Antimicrobial susceptibility patterns of Ureaplasma species and Mycoplasma hominis in pregnant women

Ureaplasma infections: update on epidemiology, antimicrobial resistance, and pathogenesis

Human Ureaplasma species are being increasingly recognized as opportunistic pathogens in human genitourinary tract infections, infertility, adverse pregnancy, neonatal morbidities, and other adult invasive infections. Although some general reviews have focused on the detection and clinical manifestations of Ureaplasma spp., the molecular epidemiology, antimicrobial resistance, and pathogenesis of Ureaplasma spp. have not been adequately explained. The purpose of this review is to offer valuable insights into the current understanding and future research perspectives of the molecular epidemiology, antimicrobial resistance, and pathogenesis of human Ureaplasma infections. This review summarizes the conventional culture and detection methods and the latest molecular identification technologies for Ureaplasma spp. We also reviewed the global prevalence and mechanisms of antibiotic resistance for Ureaplasma spp. Aside from regular antibiotics, novel antibiotics with outstanding in vitro antimicrobial activity against Ureaplasma spp. are described. Furthermore, we discussed the pathogenic mechanisms of Ureaplasma spp., including adhesion, proinflammatory effects, cytotoxicity, and immune escape effects, from the perspectives of pathology, related molecules, and genetics.

Global analysis on the mutations associated with multidrug-resistant urogenital mycoplasmas and ureaplasmas infection: a systematic review and meta-analysis

BACKGROUND

The emergence of multidrug-resistant (MDR) strains of genital pathogens, notably Mycoplasma genitalium and Ureaplasma spp., constitutes a significant global threat today. The present study aimed to evaluate the prevalence and trend of changes in MDR mycoplasma and ureaplasma strains.

METHODS

An exhaustive search was performed across the ISI Web of Science, PubMed, Scopus, ScienceDirect, and Google Scholar databases to accumulate relevant studies without restrictions until April 2023. We used event rate and corresponding 95% confidence intervals to determine the frequency of resistance-related mutations and examine the trend of antibiotic resistance changes.

RESULTS

The data from 27 studies, including 24,662 patients across 14 countries, were evaluated. Out of the total studies, 20 focused on M. genitalium infections, and five on Ureaplasma spp. The frequency of resistance-associated mutations to macrolides, tetracyclines, and fluoroquinolones in clinical strains of M. genitalium was 43.5%, 13.1%, and 18.6%, respectively. The prevalence of M. genitalium strains with double resistance and MDR was 11.0% and 17.4%, respectively. The incidence of both double-drug-resistant and MDR strains was higher in the World Health Organization (WHO) Western Pacific Region than in European and American populations. For Ureaplasma strains, resistance-associated mutations to macrolides, tetracyclines, and fluoroquinolones were 40.8%, 25.7%, and 90.3%, respectively. The rate of antibiotic resistance was higher in the African population compared to the European and WHO Western Pacific Regions. The rate of MDR Ureaplasma infections was 13.2%, with a higher incidence in the African population compared to the WHO Western Pacific and European regions.

CONCLUSION

The proliferation and spread of MDR Mycoplasma and Ureaplasma strains present a significant public health challenge. The situation is indeed alarming, and the rising trend of MDR M. genitalium and MDR Ureaplasma infections suggests that therapies involving macrolides and fluoroquinolones may become less effective.

A randomized clinical trial of antibiotic treatment duration in preterm premature rupture of membranes: 7 days vs until delivery

BACKGROUND

Antibiotic treatment in preterm premature rupture of membranes can prolong the interval from membrane rupture to delivery and improve neonatal outcomes. However, the duration of antibiotic treatment for preterm premature rupture of membranes has been rarely compared in prospective studies.

OBJECTIVE

This study aimed to investigate the optimal duration of antibiotic treatment for premature rupture of membranes. We performed a randomized controlled trial comparing neonatal morbidity and infantile neurologic outcomes between 2 groups of patients with preterm premature rupture of membranes who received antibiotic treatment for 7 days or until delivery, respectively.

STUDY DESIGN

This prospective randomized study included patients who were diagnosed with preterm premature rupture of membranes between 22+0 weeks and 33+6 weeks of gestation. The enrolled patients were randomly assigned to receive intravenous cefazolin (1 g dosage every 12 hours) and oral clarithromycin (500 mg dosage every 12 hours) either for 7 days or until delivery. The study protocol was registered at ClinicalTrials.gov under identifier NCT01503606. The primary outcome was a neonatal composite morbidity, and the secondary outcome was neurologic outcomes at 12 months of corrected age. We enrolled 151 patients and allocated 75 and 76 of them to the 7-day and until-delivery groups, respectively. Analysis was done by per protocol.

RESULTS

After excluding cases lost to follow-up and those with protocol violations, 63 (7-day regimen) and 61 (until-delivery regimen) patients with preterm premature rupture of membranes and their babies were compared. There was no significant difference in the pregnancy outcomes, including gestational age at delivery and the interval from rupture of membranes to delivery, between the 2 groups. Among the neonatal outcomes, bronchopulmonary dysplasia, intraventricular hemorrhage, retinopathy of prematurity, necrotizing enterocolitis, and proven neonatal sepsis did not differ between the groups. However, the rates of respiratory distress syndrome (32.8% vs 50.8%; P=.039) and composite neonatal morbidities (34.4% vs 53.9%; P=.026) were lower in the until-delivery group than in the 7-day group. This difference remained statistically significant after a multivariable analysis adjusting for maternal age, twin pregnancy, antenatal corticosteroids treatment, gestational age at delivery, interval from rupture of membranes to delivery, and clinical chorioamnionitis. Infantile neurologic outcomes were evaluated in 71.4% of the babies discharged alive and did not differ between the groups.

CONCLUSION

Overall, the until-delivery regimen of cefazolin and clarithromycin in preterm premature rupture of membranes led to a lower incidence of composite neonatal morbidity and respiratory distress syndrome than the 7-day regimen, and both regimens otherwise showed similar individual neonatal morbidities and infantile neurologic outcomes.

Case Report: Double trouble: a rare case of successfully treated Mycoplasma hominis and Pseudomonas aeruginosa co-infection

Background

Extra-urogenital infections due to Mycoplasma hominis (M. hominis) are rare, particularly co-infection with Pseudomonas aeruginosa (P. aeruginosa). Herein, we report on a patient who was co-infected and successfully treated despite delayed treatment.

Case presentation

We reported the case of a 43-year-old man with M. hominis and P. aeruginosa co-infection after a traffic accident. The patient developed a fever and severe infection despite postoperative antimicrobial therapies. The blood culture of wound tissues was positive for P. aeruginosa. Meanwhile, culturing of blood and wound samples showed pinpoint-sized colonies on blood agar plates and fried-egg-type colonies on mycoplasma medium, which were identified as M. hominis by matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS) and 16S rRNA sequencing. Based on antibiotic susceptibility and symptoms, ceftazidime-avibactam and moxifloxacin were administered for P. aeruginosa infection. Meanwhile, after the failure of a series of anti-infective agents, M. hominis and P. aeruginosa co-infection was successfully treated with a minocycline-based regimen and polymyxin B.

Conclusion

The co-infection with M. hominis and P. aeruginosa was successfully treated with anti-infective agents despite delayed treatment, providing information for the management of double infection.

How does gender affect ureaplasma and mycoplasma growth and antimicrobial susceptibility rates?

BACKGROUND

The aim of this study was to assess the presence of M. hominis and U. urealyticum agents, their distribution between male and female, and differences in antibiotic susceptibility in samples sent from Hisar Intercontinental Hospital's various clinics with the preliminary diagnosis of genitourinary system infection.

METHODS

The Mycoplasma IES test was used to identify M. hominis and U. urealyticum, and to determine antibiotic susceptibility results, in samples taken from patients. The findings of mycoplasma and ureaplasma culture testing samples requested between 2014 and 2021 were evaluated retrospectively from our records.

RESULTS

M. hominis was found to be positive in 7.37% of the examinations, U. urealyticum was found to be positive in 34.98% of the examinations, and either of them were found to be positive in 22.01% of the examinations. The growth rate of M. hominis and/or U. urealyticum was determined to be 24.95% in females and 10.13% in males, with the growth rate in females being greater and statistically significant (p < 0.001). According to the antibiotic susceptibility test results, clarithromycin (R 17.91%) was the most susceptible antibiotic overall for both microorganisms, while clindamycin (R 90.28%) was the most resistant. Depending on the sex, clarithromycin (R 18.40%) was found to be the most susceptible antibiotic in females, and levofloxacin (R 10.87%) to be the most susceptible in males.

CONCLUSION

Given the presence of M. hominis and U. urealyticum infections, especially in the presence of risky conditions such as pregnancy, laboratory tests for the diagnosis of these agents should be used in such studies since no urogenital infections were detected in the routine cultures of the patients followed up with the suspicion of urogenital infection. Gender differences should also be considered as a parameter in the preference of antibiotics.

Genetic Polymorphisms in MicroRNA-196a2 and the Risk of Human Abortion Related to Mycoplasma hominis

Mutations in some miRNAs are associated with human recurrent pregnancy loss (RPL). In parallel, Mycoplasma spp. are one of the most common infections in pregnant women. The objective of this study was to identify the relationship between miRNA196a-2 gene polymorphism and Mycoplasma hominis (M. hominis) infection as a possible cause of human abortion. A total of 160 cervical swab specimens were collected from women (80 samples with at least one abortion as case, and 80 samples without abortion as control). A PCR-based method using 16S rRNA gene and tetra primer amplification refractory mutation system-polymerase chain (Tetra-ARMS-PCR) were used to identify the presence of M. hominis infections and miRNA196a-2 genotypes of studied women, respectively. Results showed that 22.5% of women with abortion and 7.5% of women without abortion were infected with M. hominis, thereby suggesting a significant difference between the two groups (P < 0.05). Tetra-ARMSPCR indicated that no significant difference in frequency of genotypes existed between women experimenting abortion and control group. Independently to the presence of M. hominis infection, a significant difference (P < 0.05) was observed in genotypic frequencies of miRNA196a-2 between RPL women and those with one abortion. Estimation of the Odds Ratios indicated that the chance of recurrent abortions in TT genotypes of miRNA196a-2 was about three times more likely than CC in non-infected individuals and about five times more likely than CC in M. hominis-infected patients. Our results proposed the role of miRNA196a-2 genotypes in RPL either in M. hominis-infected or non-infected individuals.

Periprosthetic joint infection due to Mycoplasma hominis in a multiple sclerosis patient treated with fingolimod

Mycoplasma hominis is a commensal pathogen normally found in urogenital tract of humans and has been associated with a wide variety of extra-genitourinary infections, such as mediastinitis, bacteremia, and septic arthritis, particularly in immunocompromised patients. Here, we present a case of a 48-year-old male, who had been treated with fingolimod for relapsing multiple sclerosis and presented with fever and right-sided hip pain following total hip arthroplasty. CT scan revealed localized fluid collection in the right quadriceps femoris muscle adjacent to the joint cavity of right hip. The percutaneously aspirated fluid grew M. hominis, which was also isolated from blood culture. With diagnosis of periprosthetic joint infection, the patient underwent surgical debridement with retained prosthesis and was treated with antimicrobial agents. Infected granulation tissues excised from the hip was observed under an electron microscope, which revealed electron-dense rounded structures contained in neutrophils, consistent with Mycoplasma particles. Fingolimod, an immunomodulatory drug that acts on the sphingosine-1-phosphate receptor and prevents the egress of lymphocytes from lymph nodes, might increase host susceptibility to a systemic M. hominis infection.

Adverse pregnancy and birth outcomes associated with Mycoplasma hominis, Ureaplasma urealyticum and Ureaplasma parvum: a systematic review and meta-analysis

OBJECTIVES

Mycoplasma hominis, Ureaplasma urealyticum and Ureaplasma parvum (genital mycoplasmas) commonly colonise the urogenital tract in pregnant women. This systematic review aims to investigate their role in adverse pregnancy and birth outcomes, alone or in combination with bacterial vaginosis (BV).

METHODS

We searched Embase, Medline and CINAHL databases from January 1971 to February 2021. Eligible studies tested for any of the three genital mycoplasmas during pregnancy and reported on the primary outcome, preterm birth (PTB) and/or secondary outcomes low birth weight (LBW), premature rupture of membranes (PROM), spontaneous abortion (SA) and/or perinatal or neonatal death (PND).Two reviewers independently screened titles and abstracts, read potentially eligible full texts and extracted data. Two reviewers independently assessed risks of bias using published checklists. Random effects meta-analysis was used to estimate summary ORs (with 95% CIs and prediction intervals). Multivariable and stratified analyses were synthesised descriptively.

RESULTS

Of 57/1194 included studies, 39 were from high-income countries. In meta-analysis of unadjusted ORs, M. hominis was associated with PTB (OR 1.87, 95% CI 1.49 to 2.34), PROM, LBW and PND but not SA. U. urealyticum was associated with PTB (OR 1.84, 95% CI 1.34 to 2.55), PROM, LBW, SA and PND. U. parvum was associated with PTB (1.60, 95% CI 1.12 to 2.30), PROM and SA. Nine of 57 studies reported any multivariable analysis. In two studies, analyses stratified by BV status showed that M. hominis and U. parvum were more strongly associated with PTB in the presence than in the absence of BV. The most frequent source of bias was a failure to control for confounding.

CONCLUSIONS

The currently available literature does not allow conclusions about the role of mycoplasmas in adverse pregnancy and birth outcomes, alone or with coexisting BV. Future studies that consider genital mycoplasmas in the context of the vaginal microbiome are needed.

PROSPERO REGISTRATION NUMBER

CRD42016050962.

Antibiotic resistance among clinical Ureaplasma isolates from Cuban individuals between 2013 and 2018

Introduction. Acquired resistance against the antibiotics that are active against Ureaplasma species has been described.Hypothesis/Gap Statement. Diagnostics combined with antimicrobial sensitivity testing are required for therapeutic guidance.Aim. To report the prevalence of antimicrobial resistance among Cuban Ureaplasma isolates and the related molecular mechanisms of resistance.Methodology. Traditional broth microdilution assays were used for antimicrobial sensitivity testing in 262 clinical Ureaplasma species isolates from Cuban patients between 2013 and 2018, and a subset of samples were investigated in parallel with the commercial MYCO WELL D-ONE rapid culture diagnostic assay. The underlying molecular mechanisms for resistance were determined by PCR and sequencing for all resistant isolates.Results. Among the tested isolates, the tetracycline and erythromycin resistance rates were 1.9 and 1.5%, respectively, while fluoroquinolone resistance was not found. The tet(M) gene was found in all tetracycline-resistant isolates, but also in two tetracycline-susceptible Ureaplasma clinical isolates. We were unable to determine the underlying mechanism of erythromycin resistance. The MYCO WELL D-ONE kit overestimated tetracycline and erythromycin resistance in Ureaplasma spp. isolates.Conclusions. Although low levels of antibiotic resistance were detected in Cuban patients over a 5-year period, continued surveillance of the antibiotic susceptibility of Ureaplasma is necessary to monitor possible changes in resistance patterns.

Phenotypic Antimicrobial Susceptibility and Genotypic Characterization of Clinical Ureaplasma Isolates Circulating in Shanghai, China

There is a growing global concern regarding the rise of antimicrobial resistance among Ureaplasma spp. isolates. However, studies on the antimicrobial susceptibility profiles, resistance mechanisms, and clonality of Ureaplasma spp. clinical isolates are still limited and cover only some geographic regions. Firstly, Ureaplasma species from the urogenital tracts of patients in Shanghai, China, were isolated by using the culture medium (A8 and 10B broth), and identified the genotype by polymerase chain reaction (PCR). Secondly, the antimicrobial susceptibility tests were determined by using broth microdilution assay. Then, the resistance genetic determinants to fluoroquinolones (FQs), macrolides, and tetracyclines were investigated through PCR/DNA sequencing. Finally, the molecular epidemiology of Ureaplasma species was studied by multilocus sequence typing (MLST). Among 258 isolates, Ureaplasma parvum (UPA) and Ureaplasma urealyticum (UUR) were found in 226 (87.60%) and 32 (12.40%) isolates, respectively. The minimum inhibitory concentrations (MICs) of 258 Ureaplasma spp. strains ranged from 0.015 to 64μg/ml for all 11 kinds of antimicrobials. Regardless of species, the isolates were most sensitive to AZI (1.94%), JOS (3.49%), and CLA (4.23%). Among them, there were 39 (15.12%) multidrug-resistant (MDR) strains, including 32 UPA isolates. The resistance rates of UPA to CIP (91.59%), and ROX (36.28%) were significantly higher than those of UUR. Twenty six FQ-resistant isolates had amino acid substitutions in gyrA and in parC (Ser83Leu). Mutations were detected in genes encoding ribosomal proteins L4 (Thr84Ile) and L22 (Ser81Pro) in macrolide-resistant isolates. Tet(M) was found in four UPA isolates. These mutations were mainly found in UPA isolates. Sequence type 1 (ST1) was the predominant ST, which contained 18 isolates. In conclusion, this study showed a higher resistance rate (especially to ROX and CIP), higher substitution rate, and higher MDR rate among UPA strains. The most active antimicrobial agents were AZI, JOS, and CLA. Identifying UPA or UUR in clinical isolates could help clinicians to choose appropriate drugs for treatment. The main resistance mechanisms may involve gene substitution of Ser83Leu in parC and Ser81Pro in L22. ST1 was the predominant ST of Ureaplasma isolates with MDR to FQs and macrolides in Shanghai, China.

Ureasplasma and Its Role in Adverse Perinatal Outcomes: A Review

Human Ureaplasma species are the most common microbes found in amniotic fluid and in the placenta after preterm birth, and have previously been correlated with chorioamnionitis, preterm labor, and bronchopulmonary dysplasia, among other adverse birth and neonatal outcomes. Although these correlations exist, there still remains little explanation as to whether Ureaplasma plays a pathogenic role in the development of neonatal disease. In addition, Ureaplasma species are not usually identified on routine culture as they require special culture methods because of their fastidious growth requirements. Treatment of Ureaplasma with macrolides has been shown to effectively eradicate the bacteria in pregnant women and infants. However, it is unclear whether this leads to improved neonatal morbidity and mortality, or whether these generally represent commensal organisms. This review will synthesize the current perspectives about the proposed mechanisms of pathogenicity of Ureaplasma bacteria, its links to poor neonatal outcomes, and the role of screening and treatment in current clinical practice.

Molecular diagnostic of Ureaplasma urealyticum presence and tetracycline resistance in urine samples

Sexually transmitted infections (STIs) are among the most common infections in Romania. Infection with Ureaplasma urelyticum is one of the major causes of STIs and can cause serious complications. Although tetracycline is the drug commonly used to treat infections caused by U. urealyticum, several studies indicate the emergence and rapid development of strains resistant to these antibiotics in the United States or Europe. Tetracycline resistance in bacteria is encoded by a number of different genetic determinants but in mycoplasmas the only tetracycline resistance determinant that has been reported is the tetM gene. Tetracycline resistance among Ureaplasma spp. is associated with the presence of the horizontally acquired tetM resistance gene. Our study on bacterial DNA aimed to determine the presence of tetracycline-resistant U. urealyticum strains, by identifying the presence of the tetM gene. We used first void urine samples from 622 STI-suspected subjects. DNA was extracted, purified and amplified via PCR for the simultaneous detection of 6 STIs. 68 patients were diagnosed with U. urealyticum. DNA obtained from these samples was amplified using the tetM gene and U. urealyticum - specific urease gene primers. The urease gene was amplified in all samples, confirming the presence of U. urealyticum. The tetM gene was amplified in 2 samples considered tetracycline-resistant strains. The study confirmed the presence of U. urealyticum strains resistant to tetracycline in Romania. The employed technique can produce quick results both for U. urealyticum detection and determination of its resistance to tetracycline using a single easy-to-collect biological sample.

An Observational Study: Is N-Acetylcysteine Helpful in Performance Improvement of Mycoplasma IST2 Testing through Sample Homogenization?

Background

Culture is still the gold standard for the detection of genital mycoplasma which could cause urogenital infections in humans. Mycoplasma IST2 is a commercial kit widely used for the detection of M. hominis and Ureaplasma species. Its accuracy was partially impaired because clinical specimens are usually mixed with purulent or transparent mucus. We aimed to solve this problem through sample homogenization by N-acetylcysteine (NAC) treatment.

Methods

Twenty-two endocervical swab samples were collected from 22 female patients with suspected mycoplasma infection, while 11 of these specimens were with purulent or transparent mucus. Mycoplasma IST2 testing kit was used for mycoplasma culture and AST for the control group and NAC-treated group.

Results

Genital mycoplasma was detected in 15 of 22 samples for both groups. The colony number in 6 out of 11 purulent specimens (54.5%) was more than 10⁴ CFU/ml of genital mycoplasma for the NAC-treated group, while only one of 11 (9.1%) for the control group. For the nonpurulent specimens, no significant difference had been found in colony counting of genital mycoplasma between the control group and NAC-treated group (P > 0.05). The results of antimicrobial susceptibility testing for the NAC-treated group were highly similar to those for the control group.

Conclusions

Our results demonstrate that NAC is helpful in sample homogenization and NAC treatment can improve the detection efficiency of mycoplasma with Mycoplasma IST2 testing.

Antibiotic administration reduces the rate of intraamniotic inflammation in preterm prelabor rupture of the membranes

BACKGROUND

Preterm prelabor rupture of the membranes (PPROM) is frequently complicated by intraamniotic inflammatory processes such as intraamniotic infection and sterile intraamniotic inflammation. Antibiotic therapy is recommended to patients with PPROM to prolong the interval between this complication and delivery (latency period), reduce the risk of clinical chorioamnionitis, and improve neonatal outcome. However, there is a lack of information regarding whether the administration of antibiotics can reduce the intensity of the intraamniotic inflammatory response or eradicate microorganisms in patients with PPROM.

OBJECTIVE

The first aim of the study was to determine whether antimicrobial agents can reduce the magnitude of the intraamniotic inflammatory response in patients with PPROM by assessing the concentrations of interleukin-6 in amniotic fluid before and after antibiotic treatment. The second aim was to determine whether treatment with intravenous clarithromycin changes the microbial load of Ureaplasma spp DNA in amniotic fluid.

STUDY DESIGN

A retrospective cohort study included patients who had (1) a singleton gestation, (2) PPROM between 24+0 and 33+6 weeks, (3) a transabdominal amniocentesis at the time of admission, and (4) intravenous antibiotic treatment (clarithromycin for patients with intraamniotic inflammation and benzylpenicillin/clindamycin in the cases of allergy in patients without intraamniotic inflammation) for 7 days. Follow-up amniocenteses (7^th day after admission) were performed in the subset of patients with a latency period lasting longer than 7 days. Concentrations of interleukin-6 were measured in the samples of amniotic fluid with a bedside test, and the presence of microbial invasion of the amniotic cavity was assessed with culture and molecular microbiological methods. Intraamniotic inflammation was defined as a bedside interleukin-6 concentration ≥745 pg/mL in the samples of amniotic fluid. Intraamniotic infection was defined as the presence of both microbial invasion of the amniotic cavity and intraamniotic inflammation; sterile intraamniotic inflammation was defined as the presence of intraamniotic inflammation without microbial invasion of the amniotic cavity.

RESULTS

A total of 270 patients with PPROM were included in this study: 207 patients delivered within 7 days and 63 patients delivered after 7 days of admission. Of the 63 patients who delivered after 7 days following the initial amniocentesis, 40 underwent a follow-up amniocentesis. Patients with intraamniotic infection (n = 7) and sterile intraamniotic inflammation (n = 7) were treated with intravenous clarithromycin. Patients without either microbial invasion of the amniotic cavity or intraamniotic inflammation (n = 26) were treated with benzylpenicillin or clindamycin. Treatment with clarithromycin decreased the interleukin-6 concentration in amniotic fluid at the follow-up amniocentesis compared to the initial amniocentesis in patients with intraamniotic infection (follow-up: median, 295 pg/mL, interquartile range [IQR], 72-673 vs initial: median, 2973 pg/mL, IQR, 1750-6296; P = .02) and in those with sterile intraamniotic inflammation (follow-up: median, 221 pg/mL, IQR 118-366 pg/mL vs initial: median, 1446 pg/mL, IQR, 1300-2941; P = .02). Samples of amniotic fluid with Ureaplasma spp DNA had a lower microbial load at the time of follow-up amniocentesis compared to the initial amniocentesis (follow-up: median, 1.8 × 10⁴ copies DNA/mL, 2.9 × 10⁴ to 6.7 × 10⁸ vs initial: median, 4.7 × 10⁷ copies DNA/mL, interquartile range, 2.9 × 10³ to 3.6 × 10⁷; P = .03).

CONCLUSION

Intravenous therapy with clarithromycin was associated with a reduction in the intensity of the intraamniotic inflammatory response in patients with PPROM with either intraamniotic infection or sterile intraamniotic inflammation. Moreover, treatment with clarithromycin was related to a reduction in the load of Ureaplasma spp DNA in the amniotic fluid of patients with PPROM <34 weeks of gestation.

Antimicrobial Resistance in Clinical Ureaplasma spp. and Mycoplasma hominis and Structural Mechanisms Underlying Quinolone Resistance

Antibiotic resistance is a global concern; however, data on antibiotic-resistant Ureaplasma spp. and Mycoplasma hominis are limited in comparison to similar data on other microbes. A total of 492 Ureaplasma spp. and 13 M. hominis strains obtained in Hangzhou, China, in 2018 were subjected to antimicrobial susceptibility testing for levofloxacin, moxifloxacin, erythromycin, clindamycin, and doxycycline using the broth microdilution method. The mechanisms underlying quinolone and macrolide resistance were determined. Meanwhile, a model of the topoisomerase IV complex bound to levofloxacin in wild-type Ureaplasma spp. was built to study the quinolone resistance mutations. For Ureaplasma spp., the levofloxacin, moxifloxacin, and erythromycin resistance rates were 84.69%, 51.44%, and 3.59% in U. parvum and 82.43%, 62.16%, and 5.40% in U. urealyticum, respectively. Of the 13 M. hominis strains, 11 were resistant to both levofloxacin and moxifloxacin, and five strains showed clindamycin resistance. ParC S83L was the most prevalent mutation in levofloxacin-resistant Ureaplasma strains, followed by ParE R448K. The two mutations GyrA S153L and ParC S91I were commonly identified in quinolone-resistant M. hominis A molecular dynamics-refined structure revealed that quinolone resistance-associated mutations inhibited the interaction and reduced affinity with gyrase or topoisomerase IV and quinolones. The novel mutations S21A in the L4 protein and G2654T and T2245C in 23S rRNA and the ermB gene were identified in erythromycin-resistant Ureaplasma spp. As fluoroquinolone resistance in Ureaplasma spp. and Mycoplasma hominis remains high in China, the rational use of antibiotics needs to be further enhanced.

Spread of multidrug resistance among Ureaplasma serovars, Tunisia

Background

Ureaplasma spp. have been implicated in a variety of clinical conditions and certain serovars are likely to be disease-associated. Hence, the ascending trend of Ureaplasma spp. resistance to antimicrobials should deserve more attention. Here we assessed the extent of antimicrobial resistance of Ureaplasma serovars in Tunisia, and investigated the underlying molecular basis.

Methods

This study included 101 molecularly typed Ureaplasma spp. clinical strains isolated over a 12-year time period (2005–2017). The antimicrobial susceptibility was tested against nine antibacterial agents using the broth microdilution method. Neighbor-joining tree was constructed to establish the phylogenetic relationships among isolates.

Results

We found that all ureaplasma isolates were resistant to ciprofloxacin and erythromycin, intermediately resistant to azithromycin, and susceptible to doxycycline, moxifloxacin and josamycin. Ofloxacin and levofloxacin resistance was found in 73.27 and 17.82%, respectively, while 37.62% of isolates proved resistant to tetracycline. Consequently, we detected an elevated multidrug resistance rate among ureaplasma isolates (37.62%), particularly among serovars 2, 5, 8, and 9 (77.77% overall), as well as serovars 4, 10, 12, and 13 (52.63% overall). In most cases, drug resistance was found to be associated with known molecular mechanisms, yet we have identified two novel mutations in the L22 protein, which might be associated with macrolide-resistance.

Conclusion

To our knowledge, this is the first study that reports the widespread expansion of multidrug resistance among Ureaplasma serovars, a finding of importance in terms of both surveillance and antimicrobial usage.

Identification of Cultivable Bacteria in Amniotic Fluid Using Cervicovaginal Fluid Protein Microarray in Preterm Premature Rupture of Membranes

We aimed to identify cervicovaginal fluid (CVF) protein biomarkers of microbial invasion of the amniotic cavity (MIAC) in women with preterm premature rupture of membranes (PPROM), using an antibody microarray. This retrospective cohort study included 99 consecutive women with singleton pregnancies and PPROM (23-33 weeks) who underwent amniocentesis and who gave CVF samples. CVF proteomes from the MIAC (n = 20) versus non-MIAC groups (n = 20) were comparatively profiled by an antibody microarray using a nested case-control study design. The seven candidate biomarkers of interest were validated in the total cohort (n = 99) by enzyme-linked immunosorbent assays (ELISA). For comparison with candidate markers, amniotic fluid (AF) white blood cell (WBC) count was also measured. The primary outcome measure was MIAC (defined as positive AF culture). Thirty of the proteins studied exhibited significant intergroup differences. Measurements of the total cohort with ELISA confirmed a significant increase in the levels of CVF IL-8, lipocalin-2, MIP-1α, MMP-9, and TIMP-1 in women with MIAC, independent of gestational age at sampling. A combined, non-invasive model was developed by using a stepwise regression procedure, which included CVF IL-8 and CVF MMP-9 (area under the curve [AUC] = 0.763), and this AUC was comparable with the AUC of AF WBC. Using protein-antibody microarray technology, we found several novel, independent, non-invasive biomarkers to identify MIAC in women with PPROM: IL-8, lipocalin-2, MIP-1α, MMP-9, and TIMP-1. Furthermore, the combined non-invasive model (IL-8 and MMP-9) was a useful independent predictor for MIAC with good discriminatory power, similar to AF WBC count.

Comparative genomics of three clinical Ureaplasma species: analysis of their core genomes and multiple-banded antigen locus

Aim: To compare the genome sequences among clinical and American-Type Culture Collection Ureaplasma strains and to reveal the potential molecular mechanisms of multiple banded antigen (MBA) variation. Materials & methods: Two strains of Ureaplasma urealyticum 132 and 315 and one strain of Ureaplasma parvum 106 isolated from infertile males were sequenced using Illumina and Nanopore technologies. Comparative genomic analysis was performed of the three strains and two American-Type Culture Collection strains. Results & conclusion: The Ureaplasma species shared a core genome. Strains 132 and 315 shared a distant relationship with previously sequenced Ureaplasma spp. The MBA locus is more informative for studying MBA mutations than is the mba gene alone. The mechanisms of MBA variation are more flexible and complex than previously reported. The variation in MBA is not limited to the mba gene but occurs in other genes within the MBA locus.

Effect on perinatal outcome of prophylactic antibiotics in preterm prelabor rupture of membranes: network meta-analysis of randomized controlled trials

OBJECTIVES

Prophylactic antibiotics are recommended routinely for preterm prelabor rupture of membranes (PPROM), but there is an abundance of potential treatments and a paucity of comparative information. The aims of this network meta-analysis were to compare the efficiency of different antibiotic regimens on perinatal outcomes and to assess the quality of the current evidence.

METHODS

This was a network meta-analysis of randomized controlled trials comparing prophylactic antibiotics, or regimens of antibiotics, with each other or with placebo/no treatment, in women with PPROM. MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, US Registry of Clinical Trials ( www.ClinicalTrials.gov) and gray literature sources were searched. The primary outcomes were neonatal mortality and chorioamnionitis; secondary outcomes included other measures of perinatal morbidity. Relative effect sizes were estimated using risk ratios (RR) and the relative ranking of the interventions was obtained using cumulative ranking curves. The quality of evidence for the primary outcomes was assessed according to GRADE guidelines, adapted for network meta-analysis.

RESULTS

The analysis included 20 studies (7169 participants randomized to 15 therapeutic regimens). For the outcome of chorioamnionitis, clindamycin + gentamycin (network RR, 0.19 (95% CI, 0.05-0.83)), penicillin (RR, 0.31 (95% CI, 0.16-0.6)), ampicillin/sulbactam + amoxicillin/clavulanic acid (RR, 0.32 (95% CI, 0.12-0.92)), ampicillin (RR, 0.52 (95% CI, 0.34-0.81)) and erythromycin + ampicillin + amoxicillin (RR, 0.71 (95% CI, 0.55-0.92)) were superior to placebo/no treatment. Erythromycin was the only effective drug for neonatal sepsis (RR, 0.74 (95% CI, 0.56-0.97)). Clindamycin + gentamycin (RR, 0.32 (95% CI, 0.11-0.89)) and erythromycin + ampicillin + amoxicillin (RR, 0.83 (95% CI, 0.69-0.99)) were the only effective regimens for respiratory distress syndrome, whereas ampicillin (RR, 0.42 (95% CI, 0.20-0.92)) and penicillin (RR, 0.49 (95% CI, 0.25-0.96)) were effective in reducing the rates of Grade-3/4 intraventricular hemorrhage. None of the antibiotics appeared significantly more effective than placebo/no treatment in reducing the rates of neonatal death, perinatal death and necrotizing enterocolitis. No network RR could be estimated for neonatal intensive care unit admission. The overall quality of the evidence, according to GRADE guidelines, was moderate to very low, depending on the outcome and comparison.

CONCLUSIONS

Several antibiotics appear to be more effective than placebo/no treatment in reducing the rate of chorioamnionitis after PPROM. However, none of them is clearly and consistently superior compared to other antibiotics, and most are not superior to placebo/no treatment for other outcomes. The overall quality of the evidence is low and needs to be updated, as microbial resistance may have emerged for some antibiotics, while others are underrepresented in the existing evidence. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Prevalence of genital Mycoplasma and response to eradication treatment in patients undergoing assisted reproductive techniques

OBJECTIVE

Several studies have reported greater success of fertilisation by ART in couples who were not infected by Ureaplasma. Increased semen quality and better results have also been observed in couples who were treated with antibiotics to eradicate the infection. The aim of this study was to determine the prevalence of genital mycoplasmas in urine samples from male partners enrolled in the Assisted Reproduction Program (ARP) in our healthcare area so that, positive cases can be treated prior to the use of ART in order to increase the quality of semen, improve the embryo implantation rates and minimize the risk of adverse effects during pregnancy.

METHODS

This study included couples enrolled in the ARP during 2016. Mycoplasma detection was made using real-time PCR. In positive cases, both members of the couple were treated with antibiotics until eradication of the microorganism. The antibiotics used were: azithromycin, doxycycline, levofloxacin, moxifloxacin, and clindamycin.

RESULTS

Of the 205 men studied, 33 were positive: Ureaplasma urealyticum 15.1%, Mycoplasma hominis 3.9%. Eradication treatment with azithromycin failed in 50% compared to 10.2% for doxycycline. Of the 5 cases treated with levofloxacin, only 2 achieved elimination of U. urealyticum.

CONCLUSIONS

We consider that genital mycoplasma routine screening could be useful in order to increase the quality of semen which could simplify the in vitro fertilisation procedures and raise the success rate of embryo implantation and pregnancy, especially when fast, sensitive and specific technics as real time PCR are used.

Current understanding and treatment of intra-amniotic infection with Ureaplasma spp

Considerable evidence has shown that intra-amniotic infection with Ureaplasma spp. increases the risk of chorioamnionitis and preterm labor. Ureaplasma spp. are among the smallest organisms, and their isolation is uncommon in routine clinical practice because of their size and high auxotrophy. Although Ureaplasma spp. have been reported as causative agents of preterm birth, they also have a high incidence in vaginal swabs collected from healthy reproductive-age women; this has led to questions on the virulence of Ureaplasma spp. and to them being considered as harmless commensal bacteria. Therefore, many efforts have been made to clarify the pathogenicity of Ureaplasma spp. at the molecular level. Ureaplasma spp. are surrounded by lipoproteins, including multiple-banded antigen. Both multiple-banded antigen and its derivative, that is, the synthetic lipopeptide, UPM-1, induce an inflammatory response in a preterm mice model, which was adequate to cause preterm birth or stillbirth. In this review, we present an overview of the virulence mechanisms of Ureaplasma spp. and treatment of ureaplasma infection during pregnancy to prevent possible serious sequelae in infants. In addition, relevant mechanisms underlying antibiotic resistance in Ureaplasma spp. are discussed. Ureaplasma spp. are naturally resistant against β-lactam antibiotics because of the lack of a cell wall. Azithromycin is one of the effective agents that can control intrauterine ureaplasma infection. In fact, macrolide- and fluoroquinolone-resistant isolates of Ureaplasma spp. have already been observed in perinatal practice in Japan.

Successful Whole Genome Sequencing-guided Treatment of Mycoplasma hominis Ventriculitis in a Preterm Infant

We report a case of Mycoplasma hominis ventriculitis in a preterm neonate that was successfully identified with 16S ribosomal RNA sequencing and whole genome sequencing after failure to detect the pathogen with conventional diagnostic methods. The infant required doxycycline with subsequent clearance of the infection and no evidence of drug toxicity.

Next-generation-sequencing technology used for the detection of Mycoplasma hominis in renal cyst fluid: a case report

Background:Mycoplasma is an opportunistic pathogen causing both urogenital and extragenital infections. The lack of cell wall renders Mycoplasma difficult to culture and identify with ordinary methods. Next-generation sequencing (NGS) is a new technology helping a lot in the diagnosis of infective diseases. In this case, NGS played a key role in the diagnosis of Mycoplasma infection.

Case presentation: A mid-aged man suffering from renal cyst underwent cyst incision followed by invasive treatments to eliminate hematoma caused by renal artery hemorrhage. After the cyst incision operation, the patient had a persistent high temperature. The persistent increase of blood neutrophile granulocyte count and C-reaction protein suggested an unresolved infection. The empirically chosen anti-infective agents were meropenem and linezolid since the ordinary bacterial cultures of surgical site drainage and blood yielded a negative result. At postoperation day (POD) 17, NGS result of his drainage clearly indicated the pathogen was Mycoplasma hominis. At POD 24, the drug sensitivity test showed resistance to quinolones, clarithromycin and erythromycin, but intermediate to azithromycin. Since then, the antimicrobial agents were changed into azithromycin and kept unchanged until the patient was fully recovered and discharged at POD 39.

Conclusion: When the ordinary laboratory diagnostic methods failed, NGS diagnosis could reduce the hospitalization expenses and shorten the lengths of hospital stay.

The Concept of an Ideal Antibiotic: Implications for Drug Design

The emergence and spread of antibiotic-resistant pathogens is a major public health issue, which requires global action of an intersectoral nature. Multidrug-resistant (MDR) pathogens-especially "ESKAPE" bacteria-can withstand lethal doses of antibiotics with various chemical structures and mechanisms of action. Pharmaceutical companies are increasingly turning away from participating in the development of new antibiotics, due to the regulatory environment and the financial risks. There is an urgent need for innovation in antibiotic research, as classical discovery platforms (e.g., mining soil Streptomycetes) are no longer viable options. In addition to discovery platforms, a concept of an ideal antibiotic should be postulated, to act as a blueprint for future drugs, and to aid researchers, pharmaceutical companies, and relevant stakeholders in selecting lead compounds. Based on 150 references, the aim of this review is to summarize current advances regarding the challenges of antibiotic drug discovery and the specific attributes of an ideal antibacterial drug (a prodrug or generally reactive compound with no specific target, broad-spectrum antibacterial activity, adequate penetration through the Gram-negative cell wall, activity in biofilms and in hard-to-treat infections, accumulation in macrophages, availability for oral administration, and for use in sensitive patient groups).

Roles of Ureaplasma Species in Idiopathic Chronic Prostatitis: A Case-Control Study

Purpose

Because of the inconsistent symptoms associated with Ureaplasma infections, their clinical significances in genitourinary tracts are under debate. Therefore, we evaluated the presence of Ureaplasma urealyticum (UU) and Ureaplasma parvum (UP) in urine samples and examined their associations with chronic prostatitis (CP) through a case and control study.

Materials and Methods

We included 696 nonchlamydial nongonococcal (NCNG) urine samples from men; 350 were categorized into non-inflammatory CP, 88 in inflammatory CP, and 258 in non-CP group. We amplified a region in the Ureaplasma urease areas from these samples and determined their biovars using the Sanger method.

Results

Among the NCNG population, the rates of UU, UP, and non-UU/UP were 3.88%, 6.46%, and 89.66%, respectively. The overall infection rates of non-CP, inflammatory CP, and non-inflammatory CP groups were 4.15%, 6.10%, and 3.65% in UU (p=0.612) and 6.85%, 7.22%, and 6.50% in UP (p=0.968), respectively. UU infection increased the risk of white blood cell (WBC) counts (≥5) in urine (p=0.005). In contrast, UP infections did not increase the risks of urethritis. Re-analysis from the 633 men who were excluded from urethritis effects did not reveal the associations between UU infection and the clinical characteristics of CP. Furthermore, the profiles from the National Institutes of Health-Chronic Prostatitis Symptom Index questionnaire and WBC counts in expressed prostatic secretion were similar among the non-CP and the two CP groups in each Ureaplasma infection.

Conclusions

We found that UU may induce male urethritis. However, Ureapalsma species in urine were not definitively associated with the occurrence of CP.

Comparison of two identification and susceptibility test kits for Ureaplasma spp and Mycoplasma hominis in amniotic fluid of patients at high risk for intra-amniotic infection

Objective: Ureaplasma urealyticum and Mycoplasma hominis are the most common microorganisms found in the amniotic fluid of patients at risk for preterm delivery. However, culture techniques for genital mycoplasms require special conditions, are barely considered as part of the evaluation of suspected intra-amniotic infection (IAI) and the results are available within 2 and 7 days. The objectives of this study are to validate the use of two commercially available kits (Mycoplasma IES y MYCOFAST^® RevolutioN) for the identification of Ureaplasma spp. and Mycoplasma hominis in amniotic fluid, to compare the results of these kits with those obtained by culture and real-time polymerase chain reaction (qPCR) and to report the antibiotic sensitivity profile of the genital mycoplasms identified.Methods: This is a prospective cohort study including women with singleton and twin gestations between 16 and 36 weeks. Patients were admitted to perform an amniocentesis due to pregnancy complications considered at high risk for IAI (e.g. preterm labor with intact membranes, preterm prelabour rupture of membranes, short cervix, etc.), treatment of polyhydramnios, and for the assessment of fetal death and fever without a focus.Results: Overall, 93 patients underwent amniocentesis and 63 had results available for all tests. The prevalence of a positive culture was 6% (4/63). There were four cases of Ureaplasma spp. and none of Mycoplasma hominis. The qPCR identified one case as Ureaplasma spp., one case as Ureaplasma parvum and two cases as Ureaplasma urealyticum. For all tests, the diagnostic performance was as follows: sensitivity 100% [95% CI (39.8-100%)], specificity 100% [95% CI (93.9-100%)], positive predictive value 100% [95% CI (39.8-100%)] and negative predictive value 100% [95% CI (93.9-100%)]. In this cohort, Ureaplasma spp. showed low resistance to erythromycin, but a high resistance to clindamycin and clarithromycin that may change according to the antibiotic concentration.Conclusions: To our knowledge, this is the first study that validates the use of the Mycoplasma IES and MYCOFAST^® RevolutioN kits for the identification of genital mycoplasmas in amniotic fluid. The results of these kits are mostly available within 24 hours, have an excellent correlation with those from broth cultures and qPCR and characterize the antibiotic sensitivity profile of the genital mycoplasms identified, providing an opportunity for specific treatment in cases of IAI. Further validation studies in other populations are needed.

The frequency and clinical significance of intra-amniotic inflammation in twin pregnancies with preterm labor and intact membranes

OBJECTIVE

The objective of this study is to evaluate the frequency and clinical significance of intra-amniotic inflammation in twin pregnancies with preterm labor and intact membranes.

STUDY DESIGN

Amniotic fluid (AF) was retrieved from both sacs in 90 twin gestations with preterm labor and intact membranes (gestational age between 20 and 34 6/7 weeks). Preterm labor was defined as the presence of painful regular uterine contractions, with a frequency of at least 2 every 10 min, requiring hospitalization. Fluid was cultured and assayed for matrix metalloproteinase-8. Intra-amniotic inflammation was defined as an AF matrix metalloproteinase-8 concentration >23 ng/mL.

RESULTS

The prevalence of intra-amniotic inflammation for at least 1 amniotic sac was 39% (35/90), while that of proven intra-amniotic infection for at least one amniotic sac was 10% (9/90). Intra-amniotic inflammation without proven microbial invasion of the amniotic cavity was found in 29% (26/90) of the cases. Intra-amniotic inflammation was present in both amniotic sacs for 22 cases, in the presenting amniotic sac for 12 cases, and in the non-presenting amniotic sac for one case. Women with intra-amniotic inflammation observed in at least one amniotic sac and a negative AF culture for microorganisms had a significantly higher rate of adverse pregnancy outcome than those with a negative AF culture and without intra-amniotic inflammation (lower gestational age at birth, shorter amniocentesis-to-delivery interval, and significant neonatal morbidity). Importantly, there was no significant difference in pregnancy outcome between women with intra-amniotic inflammation and a negative AF culture and those with a positive AF culture.

CONCLUSION

Intra-amniotic inflammation is present in 39% of twin pregnancies with preterm labor and intact membranes and is a risk factor for impending preterm delivery and adverse outcome, regardless of the presence or absence of bacteria detected using cultivation techniques.

Mycoplasma hominis shows strain-dependent increase in resistance to selected antibiotics after symbiosis with Trichomonas vaginalis

OBJECTIVES

Mycoplasma hominis, a genetically heterogeneous, cell-wall-less bacterium, is able to live in symbiosis with the protozoan parasite Trichomonas vaginalis. Whilst the impact of this symbiosis on T. vaginalis has been investigated to a certain extent, less light has been shed on the influence on M. hominis.

METHODS

An in vitro minimum inhibitory concentration (MIC) study of the antimicrobial susceptibility of three clinical M. hominis isolates (V475, AKH136 and MhSS10) to clindamycin, moxifloxacin, ciprofloxacin and gentamicin was performed in dependence on symbiosis with T. vaginalis strain IR78.

RESULTS

Passaging of M. hominis through T. vaginalis led to an increase in MICs to all drugs investigated in M. hominis V475 and M. hominis MhSS10 (apart from gentamicin). Shifts from intermediate to resistant (MhSS10 for ciprofloxacin) and from susceptible to intermediate-resistant (V475 for gentamicin; P=0.015) were observed. Moreover, initial susceptibility of V475 to moxifloxacin (MIC=1.35μg/mL) was statistically significantly reduced (MIC=2.5μg/mL) following T. vaginalis passage concomitantly with mutations in the quinolone resistance-determining regions (QRDRs) of gyrA (S153L) and parC (E195G and K144R). In contrast, the susceptibility of M. hominis isolate AKH136 to all drugs investigated increased after passaging.

CONCLUSIONS

These findings suggest that symbiosis with T. vaginalis has an enhancing effect on selected antimicrobial resistances of distinct M. hominis isolates.

Ureaplasma urealyticum necrotizing soft tissue infection

Ureaplasma urealyticum is a urogenital commensal and often associated with localised infection. With the advent of monoclonal immunosuppressive therapy and improved diagnostic methods, reports of non-urogenital infections are accumulating. We report a rare case of U. urealyticum necrotizing soft tissue infection and left hip septic arthritis in a hypogammaglobulinaemic patient. Consideration of this organism as an etiological agent, and potential early use of nucleic-acid diagnostic investigation with empiric therapy including activity against Ureaplasma in this patient population may be warranted.

Recent advances in the prevention of preterm birth

Preterm birth (PTB) remains a major obstetric healthcare problem and a significant contributor to perinatal morbidity, mortality, and long-term disability. Over the past few decades, the perinatal outcomes of preterm neonates have improved markedly through research and advances in neonatal care, whereas rates of spontaneous PTB have essentially remained static. However, research into causal pathways and new diagnostic and treatment modalities is now bearing fruit and translational initiatives are beginning to impact upon PTB rates. Successful PTB prevention requires a multifaceted approach, combining public health and educational programs, lifestyle modification, access to/optimisation of obstetric healthcare, effective prediction and diagnostic modalities, and the application of effective, targeted interventions. Progress has been made in some of these areas, although there remain areas of controversy and uncertainty. Attention is now being directed to areas where greater gains can be achieved. In this mini-review, we will briefly and selectively review a range of PTB prevention strategies and initiatives where progress has been made and where exciting opportunities await exploitation, evaluation, and implementation.

Vaginal self-sampling as a diagnosis tool in low-income countries and potential applications for exploring the infectious causes of miscarriage

Gynecological health is a challenge in low-income countries. Personal opposition to perineal examination has been overcome by the use of vaginal self-sampling. Here, we review the use of this procedure notably in low-income countries and the main infectious causes of miscarriage. Vaginal self-sampling was mainly used for human papillomavirus detection but also to detect microorganisms causing sexually transmitted infections or bacterial vaginosis. 58 studies have been performed in low-resource countries, mainly studies performed to detect human papillomavirus in urban and peri-urban areas and demonstrating excellent acceptability. Several infectious causes of miscarriage could be tested using self-vaginal samples. In the future, such strategies coupled with a rapid-identification point-of-care method could allow the development of screening and treatment programs in rural areas in low-resource countries.

The relationship between the biovars and the antimicrobial resistance of Ureaplasma urealyticum in female patients with urogenital infections

BACKGROUND

Ureaplasma urealyticum is considered as one of the main pathogens found in women with urogenital infection. This study aimed to investigate the relationship between the biovars, serovars, and their antimicrobial resistance against antibiotics in female patients with urogenital infection.

METHODS

Two hundred and forty-six cervical secretion samples (125 female outpatients as the patient group, 121 healthy female subjects as the control group) were first collected and analyzed for U. urealyticum using the Mycoplasma Identification and Antimicrobial Susceptibility Testing; then polymerase chain reaction (PCR) was carried out to identify the biovars and serovars of U. urealyticum-positive samples.

RESULTS

The prevalence of U. urealyticum in the patient group (57. 60%) was higher than that in the control group (24.79%, P<.01). The main biovar was biovar 1, and the main serovars were 1 (S1), 3 (S3), 6 (S6) in biovar 1. Mixed infection was observed in biovar 2. According to the results of Antimicrobial Susceptibility Testing in the patient group, biovar 1 shows more resistance to minocycline, doxycycline, and azithromycin than biovar 2 (P<.05). Serovars S1, S3 and S6 have the highest resistant rate to ofloxacin (84.38%), roxithromycin (84.62%), and azithromycin (90.90%), respectively.

CONCLUSIONS

A high prevalence of U. urealyticum was observed in female patients with urogenital infections. And the biovar 1 and the serovars 1, 3, 6 were the main types of pathogens.

Antibiotic resistance among Ureaplasma spp. isolates: cause for concern?

There is growing global concern regarding the rise of antibiotic-resistant organisms. Many of these reports have focused on various Gram-positive and Gram-negative pathogens, with little attention to the genus Ureaplasma. Ureaplasma spp. are associated with numerous infectious diseases affecting pregnant women, neonates and the immunocompromised. Treatment options are extremely limited due to high levels of intrinsic resistance resulting from the unique physiology of these organisms and further restricted in cases of the developing fetus or neonate, often limiting therapeutic options to predominantly macrolides or rarely fluoroquinolones. The increasing presence of macrolide- and fluoroquinolone-resistant strains among neonatal infections may result in pan-drug resistance and potentially untreatable conditions. Here, we review the requirements for accurate measurement of antimicrobial susceptibility, provide a comprehensive review of the antimicrobial resistance (AMR) for Ureaplasma species in the literature and contextualize these results relative to some investigators' reliance on commercial kits that are not CLSI compliant when determining AMR. The dramatic variation in the resistance patterns and impact of high levels of AMR amongst neonatal populations suggests the need for continued surveillance. Commercial kits represent an excellent tool for initial antibiotic susceptibility determination and screening. However, AMR reporting must utilize internationally standardized methods, as high-titre samples, or Mycoplasma hominis-contaminated samples routinely give false AMR results. Furthermore, there is a requirement for future reports to determine the underlying AMR mechanisms and determine whether expanding AMR is due to spontaneous mutation, transmission of resistance genes on mobile elements or selection and expansion of resistant clones.

Meningitis in a Chinese adult patient caused by Mycoplasma hominis: a rare infection and literature review

Background

Mycoplasma hominis, a well known cause of neonatal infection, has been reported as a pathogen in urogenital infections in adults; however, central nervous system (CNS) infections are rare. We report here the first case of M. hominis meningitis in China, post neurosurgical treatment for an intracerebral haemorrhage in a 71-year-old male.

Case presentation

We describe a 71-year-old man who developed M. hominis meningitis after neurosurgical treatment and was successfully treated with combined azithromycin and minocycline therapy of 2 weeks duration, despite delayed treatment because the Gram stain of cerebrospinal fluid (CSF) yielded no visible organisms. The diagnosis required 16S rDNA sequencing analysis of the cultured isolate from CSF. Literature review of M. hominis CNS infections yielded 19 cases (13 instances of brain abscess, 3 of meningitis, 1 spinal cord abscess and 1 subdural empyema each). Delay in diagnosis and initial treatment failure was evident in all cases. With appropriate microbiological testing, antibiotic therapy (ranging from 5 days to 12 weeks) and often, multiple surgical interventions, almost all the patients improved immediately.

Conclusions

Both our patient findings and the literature review, highlighted the pathogenic potential of M. hominis together with the challenges prompted by rare infectious diseases in particular for developing countries laboratories with limited diagnostic resources.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-016-1885-4) contains supplementary material, which is available to authorized users.

Neonate with Mycoplasma hominis meningoencephalitis given moxifloxacin

Mycoplasma hominis is a commensal organism in the genitourinary tract that can cause life-threatening CNS infections in neonates after intrauterine infection or through vertical transmission during birth. We present a case of an 11-day-old neonate presenting with fever and supporting laboratory evidence of a CNS infection. No systemic maternal infection or maternal genitourinary tract infection occurred at the time of delivery. Empirical treatment was initiated, consisting of amoxicillin, cefotaxime, and aciclovir. After clinical deterioration, 16S ribosomal DNA PCR in cerebrospinal fluid detected M hominis, antibiotic treatment was switched to moxifloxacin, and pharmacokinetic data were obtained. This Grand Round illustrates the challenges that exist in the diagnosis and treatment of M hominis meningoencephalitis: bacterial cultures are often negative and recommended empirical antimicrobials do not provide adequate antimicrobial coverage. Optimal antimicrobial treatment regimens for M hominis meningoencephalitis are unknown. Although we describe successful treatment of a neonate with a complicated M hominis meningoencephalitis with moxifloxacin, caution with fluoroquinolone monotherapy (including moxifloxacin) has to be taken into account because resistance to fluoroquinolones has previously been described.

Prevalence and Antibiotic Susceptibility of Mycoplasma hominis and Ureaplasma urealyticum in Pregnant Women

Mycoplasma hominis (M. hominis) and Ureaplasma urealyticum (U. urealyticum) are important opportunistic pathogens that cause urogenital infections and complicate pregnancy. The aim of this study was to investigate the prevalence, effects on pregnancy outcomes, and antimicrobial susceptibilities of M. hominis and U. urealyticum. We tested vaginal swabs obtained from 1035 pregnant women for the presence of genital mycoplasmas between June 2009 and May 2014. The laboratory and clinical aspects of genital mycoplasmas infection were reviewed retrospectively, and the identification and antimicrobial susceptibility of genital mycoplasmas were determined using the Mycoplasma IST-2 kit. A total of 571 instances of M. hominis and/or U. urealyticum were detected. Of them, M. hominis was detected in two specimens, whereas U. urealyticum was detected in 472 specimens. The remaining 97 specimens were positive for both M. hominis and U. urealyticum. Preterm deliveries were frequently observed in cases of mixed infection of M. hominis and U. urealyticum, and instances of preterm premature rupture of membrane were often found in cases of U. urealyticum. The rates of non-susceptible isolates to erythromycin, empirical agents for pregnant women, showed increasing trends. In conclusion, the prevalence of M. hominis and/or U. urealyticum infections in pregnant women is high, and the resistance rate of antimicrobial agents tends to increase. Therefore, to maintain a safe pregnancy, it is important to identify the isolates and use appropriate empirical antibiotics immediately.

Drug Resistance Mechanisms in Bacteria Causing Sexually Transmitted Diseases and Associated with Vaginosis

Here, we review sexually transmitted diseases (STDs) caused by pathogenic bacteria and vaginal infections which result from an overgrowth of opportunistic bacterial microflora. First, we describe the STDs, the corresponding pathogens and the antimicrobials used for their treatment. In addition to the well-known diseases caused by single pathogens (i.e., syphilis, gonococcal infections, and chlamydiosis), we consider polymicrobial reproductive tract infections (especially those that are difficult to effectively clinically manage). Then, we summarize the biochemical mechanisms that lead to antimicrobial resistance and the most recent data on the emergence of drug resistance in STD pathogens and bacteria associated with vaginosis. A large amount of research performed in the last 10-15 years has shed light on the enormous diversity of mechanisms of resistance developed by bacteria. A detailed understanding of the mechanisms of antimicrobials action and the emergence of resistance is necessary to modify existing drugs and to develop new ones directed against new targets.

Survey on association between Mycoplasma hominis endocervical infection and spontaneous abortion using Polymerase Chain Reaction

BACKGROUND

Mycoplasma infections are suggested as etiology of adverse pregnancy outcomes.

OBJECTIVE

The aim of this study was to evaluate the association of Mycoplasma hominis (M. hominis) infection and spontaneous abortion among pregnant women.

MATERIALS AND METHODS

In this case-control study that was conducted from August 2012 to January 2013, totally, 109 women were included with spontaneous abortion with gestational ages of 10-20 weeks (Cases), and 109 women with normal pregnancy with gestational ages between 20-37 weeks (Controls) in Sanandaj, Iran. Using specific primers and extracted DNA from endocervical swabs, a PCR test was conducted for detection of M. hominis infection in women. For comparison of qualitative and quantitative variables, independent Fisher tests were used and p<0.05 was considered significant.

RESULTS

The total frequency of M. hominis infection was 6 (2.75%) in women. The frequency of M. hominis infection was 2 (1.83%) in the case group (spontaneous abortion) and 4 (3.66%) in the control group, respectively. In both case and control groups, no association was seen between M.hominis infection and spontaneous abortion (OR=0. 49, CI 95%: 0.08-2.73, p=0. 683).

CONCLUSION

M. hominis was positive in the genital tract of some pregnant women, but it was not associated with spontaneous abortion. However, to prevent adverse pregnancy outcomes in women, foetus and neonate, routine screening and treatment for the genital Mycoplasma is recommended.

Potential Molecular Targets for Narrow-Spectrum Agents to Combat Mycoplasma pneumoniae Infection and Disease

As Mycoplasma pneumoniae macrolide resistance grows and spreads worldwide, it is becoming more important to develop new drugs to prevent infection or limit disease. Because other mycoplasma species have acquired resistance to other classes of antibiotics, it is reasonable to presume that M. pneumoniae can do the same, so switching to commonly used antibiotics like fluoroquinolones will not result in forms of therapy with long-term utility. Moreover, broad-spectrum antibiotics can have serious consequences for the patient, as these drugs may have severe impacts on the natural microbiota of the individual, compromising the health of the patient either short-term or long-term. Therefore, developing narrow-spectrum antibiotics that effectively target only M. pneumoniae and no more than a small portion of the microbiota is likely to yield impactful, positive results that can be used perhaps indefinitely to combat M. pneumoniae. Development of these agents requires a deep understanding of the basic biology of M. pneumoniae, in many areas deeper than what is currently known. In this review, we discuss potential targets for new, narrow-spectrum agents and both the positive and negative aspects of selecting these targets, which include toxic molecules, metabolic pathways, and attachment and motility. By gathering this information together, we anticipate that it will be easier for researchers to evaluate topics of priority for study of M. pneumoniae.

Antimicrobial Susceptibility Patterns of Ureaplasma urealyticum and Mycoplasma hominis Isolated From Pregnant Women

BACKGROUND

Mycoplasma hominis and Ureaplasma urealyticum bring with them an increased risk of pregnancy complications, such as premature membrane rupture, vaginitis and preterm birth.

OBJECTIVES

The present investigation was carried out to study the prevalence of M. hominis and U. urealyticum in pregnant women and to study their resistance against commonly used antibiotics.

MATERIALS AND METHODS

Three hundred and fifty high vaginal swabs were taken from pregnant women. Commercial Mycoplasma IST-2 kit was used for bacterial isolation. The results of the kits were confirmed using the PCR. The pattern of antibiotic resistance was determined using the disk diffusion method.

RESULTS

Of 350 samples collected, 32 samples (9.14%) were positive for U. urealyticum and 10 samples (2.85%) were positive for M. hominis (P = 0.025). Both U. urealyticum and M. hominis were simultaneously detected in 1.14% of samples. In addition, 40 - 45-year-old pregnant women had the highest levels of U. urealyticum (27.5%), M. hominis (12.5%), and both bacteria (7.5%). U. urealyticum and M. hominis isolates harbored the highest levels of resistance against ciprofloxacin, ofloxacin, erythromycin, and tetracycline. Both isolates were susceptible to pefloxacin, clarithromycin, josamycin, and pristinamycin.

CONCLUSIONS

According to the direct correlation between the increase in the prevalence rate of genital mycoplasmas and increased age of pregnancy, initially, it is better to prevent pregnancy at older ages, and then, should a pregnancy occur, the highest levels of health cares should be provided to older pregnant women.

Ureaplasma: current perspectives

Ureaplasma species are the most prevalent genital Mycoplasma isolated from the urogenital tract of both men and women. Ureaplasma has 14 known serotypes and is divided into two biovars- Ureaplasma parvum and Ureaplasma urealyticum. The organism has several genes coding for surface proteins, the most important being the gene encoding the Multiple Banded Antigen (MBA). The C-terminal domain of MBA is antigenic and elicits a host antibody response. Other virulence factors include phospholipases A and C, IgA protease and urease. Besides genital tract infections and infertility, Ureaplasma is also associated with adverse pregnancy outcomes and diseases in the newborn (chronic lung disease and retinopathy of prematurity). Infection produces cytokines in the amniotic fluid which initiates preterm labour. They have also been reported from renal stone and suppurative arthritis. Genital infections have also been reported with an increasing frequency in HIV-infected patients. Ureaplasma may be a candidate 'co factor' in the pathogenesis of AIDS. Culture and polymerase chain reaction (PCR) are the mainstay of diagnosis. Commercial assays are available with improved turnaround time. Micro broth dilution is routinely used to test antimicrobial susceptibility of isolates. The organisms are tested against azithromycin, josamycin, ofloxacin and doxycycline. Resistance to macrolides, tetracyclines and fluoroquinolones have been reported. The susceptibility pattern also varies among the biovars with biovar 2 maintaining higher sensitivity rates. Prompt diagnosis and initiation of appropriate antibiotic therapy is essential to prevent long term complications of Ureaplasma infections. After surveying PubMed literature using the terms 'Ureaplasma', 'Ureaplasma urealyticum' and 'Ureaplasma parvum', relevant literature were selected to provide a concise review on the recent developments.

A new antibiotic regimen treats and prevents intra-amniotic inflammation/infection in patients with preterm PROM

OBJECTIVES

To determine whether a new antibiotic regimen could reduce the frequency of intra-amniotic inflammation/infection in patients with preterm PROM.

STUDY DESIGN

This retrospective cohort study was conducted to evaluate the effect of antibiotics on the frequency of intra-amniotic inflammation/infection based on the results of follow-up transabdominal amniocenteses from 89 patients diagnosed with preterm PROM who underwent serial amniocenteses. From 1993-2003, ampicillin and/or cephalosporins or a combination was used ("regimen 1"). A new regimen (ceftriaxone, clarithromycin and metronidazole) was used from 2003-2012 ("regimen 2"). Amniotic fluid was cultured and matrix metalloproteinase-8 (MMP-8) concentrations were measured.

RESULTS

(1) The rates of intra-amniotic inflammation and intra-amniotic inflammation/infection in patients who received regimen 2 decreased during treatment from 68.8% to 52.1% and from 75% to 54.2%, respectively. In contrast, in patients who received regimen 1, the frequency of intra-amniotic inflammation and infection/inflammation increased during treatment (31.7% to 55% and 34.1% to 58.5%, respectively); and (2) intra-amniotic inflammation/infection was eradicated in 33.3% of patients who received regimen 2, but in none who received regimen 1.

CONCLUSION

The administration of ceftriaxone, clarithromycin and metronidazole was associated with a more successful eradication of intra-amniotic inflammation/infection and prevented secondary intra-amniotic inflammation/infection more frequently than an antibiotic regimen which included ampicillin and/or cephalosporins in patients with preterm PROM.

Antibiotic Resistance among Clinical Ureaplasma Isolates Recovered from Neonates in England and Wales between 2007 and 2013

Ureaplasma spp. are associated with numerous clinical sequelae with treatment options being limited due to patient and pathogen factors. This report examines the prevalence and mechanisms of antibiotic resistance among clinical strains isolated from 95 neonates, 32 women attending a sexual health clinic, and 3 patients under investigation for immunological disorders, between 2007 and 2013 in England and Wales. MICs were determined by using broth microdilution assays, and a subset of isolates were compared using the broth microdilution method and the Mycoplasma IST2 assay. The underlying molecular mechanisms for resistance were determined for all resistant isolates. Three isolates carried the tet(M) tetracycline resistance gene (2.3%; confidence interval [CI], 0.49 to 6.86%); two isolates were ciprofloxacin resistant (1.5%; CI, 0.07 to 5.79%) but sensitive to levofloxacin and moxifloxacin, while no resistance was seen to any macrolides tested. The MIC values for chloramphenicol were universally low (2 μg/ml), while inherently high-level MIC values for gentamicin were seen (44 to 66 μg/ml). The Mycoplasma IST2 assay identified a number of false positives for ciprofloxacin resistance, as the method does not conform to international testing guidelines. While antibiotic resistance among Ureaplasma isolates remains low, continued surveillance is essential to monitor trends and threats from importation of resistant clones.

A new anti-microbial combination prolongs the latency period, reduces acute histologic chorioamnionitis as well as funisitis, and improves neonatal outcomes in preterm PROM

OBJECTIVE

Antibiotic administration is a standard practice in preterm premature rupture of membranes (PROM). Specific anti-microbial agents often include ampicillin and/or erythromycin. Anaerobes and genital mycoplasmas are frequently involved in preterm PROM, but are not adequately covered by antibiotics routinely used in clinical practice. Our objective was to compare outcomes of PROM treated with standard antibiotic administration versus a new combination more effective against these bacteria.

STUDY DESIGN

A retrospective study compared perinatal outcomes in 314 patients with PROM <34 weeks receiving anti-microbial regimen 1 (ampicillin and/or cephalosporins; n = 195, 1993-2003) versus regimen 2 (ceftriaxone, clarithromycin and metronidazole; n = 119, 2003-2012). Intra-amniotic infection/inflammation was assessed by positive amniotic fluid culture and/or an elevated amniotic fluid MMP-8 concentration (>23 ng/mL).

RESULTS

(1) Patients treated with regimen 2 had a longer median antibiotic-to-delivery interval than those with regimen 1 [median (interquartile range) 23 d (10-51 d) versus 12 d (5-52 d), p < 0.01]; (2) patients who received regimen 2 had lower rates of acute histologic chorioamnionitis (50.5% versus 66.7%, p < 0.05) and funisitis (13.9% versus 42.9%, p < 0.001) than those who had received regimen 1; (3) the rates of intra-ventricular hemorrhage (IVH) and cerebral palsy (CP) were significantly lower in patients allocated to regimen 2 than regimen 1 (IVH: 2.1% versus 19.0%, p < 0.001 and CP: 0% versus 5.7%, p < 0.05); and (4) subgroup analysis showed that regimen 2 improved perinatal outcomes in pregnancies with intra-amniotic infection/inflammation, but not in those without intra-amniotic infection/inflammation (after adjusting for gestational age and antenatal corticosteroid administration).

CONCLUSION

A new antibiotic combination consisting of ceftriaxone, clarithromycin, and metronidazole prolonged the latency period, reduced acute histologic chorioamnionitis/funisitis, and improved neonatal outcomes in patients with preterm PROM. These findings suggest that the combination of anti-microbial agents (ceftriaxone, clarithromycin, and metronidazole) may improve perinatal outcome in preterm PROM.