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\begin{document}

\title{Ureaplasma screening for pregnant individuals who are at high risk for
preterm birth: a retrospective study.}



\author[1]{Tetsuya Kawakita}%
\author[2]{Jerri Waller}%
\author[3]{Tracey DeYoung}%
\author[3]{Nehme Lea}%
\author[4]{Madison Collazo}%
\author[5]{Carole Barake}%
\author[3]{Monica Ethirajan}%
\author[3]{Camille Kanaan}%
\author[3]{Alfred Abuhamad}%
\affil[1]{MedStar Washington Hospital Center}%
\affil[2]{Affiliation not available}%
\affil[3]{Eastern Virginia Medical School}%
\affil[4]{Inova Fairfax Hospital}%
\affil[5]{The University of Texas Medical Branch at Galveston}%


\vspace{-1em}



  
  \date{May 25, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
Objective: To examine gestational age at delivery according to
Ureaplasma cervical culture results and whether pregnant individuals
received antibiotics. Study Design: A retrospective cohort study
Setting: Single academic institution Population: All pregnant
individuals with risk factors for preterm birth including those with a
history of preterm birth, recurrent pregnancy loss, or pregnancy
requiring cervical cerclage. Methods: We plotted Kaplan-Meier curves to
investigate the association between the gestational age at delivery and
Ureaplasma culture results (negative; positive and treated; or positive
but did not receive the treatment). A Cox proportional regression model
was used to calculate Hazard ratio (HR) with 95\% confidence intervals
(95\%CI), controlling for confounders. Main outcome: Gestational age at
delivery. Results: Of 607 individuals, 258 (42.5\%) had a negative
Ureaplasma culture, 308 (50.7\%) had a positive Ureaplasma culture and
received treatment, and 41 (6.8\%) had a positive Ureaplasma culture and
did not receive treatment. Compared to those who had a positive
Ureaplasma culture but did not receive treatment, those who had a
negative Ureaplasma culture did not have a decreased risk (HR 1.03;
95\%CI 0.74-1.44). Compared to those who had a positive Ureaplasma
culture but did not receive treatment, those who had a positive
Ureaplasma culture and received treatment did not have a decreased risk
(HR 0.91; 95\%CI 0.66-1.27). The treatment failure rate of Ureaplasma
after treatment was 78.6\% (95\%CI 72.8-83.7\%). Conclusion: Routine
Ureaplasma cervical culture is not recommended for pregnant individuals
who are at high risk for preterm birth%
\end{abstract}%



\sloppy


Ureaplasma screening for pregnant individuals who are at high risk for
preterm birth: a retrospective study.

\textbf{Authors:} Tetsuya Kawakita\textsuperscript{1}, MD, MS; Jerri
Waller\textsuperscript{1}, MD; Tracey DeYoung\textsuperscript{1}, MD;
Lea Nehme\textsuperscript{1}, MD; Madison C. Collazo\textsuperscript{2},
MD; Carole Barake\textsuperscript{3}, MD; Monica A.
Ethirajan\textsuperscript{1}, MS, MPH; Camille M.
Kanaan\textsuperscript{1}, MD; Alfred Abuhamad\textsuperscript{1}, MD

\textbf{Institutions:}

\textsuperscript{1} Department of Obstetrics and Gynecology, Eastern
Virginia Medical School, Norfolk, VA, USA

\textsuperscript{2} Department of Obstetrics and Gynecology, Inova
Fairfax Hospital, Falls Church, VA, USA

\textsuperscript{3} Department of Obstetrics and Gynecology, University
of Texas Medical Branch, Galveston, TX, USA

\textbf{Corresponding author:}

Tetsuya Kawakita, MD, MS, 825 Fairfax Avenue, Suite 310, Norfolk VA,
23507

Email: Tetsuya.x.kawakita@gmail.com

Short title: Ureaplasma and preterm birth

The authors report no conflict of interest.

\textbf{Contribution to authorship}

TK and CK conceived the idea for the study. TK and NL wrote the article.
TK is the corresponding author of the study. TK and CB planned and
carried out the study. JCH conducted the analyses. TK, CK, AA, and NL
contributed to the interpretation of the data. TK, JW, TD, CB, MC, and
ME conducted data collection. TK, NL, CK, and AA critically revised
earlier drafts of the article for important intellectual content and
gave final approval of the version to be published.

\textbf{Details of Ethics Approval}

Eastern Virginia Medical School Institutional Review Board

IRB \#21-02-XX-0032

Approval April 30, 2021

\textbf{Abstract:}

\textbf{Objective:} To examine gestational age at delivery according to
Ureaplasma cervical culture results and whether pregnant individuals
received antibiotics.

\textbf{Study Design:} A retrospective cohort study

\textbf{Setting} : Single academic institution

\textbf{Population} : All pregnant individuals with risk factors for
preterm birth including those with a history of preterm birth, recurrent
pregnancy loss, or pregnancy requiring cervical cerclage.

\textbf{Methods} : We plotted Kaplan-Meier curves to investigate the
association between the gestational age at delivery and Ureaplasma
culture results (negative; positive and treated; or positive but did not
receive the treatment). A Cox proportional regression model was used to
calculate Hazard ratio (HR) with 95\% confidence intervals (95\%CI),
controlling for confounders.

\textbf{Main outcome:} Gestational age at delivery.

\textbf{Results:} Of 607 individuals, 258 (42.5\%) had a negative
Ureaplasma culture, 308 (50.7\%) had a positive Ureaplasma culture and
received treatment, and 41 (6.8\%) had a positive Ureaplasma culture and
did not receive treatment. Compared to those who had a positive
Ureaplasma culture but did not receive treatment, those who had a
negative Ureaplasma culture did not have a decreased risk (HR 1.03;
95\%CI 0.74-1.44). Compared to those who had a positive Ureaplasma
culture but did not receive treatment, those who had a positive
Ureaplasma culture and received treatment did not have a decreased risk
(HR 0.91; 95\%CI 0.66-1.27). The treatment failure rate of Ureaplasma
after treatment was 78.6\% (95\%CI 72.8-83.7\%).

\textbf{Conclusion:} Routine Ureaplasma cervical culture is not
recommended for pregnant individuals who are at high risk for preterm
birth.

This study was not funded.

Keywords:

Antibiotics- Preterm birth- Recurrence - Ureaplasma

\section*{Introduction}

{\label{introduction}}

Preterm birth, defined as birth before 37 weeks' gestation, complicates
approximately 10\% of all live births and is the leading cause of
neonatal mortality and long-term neonatal neurologic sequelae. Pregnant
individuals with a previous history of preterm birth or second-trimester
loss are especially at a higher risk of preterm birth; the incidence of
a subsequent preterm birth is approximately 20-30\%. Another well-known
risk factor for preterm birth is genital tract infections or
colonization such as Chlamydia trachomatis, bacterial vaginosis,
Trichomonas vaginalis, and Ureaplasma species. Given these associations,
we started a quality improvement study that performs Ureaplasma cervical
culture in addition to routine sexually transmitted infection screening
for pregnant individuals with high-risk factors for preterm birth.

Ureaplasma species are normal genital flora, carried by 50-80\% of
pregnant and non-pregnant individuals. Some studies showed that
Ureaplasma species are associated with spontaneous preterm birth whereas
others did not confirm this association. A proposed mechanism is the
presence of toxins and cytokines from Ureaplasma, which lead to high
levels of prostaglandins, and later either induce preterm labor or
preterm prelabour rupture of membranes (PPROM). Despite this
association, previous studies did not show that antibiotics including
Erythromycin and Clindamycin to treat Ureaplasma for asymptomatic
individuals actually decrease spontaneous preterm birth. This lack of
effectiveness could be due to difficulty eradicating Ureaplasma species.
A randomized control trial of 60 pregnant individuals who presented with
preterm labor or PPROM showed that 93.3\% of individuals still had a
positive culture for Ureaplasma after 1 gram of Azithromycin. These
studies did not treat sexual partners, nor treat pregnant individuals
again if the culture was positive after the initial treatment.

It is not known if treating both pregnant individuals and their sexual
partners would result in lower positivity rates after treatment, as well
as improvement of gestational age at delivery. Since 2014, our
institution has been performing cervical cultures of pregnant
individuals who are at high-risk for preterm birth and treating both
pregnant individuals and their sexual partners. We sought to examine
gestational age at delivery according to Ureaplasma cervical culture
results and whether pregnant individuals received appropriate
antibiotics. We also sought to examine the Ureaplasma positive rates
after treatment of pregnant individuals and their partners. Given the
data in the literature, we hypothesized that treatment of Ureaplasma was
not associated with improved gestational age at delivery, and the
treatment failure rate would be high.

\textbf{Methods}

This was a retrospective study of pregnant individuals who had
Ureaplasma cervical culture at an academic institution from January 2014
to December 2020. Our Institutional Review Board approved this study. In
2014, we started a quality improvement project in which we routinely
obtained Ureaplasma cervical culture for all pregnant individuals with
risk factors for preterm birth (history of preterm births or PPROM,
history of recurrent pregnancy loss, pregnancy with multiple gestations,
or pregnancy requiring cerclage). The American College of Obstetricians
and Gynecologists (ACOG) defined preterm birth as delivery less than 37
weeks' gestation. PPROM was defined as rupture of membranes prior to the
onset of labor less than 37 weeks' gestation. Recurrent pregnancy loss
is defined as 2 or more consecutive early pregnancy losses. Indications
for cerclage included history indication, ultrasound indication due to
the short cervix, or physical exam indication. These indications were
documented in the medical record.

We excluded individuals who had Ureaplasma cervical culture for preterm
contraction, multiple gestation, or unknown indications. Therefore, we
only analyzed pregnant individuals with singleton pregnancies who had
Ureaplasma cervical culture that was obtained for a history of preterm
births, a history of recurrent pregnancy loss, or cervical cerclage. We
also limited analyses to pregnant individuals who had Ureaplasma
cervical culture at or prior to 20 weeks' gestation, since we wanted to
assess the effectiveness of early intervention. In addition, we excluded
pregnant individuals if they delivered within two weeks of the initial
Ureaplasma cervical culture since these individuals would not have
enough time to receive the treatment. Pregnant individuals were
categorized according to the initial Ureaplasma cervical culture results
and whether they received appropriate antibiotics (negative; positive
and received treatment; and positive but did not receive treatment
{[}including those who did not receive appropriate antibiotics{]}).

Ureaplasma cervical culture was obtained at the first prenatal visit by
inserting a vaginal speculum and removing the excess mucus from the
cervical opening, using a cotton swab. The specimen collection swab was
then placed within the external cervical os and gently rotated for 30
seconds for appropriate sampling. The swab was then removed avoiding
contact with the vaginal walls and immediately placed into the transport
tube which was securely capped. Aptima\selectlanguage{ngerman}® swab was commonly utilized for
this procedure. This test detects Mycoplasma genitalium, Mycoplasma
hominis, and Ureaplasma species through nucleic acid amplification. If
Ureaplasma cervical culture was positive, we prescribed Azithromycin for
pregnant individuals and Doxycycline for sexual partners (Box 1). If
pregnant individuals received antibiotics, we obtained Ureaplasma
cervical culture 4 weeks after the initial treatment and treated them
again if the second cervical culture was positive. Alternative
antibiotics regimens in case of drug allergy are presented in Box 1.

Our primary outcome was gestational age at delivery. The estimated due
date (EDD) was based on the date of the last menstrual period confirmed
by first-trimester ultrasound. Secondary outcomes included Ureaplasma
cervical culture positive 4 weeks after the initial treatment (treatment
failure), preterm birth less than 37 weeks' gestation, spontaneous
preterm birth less than 37 weeks' gestation, spontaneous preterm birth
less than 34 weeks' gestation, chorioamnionitis, PPROM, pregnancy loss
less than 22 weeks' gestation, neonatal intensive care unit (NICU)
admission, neonatal respiratory distress syndrome (RDS) or transient
tachypnea of newborn (TTN), and stillbirth or neonatal demise.

Ureaplasma treatment failure rates were assessed according to the
indications for Ureaplasma cervical cultures. For the analysis of the
treatment failure rate, we only included pregnant individuals who had a
positive Ureaplasma cervical culture, received treatment, and had a
repeat Ureaplasma cervical culture after the initial treatment. Because
some individuals had several indications for Ureaplasma cervical
cultures, we classified mutually exclusive categories for indications
using the following hierarchy. First, if individuals had cerclage, the
indication was classified as ``cerclage.'' Second, if individuals had a
history of preterm births, the indication was classified as ``history of
preterm birth.'' Third, if individuals had a history of recurrent
pregnancy loss, the indication was classified as ``recurrent pregnancy
loss.'' The hierarchy was maintained if individuals had more than one
indication, with the highest-order indication prioritized to assign the
classification. For example, if an individual had a history of preterm
birth and underwent cervical cerclage, this individual was classified as
``cerclage'' group.

We calculated the sample size based on the following assumptions. We
assumed that 90\% of individuals with a positive Ureaplasma culture
would receive treatment. To obtain an alpha of 0.05 and the power of
80\% and detect a Hazard ratio of 0.6, we would need 224 individuals
with a positive Ureaplasma culture (201 with appropriate antibiotics and
23 without appropriate antibiotics).

Descriptive statistics were calculated for all study variables.
Chi-square test, Fisher's exact test, Student's t-test, Wilcoxon rank
sum test, or Kruskal-Wallis tests were performed as appropriate. A
P-value \textless{}0.05 was considered significant. We plotted the
Kaplan-Meier curves to investigate the association between the
gestational age at delivery and Ureaplasma culture results (negative;
positive and received treatment; or positive but did not receive
treatment). Log-rank test was performed to obtain P-value to compare
Kaplan-Meier curves. A Cox proportional regression model was used to
calculate Hazard ratio (HR) with 95\% confidence intervals (95\%CI),
controlling for variables with a P\textless{}0.05 based on bivariable
analyses. For secondary outcomes, multivariable logistic models were
used to calculate adjusted P-value and adjusted odds ratios (aOR) with
95\% confidence intervals (95\%CI), controlling for variables with a
P\textless{}0.05 based on bivariable analyses (Ureaplasma negative as a
referent). A simple logistic regression was used to examine the
association between the treatment failure rate and cervical culture
indications (history of preterm birth as a referent). All statistical
analyses were performed using Stata/SE 17.0 (StataCorp, College Station,
TX).

\textbf{Results}

Of 607 pregnant individuals. 258 (42.5\%) had a negative Ureaplasma
culture, 308 (50.7\%) had a positive Ureaplasma culture and received
treatment, and 41 (6.8\%) had a positive Ureaplasma culture and did not
receive treatment. (Figure 1).

Maternal demographics are presented in Table 1. There were statistical
differences in distributions and proportions of maternal age, race and
ethnicity, smoking, illicit drug, Trichomonas vaginalis co-infection,
and reason for Ureaplasma culture. Compared to pregnant individuals who
had a negative culture, those who had a positive Ureaplasma and received
treatment were more likely to be younger, non-Hispanic black,
co-infected with Trichomonas vaginalis, and have Ureaplasma culture
indicated for a history of preterm birth (P\textless{}0.05). Compared to
pregnant individuals who had a negative culture, those who had a
positive Ureaplasma and did not receive treatment were more likely to be
smokers (P=0.02).

Kaplan Meier curves are presented in Figure 2. There was no difference
in gestational age at delivery (Log-rank P=0.40). There was no
difference in median gestational age at delivery between groups
(negative 37.4 {[}interquartile 36.0-39.0{]} weeks vs. positive and
received treatment 37.7 {[}35.6-39.0{]} weeks vs. positive and did not
receive treatment 37.3 {[}36.0-38.7{]} weeks; P =0.57). Hazard ratios
are presented in Table 2. Compared to those who had a positive
Ureaplasma culture but did not receive treatment, those who had a
negative Ureaplasma culture did not have decreased a risk (HR 1.02;
95\%CI 0.73-1.42). Similarly, compared to those who had a positive
Ureaplasma culture but did not receive treatment, those who had a
positive Ureaplasma culture and received treatment did not have a
decreased risk (HR 0.90; 95\%CI 0.65-1.25). Individuals who had
Ureaplasma culture for recurrent pregnancy loss compared to those who
had Ureaplasma culture for a history of preterm birth had a decreased
risk (HR 0.54; 95\%CI 0.35-0.85). Secondary outcomes are presented in
Table 3. There were no differences in secondary outcomes across the
groups.

Of 308 individuals who had a positive Ureaplasma culture and received
treatment, 234 (76\%) had a follow-up Ureaplasma culture. The overall
treatment failure rate after the initial treatment was 78.6\% (184/234;
95\%CI 72.8-83.7\%). Rates of treatment failure according to reasons for
Ureaplasma culture are presented in Table 4. Compared to a history of
preterm births, cerclage was associated with decreased odds of treatment
failure (odds ratio 0.33; 95\%CI 0.18-0.61).

\textbf{Discussion}

In our cohort of 607 pregnant individuals who were at high risk for
preterm birth, we found that those who had a positive Ureaplasma culture
but did not receive treatment had comparable gestational age at delivery
compared to those who have negative Ureaplasma culture as well as those
who had a positive Ureaplasma culture and received treatment. Further,
the rate of treatment failure after the initial treatment was very high
(78.6\%). We also found that cerclage was associated with lower odds of
recurrence compared to a history of preterm birth.

We found that treatment failure of Ureaplasma was very high even after
treatment of pregnant individuals and their sexual partners. This
finding was consistent with a previous study that showed that treatment
of pregnant individuals with preterm labor or PPROM with Azithromycin
resulted in a 93.3\% treatment failure rate. Interestingly, studies of
intra-amniotic Ureaplasma infection showed that treatment of infection
resulted in a high rate of clearance of infection (79\%). Given that
Ureaplasma species are normal genital flora, eradication of Ureaplasma
might be challenging. We found that pregnant individuals who had a
cervical culture due to cerclage had lower odds of recurrence compared
to those who had a cervical culture due to a history of preterm births.
We speculate that these lower odds could be due to abstinence from
intercourse after cerclage placement. In non-pregnant individuals,
sexual intercourse permits the spread of the various Ureaplasma species
with their different resistance profiles. In pregnant individuals, those
who had sexual intercourse 3 times or greater per week had a Ureaplasma
positive rate of 37\%, which was much higher than 18\% for those who had
intercourse less than 3 times per week (P=0.02). It is noteworthy that
even though our institution treated all sexual partners with
Doxycycline, the treatment failure rate remained high.

We found that giving appropriate antibiotics was not associated with an
improvement in gestational age at delivery. Despite the use of different
antibiotics, our finding was consistent with previous studies that
showed treatment of Ureaplasma was not associated with improvement of
adverse pregnancy outcomes compared to no treatment. For example, a
double-blind randomized control trial that randomized pregnant
individuals who tested positive for Ureaplasma Urealyticum to either
erythromycin treatment or placebo did not show significant differences
in gestational age at delivery, PPROM, or neonatal outcomes. Our study
is unique, however, since our protocol adopts an Azithromycin regimen
and treats their sexual partners.

It is important to note that giving antibiotics to pregnant individuals
could change bacterial flora and could have unknown consequences. Even
though Azithromycin is not associated with short-term neonatal adverse
outcomes, little is known regarding the long-term outcomes. A previous
study has indicated that antibiotics may be associated with an infant
gut microbiota imbalance during the first year of life. Future studies
that examine long-term neonatal and infants' outcomes associated with
prenatal Azithromycin exposure would be useful.

Our study has many strengths. In 2014, our institution started a quality
improvement project that tests and treats pregnant individuals with a
positive Ureaplasma cervical culture as well as their sexual partners.
Our protocol was to repeat Ureaplasma cervical culture after the initial
treatment and treat again if treatment failure is noted. Though previous
studies treated pregnant individuals only once, we thought repeating
Ureaplasma cervical culture was important due to the high treatment
failure rate. We believe the quality of our data is high: data were
obtained from a chart review of outpatient, inpatient, and anesthesia
records. We think that this study sets a good example of a quality
improvement project; given the high rate of treatment failure despite
treatment of pregnant individuals and sexual partners, our institution
decided to stop routine Ureaplasma cervical culture for pregnant
individuals who were at high risk for preterm birth. Our study
underscores the importance of assessing the effects of a quality
improvement project and changing our practice based on study findings.

Our study is not without limitations. Given the retrospective nature of
the study, we were not able to assess the compliance rates of treatment
for pregnant individuals and their sexual partners. We tried to adjust
for covariates using cox or multivariable logistic regression models.
However, there could be residual confounding. Since this was a
retrospective cohort study, we were only able to assess association but
not causation. Our study was from a single academic center. Therefore,
our findings may not be generalizable in other clinical settings.
Unfortunately, due to our protocol of treating all pregnant individuals
who had positive Ureaplasma culture, the sample size of pregnant
individuals who had a positive Ureaplasma culture and did not receive
treatment was low. Since our study was powered to examine gestational
age at delivery, other analyses were exploratory. Lastly, we did not
differentiate the Ureaplasma species. It is possible that some species
of Ureaplasma such as Ureaplasma parvum but not Ureaplasma Urealyticum
are associated with spontaneous preterm birth.

\textbf{Conclusion}

Ureaplasma species are commonly isolated from pregnant individuals who
are at high-risk for preterm birth. The treatment failure rate was very
high even after treating pregnant individuals and their sexual partners.
There were no statistical differences in gestational age at delivery as
well as adverse pregnancy outcomes regardless of Ureaplasma culture
results and whether pregnant individuals received treatment. Routine
Ureaplasma cervical culture is not recommended for pregnant individuals
who are at high risk for preterm birth.

\textbf{Figure legend:}

Figure 1. Cohort diagram

Figure 2. Kaplan-Meier curve

\textbf{Box 1. Institution management of Ureaplasma and Mycoplasma
infection in pregnancy:}\selectlanguage{english}
\begin{longtable}[]{@{}lll@{}}
\toprule
\begin{minipage}[b]{0.32\columnwidth}\raggedright\strut
\textbf{Screening Criteria}\strut
\end{minipage} & \begin{minipage}[b]{0.32\columnwidth}\raggedright\strut
All pregnant individuals at increased risk for preterm delivery,
including: Individuals with a history of prior pre-term delivery or
PPROM Individuals with a history of two or more unexplained
first-trimester SABs Individuals with multiple gestations Individuals
who are receiving a cerclage\strut
\end{minipage} & \begin{minipage}[b]{0.32\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\textbf{Antibiotics Regimen}\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\textbf{1\textsuperscript{st} Line Regimen}\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\textbf{Alternative Regimen}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Ureaplasma\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Azithromycin 500mg PO x 1 then 250mg PO daily for a total of 7
days\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Clindamycin 300mg PO BID x 7 days\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Mycoplasma\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Clindamycin 300mg PO BID x 7 days\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Ureaplasma + Mycoplasma\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Azithromycin 500mg PO x 1 then 250mg PO daily for a total of 7 days And
Clindamycin 300mg PO BID x 7 days\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\textbf{Partner Treatment}\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Doxycycline\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\textbf{Rescreening}\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Test-of-cure can be offered 3-4 weeks following completion of antibiotic
therapy with re-treatment x 1 if still positive\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Treatment with more than two courses of antibiotics is not
recommended\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\textbf{Hosted file}

\verb`Figures Ureaplasma 10192022.pptx`  available at \url{https://authorea.com/users/510811/articles/591926-ureaplasma-screening-for-pregnant-individuals-who-are-at-high-risk-for-preterm-birth-a-retrospective-study}

\textbf{Hosted file}

\verb`Tables Ureaplasma 10192022.docx`  available at \url{https://authorea.com/users/510811/articles/591926-ureaplasma-screening-for-pregnant-individuals-who-are-at-high-risk-for-preterm-birth-a-retrospective-study}

\selectlanguage{english}
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