Clinical and Morphological Diagnosis and Treatment of Sexually Transmitted Diseases - Yakimova T. P. 2007

Mycoplasma infection: features of morphological diagnosis and clinical course. Treatment of mycoplasma infection

Mycoplasmosis is an acute infectious disease caused by Mycoplasmas. Mycoplasmoses are widespread among the population.

Data on the prevalence of mycoplasma infection among the population vary significantly, ranging from 10 to 50%. Mycoplasmas are most frequently detected in individuals aged 30–40 years. According to many authors, they are transmitted primarily through sexual contact.

The clinical picture manifests depending on the infection of specific Organs. The entry portals are the mucous membranes of the respiratory or urogenital tract, which is determined by the species of mycoplasmas. The pathogen is transmitted via airborne droplets and sexual contact. In infected pregnant women, intrauterine infection of the fetus may occur.

Mycoplasmas are widespread in nature. They have been found in mammals, birds, fish, Mollusks, insects, and plants. It has been established that humans are the natural hosts for at least 14 species of mycoplasmas. Mycoplasma hominis (M. h.), Mycoplasma genitalium (M. g.), and Ureaplasma urealyticum are considered pathogens of urogenital tract infections. Mycoplasmas frequently colonize the urogenital tract of adults, children, and newborns. Children born via Cesarean Section are sometimes infected with this pathogen.

Data on infection rates are highly variable. Mycoplasma hominis can be detected in 50–60% of healthy women and 60–75% of patients. These microorganisms are frequently isolated from female patients with bacterial vaginosis and cervicitis. In the latter case, associations of M. hominis and Gardnerella vaginalis are observed; that is, the persistence of mycoplasmas in the Vagina of women with bacterial vaginosis and cervicitis is associated with the presence of other microflora typical of this syndrome. Furthermore, in some cases, the combination of bacterial vaginosis and mycoplasma infection is accompanied by a significant increase in serum IgG Antibodies to Mycoplasma hominis (28.7 ± 0.25 EIU) compared to the level of antimycoplasma antibodies in women without bacterial vaginosis (16.7 ± 0.18 EIU, p < 0.01). The presence of mycoplasmas significantly reduces the efficacy of antimicrobial therapy due to their high resistance to many Antibiotics. The complexity of the vaginal microflora profile in the presence of Mycoplasma hominis lies in the fact that this pathogen largely depends on the vital activity of accompanying microorganisms. In other words, symbiotic and syntrophic relationships exist between Mycoplasma hominis and other Bacteria. Until the factors influencing Changes in the vaginal flora are clarified, the causes of bacterial vaginosis cannot be determined, and a Prevention plan cannot be developed. Women frequently serve as asymptomatic carriers of ureaplasmas, as not all develop vaginitis, cystitis, and salpingitis. These women can act as a reservoir and source of ureaplasma infection.

Latent ureaplasma infection can transition into a chronic recurrent form under METABOLISM/18.html">The Influence of concomitant bacterial, viral, chlamydial, fungal, or other infections.

Mycoplasmas are a group of highly diverse and morphologically distinct microorganisms (150–200 nm) capable of Replication on Cell-free media. They lack a rigid Cell wall and are covered by a trilaminar cytoplasmic membrane. On nutrient media during bacteriological studies, mycoplasmas grow as characteristic colonies with a dense center growing into the medium and delicate, lacy edges. After 3–5 days of incubation, they may reach a size of 1.5–2 mm, but most often they are so small that they are difficult to see with the naked eye. Different species of mycoplasmas are similar in appearance and colony Structure. Mycoplasmas are Gram-positive, exhibit extremely low sensitivity to most stains, and stain better with prolonged staining.

Numerous studies on the Morphology of mycoplasmas indicate their extreme polymorphism: spherical, annular, coccobacillary forms, as well as filamentous, branching, bizarre forms, and small elementary bodies ranging in size from 125 to 250 nm. In size, elementary bodies approach large Viruses, Herpes simplex virus, chlamydia, and vaccinia virus. Electron microscopic studies of mycoplasmas isolated from humans have revealed the presence of coccoid and discoid forms. The maximum size of individual structures reached 200 nm, and dividing and budding Cells were observed. Elementary bodies stain with Romanowsky-Giemsa and do not stain with other Dyes, including Gram stain.

Various hypotheses exist regarding The Development of mycoplasma microstructures, specifically as a sequential transition of 5 different phases or as having a biphasic cycle. In terms of colony shape and structure, microscopic element morphology, and reproduction characteristics, mycoplasmas are very similar to bacterial L-forms, differing only in a more granular surface, somewhat smaller dimensions, and pronounced polymorphism. Mycoplasmas lack a rigid cell wall, often lose diaminopimelic acid and the mucopeptide complex, and possess plasticity. Mycoplasmas are covered by a trilaminar cytoplasmic membrane and consist of bodies varying in shape, size, and optical density.

The generally accepted method of laboratory Diagnosis is direct Microscopy of smears stained with Romanowsky-Giemsa, which reveals the morphological structures of mycoplasmas, as well as the number of epithelial cells, leukocytes, and lactobacilli. However, light microscopy may not always detect mycoplasmas due to their small size. To isolate mycoplasmas, inoculations onto special nutrient media (Solid and liquid) should be used. The identification of isolated mycoplasmas is based on the detection of characteristic microcolonies resembling a "fried egg".

Laboratory Diagnosis of urogenital mycoplasmoses requires a sequence of Laboratory tests. The analyzed material is inoculated onto solid and liquid media and incubated at 37°C. Ureaplasmas usually grow within 1–3 days, and Mycoplasma hominis within 3–5 days. Cultures on solid media are examined under low Microscope magnification on days 3–5 of incubation and later. Mycoplasmas form larger colonies than ureaplasmas.

Screening for ureaplasmosis should be performed in all men, women, and children who consult a doctor regarding Inflammatory Diseases of the urogenital organs, as well as in all sexual partners or suspected sources of ureaplasmosis transmission and individuals with clinical or epidemiological suspicions of the disease.

In Urogenital Mycoplasmosis, urine, urethral and cervical scrapings, vaginal smears, Amniotic Fluid, and fetal organs from spontaneous abortions or stillbirths are used for examination.

Unlike viruses and chlamydia, mycoplasmas are capable of multiplying on cell-free nutrient media. To detect even the "large" colonies formed on solid nutrient media, it is necessary to examine them under a microscope at 60–100x magnification, while an even higher magnification is used for T-mycoplasmas. The name "ureaplasmas" comes from the ability of this species of mycoplasmas to produce the enzyme urease, which breaks down urea with The formation of carbon dioxide and ammonia.

Proper preparation of the patient for laboratory testing is of paramount importance in Laboratory Diagnostics. In men, it is necessary to examine discharges or scrapings from the Urethra and paraurethral ducts if inflamed. When examining women, vaginal, urethral, cervical, and greater vestibular gland discharges must be collected. Pregnant women are examined at any stage of Pregnancy from all potential sites of inflammation. In the second half of pregnancy, the mucopurulent discharge flowing from the cervical canal is carefully collected. Serological reactions—such as the Complement fixation test (CFT) and the indirect hemagglutination (IHA) test—are used for the laboratory confirmation of mycoplasmosis. The diagnosis is confirmed by a 4-fold or greater increase in antibody titer.

In girls, the discharge from the mucous membrane of the urethra and vagina is examined. In doing so, without using specula, an ear curette or probe is carefully inserted into the hymenal opening.

The practical Implementation of advanced Laboratory Diagnostic Methods will undoubtedly contribute to the further Study of the pathogenicity of urogenital mycoplasmosis—including ureaplasmosis, a pathogen of uncontrolled sexually transmitted disease causing various ascending ureaplasmal infections—and to understanding its etiological role in inflammatory processes of the human Urogenital System.

In non-gonococcal urethritis (NGU) caused by ureaplasmal infection (UPI), after an incubation period of up to 1 month, mild burning and itching appear in the urogenital area. Urethral discharge is usually scant. Patients often note gluing of the external urethral meatus. The first portion of urine may contain purulent threads and be slightly turbid. The disease is characterized by a protracted course. In some patients, the process spreads to other sections (prostatitis, vesiculitis, epididymitis).

Clinical manifestations of the ureaplasmal inflammatory process lack characteristic features and differ little from inflammatory Diseases of the urogenital organs of other etiologies. The disease usually proceeds with lesser acuity, a higher frequency of complications, and significant resistance to therapy. Ureaplasma infection can occur without symptoms or subjective sensations and therefore, as a rule, is detected too late, in a chronic form.

In girls, ureaplasmosis manifests more prominently than in adults, presenting as acute and subacute forms of vulvovaginitis; however, the cervix and urethra are also frequently involved in the inflammatory process.

Many authors have established the existence of asymptomatic mycoplasma carriage, as they are isolated from individuals who considered themselves healthy.

In mycoplasmal fetal involvement, aspiration syndrome, interstitial Pneumonia, funiculitis, cardiopathy, and other conditions are observed.

Newborns may exhibit meningitis, encephalitis, Brain abscess, Skin necrosis, Conjunctivitis, pneumonia, septicemia, and other disorders. This is most frequently observed in premature infants and may be caused not so much by the pathogenic properties of mycoplasmas as by a decrease or suppression of Immunity.

A complication of ureaplasma infection involving the endometrium in women is Infertility. It has also been shown that infected men exhibit a decreased ability of the sperm HEAD to move and a general reduction in sperm motility, which can lead to diminished sperm penetration capacity and consequent infertility. This causes failures in extracorporeal Fertilization followed by embryo transfer into the Uterus.

Regarding The problem of ureaplasmal pathology in the human urogenital tract, the Etiology has been established, and methods for laboratory diagnosis of the infection have been developed. However, many questions remain unstudied, and epidemiological issues require resolution—specifically, determining the true scale of population colonization by ureaplasmas and conducting large-scale randomized trials with controls that account for geographic, socio-economic factors, and obstetric-gynecological history.

Treatment

Although etiotropic therapy plays a crucial role, the treatment of patients with mycoplasmosis cannot be standardized. It must be comprehensive, incorporating etiotropic, pathogenetic, and symptomatic agents. Taking into account the clinical form and severity of the disease, as well as the presence of complications and comorbidities, the Selection of drugs and the duration of the treatment course should be tailored to each individual.

Numerous studies have demonstrated that tetracycline antibiotics, as well as erythromycin, oleandomycin, streptomycin, levomycetin, lincomycin, kanamycin, and gentamicin, can be used for patient treatment according to standard regimens.

Antibiotic susceptibility varies depending on the species of mycoplasmas. Of particular practical interest is the susceptibility of T-mycoplasmas, which are associated with a range of urogenital tract disorders.

Sometimes, despite high sensitivity to tetracycline, administering this antibiotic does not lead to a complete cure, and in some patients, mycoplasmas continue to be detected even after treatment. These individuals may occasionally experience a disease relapse. Despite this, many authors widely utilize tetracycline antibiotics and erythromycin, considering them to be highly effective.

When treating mycoplasma urethritis with tetracycline or oxytetracycline at a dose of 0.5 g every 6 hours for 10 days, a favorable therapeutic effect is observed. A 7-day course of tetracycline treatment is also recommended. Initially, a loading dose of 1.5 g is administered, followed by 0.5 g every 6 hours.

Erythromycin is prescribed according to a similar regimen. Both antibiotics exhibit comparable therapeutic efficacy, although in vitro their effects on mycoplasmas differ. It is recommended to wash down erythromycin with a weak solution of baking soda, as The activity of the antibiotic is significantly enhanced in an alkaline environment. Furthermore, erythromycin should be prescribed for retreatment in cases where tetracycline has proven ineffective.

For the therapy of non-gonococcal urethritis, streptomycin or oxytetracycline are used effectively, which serves as indirect confirmation of the etiological role of mycoplasmas in these conditions. Successful treatment with these antibiotics results in the eradication of T-mycoplasmas from the urogenital tract.

To prevent relapses or reinfection, it is necessary to administer these antibiotics simultaneously to sexual partners, even if one partner is symptomatic and the other is virtually healthy.

In cases of severe, complicated forms of ureaplasmal infection (UPI), The Use of sigmamycin is recommended at 1 capsule (0.25 g) 4 times a day for 5–6 days.

When treating patients suffering from genital mycoplasmal infections, regimens utilizing higher single and cumulative doses of antibiotics are employed. Patients receive oral tetracycline at 500 mg every 6 hours after meals for 2 weeks. Additionally, for patients with uncomplicated forms, oral doxycycline is recommended: 0.2 g every 12 hours on the first day, followed by 0.1 g every 12 hours for the subsequent 2 weeks. If patients poorly tolerate tetracycline, it is replaced with erythromycin at 0.5 g 4 times a day.

Furthermore, erythromycin is used in combination with rifampicin for complicated forms of urogenital mycoplasmal disease. In such cases, rifampicin is recommended According to the following schedule: 900 mg orally once on the 1st day, 150 mg 4 times a day on the 2nd and 3rd days, and 150 mg 3 times a day for the following 3 days. Alongside this, patients should take nystatin or levorin orally.

If patients exhibit pronounced immunological disorders, immunomodulators should be employed, such as tactivin (T-activin) at 100 mcg subcutaneously daily for 5–14 days. If necessary, treatment courses are repeated. A course of general strengthening therapy is also recommended.

Tetracycline is prescribed at 0.3 g 5 times a day for 10–12 days in combination with levorin and Vitamins. Tetracycline may be substituted with its derivatives, notably metacycline (rondomycin), prescribed at 600 mg on the 1st day, followed by 300 mg every 8 hours for 8 days (total course dose of 9 g), or 300 mg 4 times a day (total course dose of 12 g), or doxycycline (vibramycin) at 0.1 g twice a day (total course dose of 2–3 g). In a hospital Setting, gentamicin can be used at 40 mg intramuscularly 3 times a day for a total course of 840 mg; this drug may be combined with oral doxycycline at 0.1 g 3 times a day after meals, up to a total course dose of 2.5 g.

For sluggish (torpid) and chronic forms of ureaplasmosis, it is preferable to initiate treatment with comprehensive immunostimulation combined with local therapy. In this approach, methyluracil is administered orally after meals at 0.5 g 4 times a day for 12–14 days. Simultaneously, pyrorogenal is given, starting with 25–50 PID for women and 50–75 PID for men via intramuscular injections, which are repeated every 1–2 days while increasing the dose by 25–50–100 PID depending on the body's reaction. The treatment course consists of 10–15 injections. If pyrorogenal is unavailable, prodigiosan can be administered intramuscularly, starting at 15 mcg and increasing the dose by 10–15 mcg every 4–5 days, with a course of 4–5 injections.

For the treatment of ureaplasmosis, tarivid can be used, administered orally at 400 mg for the initial dose, followed by subsequent doses of 200 mg every 12 hours for 10 days, or ciprofloxacin at 500 mg for the initial dose and 250 mg every 12 hours thereafter for 10 days. Local Treatment of the inflammatory process in men involves the administration of tetracycline in a sterile isotonic sodium chloride solution into the urethra. For women, to achieve a local effect on the pathogen, the Introduction of vaginal suppositories or vaginal tampons with tetracycline ointment after vaginal douching is recommended. General strengthening therapy is administered according to indications using standard regimens with appropriate drugs.

Most mycoplasmas are susceptible to tetracycline antibiotics, many macrolides, Lincosamides (except Ureaplasma), and Streptogramins, and are less susceptible to chloramphenicol. They show high susceptibility to ciprofloxacin, defloxacin, and ofloxacin.

In the treatment of ureaplasmal infection, vibramycin, tobramycin, and minocycline have proven to be the most effective antibiotics, whereas streptomycin and kanamycin demonstrated low efficacy.

Neomycin acts actively against mycoplasmas, and spectinomycin acts against Ureaplasma. Both pathogens are susceptible to pristinamycin, maxaquin (lomefloxacin), and virginiamycin.

The antibiotic susceptibility of freshly isolated mycoplasma strains in vitro does not always correlate with their clinical therapeutic efficacy. In the treatment of urogenital mycoplasmoses, selected specific drugs should not produce adverse side effects, particularly when treating pregnant women. Tetracyclines can exert toxic effects on the fetus and newborns; therefore, erythromycin is preferred for the sanitation of pregnant women.

Treatment efficacy depends on accurate diagnosis and the timely application of rational therapy.

For the sanitation of pregnant women from 12 weeks of gestation onwards, it is recommended to prescribe oral erythromycin at 0.2 g 4 times a day for one week.

Erythromycin is also recommended for specific therapy in infants born with intrauterine ureaplasmal infection, at a dose of 20–40 mg per kg of body weight administered via drip infusion. Additionally, immunoglobulin is suggested as a form of non-specific therapy.

Each individual case requires a tailored approach to treatment. In A number of cases, a combination of tetracycline antibiotics with macrolides, or with gentamicin and kanamycin combined with local treatment, proves to be highly effective. Good treatment outcomes have been demonstrated not only by doxycycline, but also by macropen (at a cumulative course dose of 8.0 g) and sumamed (4.5 g).

For mixed chlamydial-bacterial infections in women, a comprehensive treatment method is recommended, which includes doxycycline in combination with human leukocyte interferon and local therapy.

Doxycycline is prescribed on the 1st day at a dose of 0.2 g, followed by 0.1 g every 12 hours for the next 10 days (total course dose - 2.0 g). Interferon is diluted in 2 ml of distilled Water and administered via vaginal tampons for 10 days. If trichomonads or gardnerellae are detected, trichopolum or tinidazole is recommended.

A follow-up Assessment of the microbiocenosis state should be performed 4 weeks after the completion of any treatment, as antibiotics significantly alter the natural vaginal microbiocenosis.

If abnormalities are detected, oral administration of lactobacterin, bifidumbacterin, bifiliz, and other similar agents is recommended.

The antibiotics used exhibit bacteriostatic rather than bactericidal activity, which makes the Immune Response a critical factor. Furthermore, the intensive clinical use of the aforementioned drugs for treating mycoplasmoses can lead to The Emergence of Antibiotic Resistance. Consequently, it is necessary either to increase the drug dosage or to modify the treatment strategy.

Macrolide antibiotics, such as rokitamycin and josamycin, are suggested for the treatment of genital mycoplasma infections. They effectively penetrate cells and accumulate within them at higher concentrations than Other Antibiotics of the same Class.

Oral treatment is administered daily, twice a day at 400-500 mg for 15-30 days, and is well tolerated by patients.

Prescribing prolonged or repeated courses of antibacterial drugs based solely on their detection in patients lacking clinical manifestations of an inflammatory process is an unjustified practice.

Thus, the following antibiotics are used as etiotropic therapy: doxycycline or monocycline, 0.1 g each twice daily for 7-10 days; erythromycin, 0.5 g 4 times daily for 10 days; pefloxacin or lomefloxacin, 0.6 g each once daily for a week; or azithromycin, 250 mg twice daily for 7-10 days.

Treatment for pregnant women after 12 weeks is carried out with erythromycin according to the standard regimen.

In cases of mixed gonococcal-ureaplasmal, chlamydial-ureaplasmal, trichomonal-ureaplasmal, ureaplasmal-Gardnerellosis infections, or combinations of three or more infections simultaneously, antigonococcal treatment is administered first, followed by the treatment of the remaining infections.

For chlamydial-ureaplasmal infection, tetracycline and sulfonamides are prescribed either individually or in combination, but in doses sufficient to cure both infections. Treatment for girls suffering from ureaplasmosis and mixed infections is carried out using the same drugs at age-appropriate doses.

In women, Bacteriological examination OF smears and scrapings is performed 7-8 days after the completion of treatment. Subsequent examinations are carried out over the course of three menstrual cycles, preferably just before menstruation or 1-2 days after its cessation. Girls who have undergone treatment for ureaplasmosis are subject to monthly examinations for 3 months.

In men, 7-10 days after the completion of treatment, visual and Palpation examination of the urethra, palpation of the Prostate Gland and Seminal Vesicles, and bacteriological examination of their secretion are performed. If ureaplasmas are not detected in the discharge or scraping of the urethra and in the sediment of the first portion of freshly voided urine, and clinical manifestations of the disease are absent, a repeat examination and urethroscopy are performed a month later. Patients are considered cured if, after treatment, repeated follow-up examinations fail to detect ureaplasmas within 1 month for men and within three menstrual cycles for women. The criterion for cure is the absence of ureaplasma and local inflammatory signs.

Due to the fact that a past infection does not confer lasting immunity, cases of reinfection occur, typically when only one of the sexual partners is treated.

The spread of the disease is facilitated by casual, promiscuous sexual contacts. Individuals who have had sexual contact with infected persons should be regarded as active or potential sources of this infection. For prevention, chemical agents (alcohol, ether, chloramine, etc.) should be used, alongside boiling or sterilization. Prevention of ureaplasmal infections should be based on General Principles for combating Sexually Transmitted Diseases. Individual prophylaxis should be carried out using standard methods accepted in dermatovenereological practice.