SECTION 8 Clinical Microbiology: Bacteria
186 
Mycoplasma and Ureaplasma
JØRGEN SKOV JENSEN
KEY CONCEPTS
• Mycoplasmas are primarily mucosal pathogens, but some
species may cause invasive infections in susceptible hosts.
• Mycoplasma pneumoniae causes mild upper respiratory tract
symptoms but is a major cause of community acquired pneu-
monia in older children and young adults. Macrolide resistance
is spreading and in some areas is nearly 100% (Asia) but is
considerably lower in Europe and in the USA.
• Mycoplasma genitalium is an emerging sexually transmitted
infection and an established cause of acute and persistent or
recurrent non-gonococcal urethritis. Macrolide resistance is
spreading and alternative treatment with moxifloxacin is threat-
ened, leaving very few options for treatment.
• Mycoplasma hominis and ureaplasmas are common urogenital
commensals, but may cause disease in a susceptible host.
• Ureaplasma urealyticum but not U. parvum may cause male
non-gonococcal urethritis when present in high concentrations.
• Mycoplasma hominis and ureaplasmas should be considered
in wound infections after urogenital tract surgery or after
transplantation.
Introduction
The class Mollicutes (meaning ‘soft skin’), trivially known as mycoplas-
mas, comprise some of the smallest free-living micro-organisms. They
lack the cell wall found in most other bacteria and, consequently, they
are resistant to β-lactam antimicrobials. The small size of the myco-
plasma genome limits the metabolic capabilities, making culture of
some mycoplasmas difficult or impossible. Mycoplasmas isolated com-
monly from humans belong to the genera Mycoplasma and Ureaplasma
within the order Mycoplasmatales. The genus Ureaplasma (‘ureaplas-
mas’) is unique in the ability to hydrolyze urea.
The Mollicutes are also economically important plant and animal
pathogens. Although most species have strict host specificities, some
of the animal mycoplasmas may occasionally cause infections in
humans.
Currently, 14 Mycoplasma species and two Ureaplasma species are
considered human mycoplasmas (summarized in Table 186-1). In
this chapter, only the five species of clinical significance will be
considered:
• Mycoplasma pneumoniae
• Mycoplasma genitalium
• Mycoplasma hominis
• Ureaplasma urealyticum
• Ureaplasma parvum.
Mycoplasma pneumoniae
Nature
Mycoplasma pneumoniae is an important respiratory tract pathogen. It
grows slowly in specialized bacteriological media, and infection is pri-
marily diagnosed by nucleic acid amplification tests (NAAT), or indi-
rectly by serology.
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Epidemiology
M. pneumoniae causes mild upper respiratory tract symptoms more
often than severe disease, and infections have been described from
most parts of the world. In temperate climates, most infections are
reported during late summer until mid-winter. However, the infection
is endemic throughout the year with epidemic peaks about every 4–7
years.1 The incubation period ranges from 2 to 4 weeks. Spread from
person to person occurs slowly, usually where there is continual or
repeated close contact, as within a family.2,3
M. pneumoniae is only responsible for a minority of all upper tract
infections, where viral infection is the dominating cause, but it is a
significant cause of lower respiratory tract infections being reported in
15–20% of all pneumonias in the USA.4 In closed communities such
as military camps and institutions, outbreaks with a high attack rate
have been reported.3
Pathogenicity
Infection with M. pneumoniae probably happens in all age groups but
the risk of developing pneumonia varies with age. Approximately 25%
of children 5–15 years old with M. pneumoniae infection develop
pneumonia, whereas this is the case in only about 7% of younger
adults, although they often experience milder disease. Pneumonia is
less frequent thereafter, but is more severe in older patients.5
A crucial step in M. pneumoniae infection is the adherence of the
organisms to respiratory mucosal epithelial cells, which is mediated by
a specialized terminal tip-structure carrying the P1 main adhesion
protein and accessory proteins. After attachment to the ciliated epithe-
lium, M. pneumoniae secretes hydrogen peroxide leading to ciliostasis,
and subsequent necrosis of the epithelium.6 The pneumonia is mainly
caused by peribronchiolar and perivascular pulmonary infiltration
with lymphocytes and is mainly an immune-pathological process since
immunosuppression prevents pneumonia or diminishes its severity.7
Prevention
No vaccine against M. pneumoniae has been developed, and early
attempts with vaccination resulted in more severe disease. Azithromy-
cin treatment has been used successfully to prevent spread of epidem-
ics in confined settings, but is not generally recommended.8
Diagnostic Microbiology
Diagnosis can be made by molecular methods such as NAAT, serology
and culture. Traditionally, serology has been the primary diagnostic
method, but this is increasingly being replaced by molecular methods.
NAATs such as polymerase chain reaction (PCR) are capable of provid-
ing rapid diagnostic results in the acute phase of the disease, where it
may direct antimicrobial treatment. Various gene targets have been
used, but no standardization or general recommendations exist.9
Recently, commercially available detection kits have received US Food
and Drug Administration (FDA) approval.
Serology is generally less costly than NAATs, but since antibodies
peak at 3–4 weeks after onset of disease, this method may have less
relevance in the acute phase of the disease. Commercially available
enzyme immunoassays specific for IgG and/or IgM are commonly
used. IgM detection is much less reliable in re-infection, which is most
often the case in adults. Cold agglutinins, detected by agglutination of
O Rh-negative erythrocytes at 4 °C, correlate with specific IgM and are