimis S, Chatzipanagiotou S. Incidence and antimicrobial
susceptibilities of genital mycoplasmas in outpatient women with clinical
vaginitis in Athens, Greece. J Antimicrob Chemother. 2008;62(1):122-5.
11. Dongya M, Wencheng X, Xiaobo M, Lu W. Transition mutations in 23S
rRNA account for acquired resistance to macrolides in Ureaplasma
urealyticum. Microb Drug Resist. 2008;14(3):183-6.
12. Xiao L, Crabb DM, Duffy LB, Paralanov V, Glass JI, Hamilos DL, et al.
Mutations in ribosomal proteins and ribosomal RNA confer macrolide
resistance in human Ureaplasma spp. Int J Antimicrob Agents.
2011;37(4):377-9.
13. Degrange S, Renaudin H, Charron A, Bebear C, Bebear CM. Tetracycline
resistance in Ureaplasma spp. and Mycoplasma hominis: prevalence in
Bordeaux, France, from 1999 to 2002 and description of two tet(M)-
positive isolates of M. hominis susceptible to tetracyclines. Antimicrob
Agents Chemother. 2008;52(2):742-4.
14. Mardassi BB, Aissani N, Moalla I, Dhahri D, Dridi A, Mlik B. Evidence
for the predominance of a single tet(M) gene sequence type in
tetracycline-resistant Ureaplasma parvum and Mycoplasma hominis
isolates from Tunisian patients. J Med Microbiol. 2012;61(Pt 9):1254-61.
15. Drlica K, Zhao X. DNA gyrase, topoisomerase IV, and the 4-quinolones.
Microbiol Mol Biol Rev. 1997;61(3):377-92.
16. CLSI. Methods for antimicrobial susceptibility testing for human
mycoplasmas; Approved guideline. CLSI Document M43-A: Wayne, PA:
Clinical and Laboratory Standards Institute; 2011.
17. Clegg A, Passey M, Yoannes M, Michael A. High rates of genital
mycoplasma infection in the highlands of Papua New Guinea determined
both by culture and by a commercial detection kit. J Clin Microbiol.
1997;35(1):197-200.
18. McDonald HM, O'Loughlin JA, Jolley PT, Vigneswaran R, McDonald PJ.
Changes in vaginal flora during pregnancy and association with preterm
birth. J Infect Dis. 1994;170(3):724-8.
19. Donders GG, Van Bulck B, Caudron J, Londers L, Vereecken A, Spitz B.
Relationship of bacterial vaginosis and mycoplasmas to the risk of
spontaneous abortion. Am J Obstet Gynecol. 2000;183(2):431-7.
20. Olomu IN, Hecht JL, Onderdonk AO, Allred EN, Leviton A. Perinatal
correlates of Ureaplasma urealyticum in placenta parenchyma of singleton
pregnancies that end before 28 weeks of gestation. Pediatrics.
2009;123(5):1329-36.
21. Robertson JA, Honore LH, Stemke GW. Serotypes of Ureaplasma
urealyticum in spontaneous abortion. Pediatr Infect Dis. 1986;5(6
22.
Suppl):S270-2.
Zhu C, Liu J, Ling Y, Dong C, Wu T, Yu X, et al. Prevalence and
antimicrobial susceptibility of Ureaplasma urealyticum and Mycoplasma
hominis in Chinese women with genital infectious diseases. Indian J
Dermatol Venereol Leprol. 2012;78(3):406-7.
23. Schneider SC, Tinguely R, Droz S, Hilty M, Dona V, Bodmer T, et al.
Antibiotic Susceptibility and Sequence Type Distribution of Ureaplasma
Species Isolated from Genital Samples in Switzerland. 2015;59(10):6026-
31.
24. Valentine-King MA, Brown MB. Antibacterial Resistance in Ureaplasma
Species and Mycoplasma hominis Isolates from Urine Cultures in
College-Aged Females. Antimicrob Agents Chemother.
2017;61(10):e01104-17.
25. Ardic N OO, Ilga U, Turhan V, Haznedaroglu T, Ozyurt M. Investigation
of the Frequency And Antibiotic Susceptibility of Mycoplasma/
Ureaplasma in Urine Samples With Leukocyturia by Different
Commercial Methods. The Internet Journal of Infectious Diseases.
2005;4(2):1-6.
26. Roberts MC. Update on macrolide-lincosamide-streptogramin, ketolide,
and oxazolidinone resistance genes. FEMS Microbiol Lett.
2008;282(2):147-59.