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{{Trichomoniasis}}
{{Trichomoniasis}}
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==Overview==
==Overview==
Trichomoniasis can usually be cured with the prescription drug, [[metronidazole]], given by mouth in a single dose. The symptoms of trichomoniasis in infected men may disappear within a few weeks without treatment. However, an infected man, even a man who has never had symptoms or whose symptoms have stopped, can continue to infect or re-infect a female partner until he has been treated. Therefore, both partners should be treated at the same time to eliminate the parasite. Persons being treated for trichomoniasis should avoid sex until they and their sex partners complete treatment and have no symptoms. Metronidazole can be used by pregnant women. Having trichomoniasis once does not protect a person from getting it again. Following successful treatment, people can still be susceptible to re-infection.
[[Antimicrobial]] therapy is the standard of care for trichomoniasis in both genders once the diagnosis has been confirmed. The symptoms of trichomoniasis among infected men may disappear within a few weeks even without treatment, but asymptomatic men may continue to be infectious and should therefore be treated. [[Antimicrobial]] therapy generally includes either [[metronidazole]] or [[tinidazole]] 2 g PO in a single dose. Prolonged therapy for 7 days is indicated among patients who fail to respond to the initial course of therapy. Following successful treatment, individuals may still be susceptible to re-infection.


==Medical Therapy==
==Medical Therapy==
===Pharmacotherapy===
[[Antimicrobial]] therapy is the standard of care for trichomoniasis in both genders once the diagnosis has been confirmed.<ref name="pmid15489348">{{cite journal| author=Cudmore SL, Delgaty KL, Hayward-McClelland SF, Petrin DP, Garber GE| title=Treatment of infections caused by metronidazole-resistant Trichomonas vaginalis. | journal=Clin Microbiol Rev | year= 2004 | volume= 17 | issue= 4 | pages= 783-93, table of contents | pmid=15489348 | doi=10.1128/CMR.17.4.783-793.2004 | pmc=523556 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15489348  }} </ref><ref name="pmid23322080">{{cite journal| author=Coleman JS, Gaydos CA, Witter F| title=Trichomonas vaginalis vaginitis in obstetrics and gynecology practice: new concepts and controversies. | journal=Obstet Gynecol Surv | year= 2013 | volume= 68 | issue= 1 | pages= 43-50 | pmid=23322080 | doi=10.1097/OGX.0b013e318279fb7d | pmc=3586271 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23322080  }} </ref><ref name="Std"> http://www.cdc.gov/std/tg2015/trichomoniasis.htm, Accessed on September 13, 2016</ref> The symptoms of trichomoniasis in infected men may disappear within a few weeks even without treatment, but asymptomatic men may continue to be infectious and should therefore be treated.
;Shown below is a table summarizing the preferred and alternative empiric treatment for meningitis.
===Antimicrobial Regimen===
{| class="wikitable" border="1" style="background:FloralWhite"
|- align="center"
|'''Pathogen'''
|'''Optimal Treatment'''
|'''Duration of Treatment'''
|'''Alternative Treatment'''
|}
*''[[Metronidazole]]:'' 2 g orally in a single dose, or
*''[[Tinidazole]]:'' 2 g orally in a single dose
*Alternative Regimen: ''Metronidazole'' 500 mg orally twice a day for 7 days
Patients should be advised to avoid consuming [[alcohol]] during treatment with metronidazole or tinidazole. Abstinence from alcohol use should continue for 24 hours after completion of metronidazole or 72 hours after completion of tinidazole.  
 
The [[nitroimidazole]]s comprise the only class of drugs useful for the oral or [[parenteral]] therapy of trichomoniasis. Of these drugs, metronidazole and tinidazole are available in the United States and are cleared by the [[FDA]] for the treatment of trichomoniasis. In [[randomized clinical trials]], the recommended metronidazole regimens have resulted in cure rates of approximately 90%–95%, and the recommended tinidazole regimen has resulted in cure rates of approximately 86%–100%. The appropriate treatment of sex partners might increase these reported rates. [[Randomized controlled trials]] comparing single 2 g doses of metronidazole and tinidazole suggest that tinidazole is equivalent to, or superior to, metronidazole in achieving parasitologic cure and resolution of symptoms. Treatment of patients and sex partners results in relief of symptoms, microbiologic cure, and reduction of [[transmission]].  
 
Metronidazole gel is considerably less efficacious for the treatment of trichomoniasis (<50%) than oral preparations of metronidazole. Topically applied [[antimicrobials]] (e.g., metronidazole gel) are unlikely to achieve therapeutic levels in the [[urethra]] or perivaginal glands; therefore, use of the gel is not recommended. Several other topically applied antimicrobials occasionally have been used for treatment of trichomoniasis; however, these preparations probably do not have greater efficacy than metronidazole gel.
 
===Follow-Up===
Follow-up is unnecessary for men and women who become asymptomatic after treatment or who are initially asymptomatic. Some strains of T. vaginalis can have diminished susceptibility to metronidazole; however, infections caused by the majority of these organisms respond to tinidazole or higher doses of metronidazole. Low-level metronidazole resistance has been identified in 2%–5% of cases of vaginal trichomoniasis. High-level resistance is rare. Tinidazole has a longer serum half-life and reaches higher levels in genitourinary tissues than metronidazole. In addition, many T. vaginalis isolates have lower [[minimum inhibitory concentration]]s (MICs) to tinidazole than metronidazole.  


If treatment failure occurs with metronidazole 2 g single dose and reinfection is excluded, the patient can be treated with metronidazole 500 mg orally twice daily for 7 days or tinidazole 2 g single dose. For patients failing either of these regimens, clinicians should consider treatment with tinidazole or metronidazole at 2 g orally for 5 days. If these therapies are not effective, further management should be discussed with a specialist. The consultation should ideally include determination of the susceptibility of T. vaginalis to metronidazole and tinidazole. Consultation and T. vaginalis susceptibility testing is available from CDC.
:*1. '''''T. vaginalis'' infection in women'''
::*Preferred regimen:  [[Metronidazole]] 500  mg PO bid for 7 days
::*Alternative regimen: [[Tinidazole]] 2 g PO in a single dose
::*Note: Patients should avoid sexual contact until they are fully cured of trichomoniasis
::*Note: Testing for other STIs, including [[HIV|HIV,]] [[syphilis]], [[gonorrhea]], and [[chlamydia]], should be performed for persons with ''T. vaginalis''.
::
::2. '''''T. vaginalis'' infection in men'''
::* Preferred regimen: [[Metronidazole]] 2 g PO in a single dose
::* Alternative regimen: [[Tinidazole]] 2 g PO in a single dose
::* Note: Patients should avoid sexual contact until they are fully cured of trichomoniasis
::*Note: Testing for other STIs, including [[HIV|HIV,]] [[syphilis]], [[gonorrhea]], and [[chlamydia]], should be performed for persons with ''T. vaginalis''.
:*2. '''''T. vaginalis'' infection in pregnant and lactating Women'''
::*2.1 '''Pregnant women'''
:::*Preferred regimen: [[Metronidazole]] 2 g PO in a single dose
::*2.2 '''Post-partum and Breastfeeding'''
:::*Preferred regimen (1): [[Metronidazole]] 500 mg PO bid for 7 days
:::*Preferred regimen (2): [[Tinidazole]] 2 g PO in a single dose
:::*Note (1): Do not breastfeed for 12-24 hrs following [[Metronidazole]] and 72 hrs following  [[Tinidazole]]
:::*Note (2): Symptomatic pregnant women, regardless of pregnancy stage, should be tested and considered for treatment.<ref>Trintis, J., et al. "Neonatal Trichomonas vaginalis infection: a case report and review of literature." International journal of STD & AIDS 21.8 (2010): 606-607.</ref> Pregnant women should be advised of the risk and benefits to treatment as infection (definitely) and treatment (possibly)
:::*Note (3): Pregnant women with HIV who are treated for T. vaginalis infection should be retested 3 months after treatment.
:*3. '''''T. vaginalis'' infection in patients with HIV'''
::*Preferred regimen: [[Metronidazole]] 500  mg PO bid for 7 days
:*4. '''Persistent or recurrent trichomoniasis'''<ref name="urlwww.cdc.gov">{{cite web |url=https://www.cdc.gov/std/treatment-guidelines/STI-Guidelines-2021.pdf |title=www.cdc.gov |format= |work= |accessdate=}}</ref>
::*4.1 '''Treatment failure:'''
::**4.1.1 In a woman after completing a regimen and has been re-exposed to an untreated partner
::***Preferred regimen: [[Metronidazole]] 500  mg PO bid for 7 days
::**4.1.2 In a woman after completing a regimen and no re-exposure has occurred:
::***Preferred regimen (1): [[Metronidazole]] 2 g PO for 7 days
::***Preferred regimen (2): [[Tinidazole]] 2 g PO for 7 days
::**4.1.3 In men after completing a regimen and has been re-exposed to an untreated partner
::***Preferred regimen: [[Metronidazole]] single 2-g dose.
::**4.1.4 In men after completing a regimen and no re-exposure has occurred:
::**Preferred regimen (1): [[Metronidazole]] 500 mg PO BID for 7 days.
::*4.2 '''Nitroimidazole-resistant ''T. vaginalis'''''
::*Antibiotic susceptibility testing recommended
::*Preferred regimen: [[Tinidazole]] or [[metronidazole]]  2 g daily for 7 days
::*Alternative regimen (1):  high-dose oral [[tinidazole]] 2 g daily plus  [[tinidazole]] 500 mg BID intravaginal for 14 days
::*Alternative regimen (2): If the first failed, high-dose oral [[tinidazole]] 1 g TID plus [[paromomycin]] 4 g of 6.25% intravaginal [[paromomycin]] cream nightly for 14 days.


===Special Considerations ===
===Treatment of Sexual Partners===
====Allergy, Intolerance, and Adverse Reactions====


Metronidazole and tinidazole are both [[nitroimidazole]]s. Patients with an immediate-type [[allergy]] to a nitroimidazole can be managed by metronidazole [[desensitization]] in consultation with a specialist. Topical therapy with drugs other than nitroimidazoles can be attempted, but cure rates are low (<50%).
*Sexual partners of patients with trichomoniasis should be treated.<ref name="Std"> http://www.cdc.gov/std/tg2015/trichomoniasis.htm, Accessed on September 13, 2016</ref><ref>Kissinger, Patricia, et al. "Patient-delivered partner treatment for Trichomonas vaginalis infection: a randomized controlled trial." Sexually transmitted diseases 33.7 (2006): 445-450.</ref>
*Patients and their sexual partners should avoid sexual contact until they are fully cured of trichomoniasis.


====Pregnancy====
===Follow-up===


Vaginal trichomoniasis has been associated with adverse pregnancy outcomes, particularly [[premature rupture of membranes]], [[preterm]] delivery, and [[low birth weight]]. However, data do not suggest that metronidazole treatment results in a reduction in [[perinatal]] morbidity. Although some trials suggest the possibility of increased [[prematurity]] or low birth weight after metronidazole treatment, limitations of the studies prevent definitive conclusions regarding risks of treatment . Treatment of T. vaginalis might relieve symptoms of [[vaginal discharge]] in pregnant women and might prevent respiratory or [[genital]] infection of the newborn and further sexual [[transmission]]. Clinicians should counsel patients regarding the potential risks and benefits of treatment. Some specialists would defer therapy in asymptomatic pregnant women until after 37 weeks’ [[gestation]]. In addition, these pregnant women should be provided careful counseling regarding condom use and the continued risk of sexual transmission.
*Patients should be re-evaluated at the end of the [[antimicrobial]] therapy regimen to determine whether therapy has been successful.
 
*Patients should be instructed that they are still susceptible to re-infection.
Women may be treated with 2 g of metronidazole in a single dose. Metronidazole is pregnancy category B (animal studies have revealed no evidence of harm to the fetus, but no adequate, well-controlled studies among pregnant women have been conducted). Multiple studies and meta-analyses have not demonstrated a consistent association between metronidazole use during pregnancy and [[teratogenic]] or [[mutagenic]] effects in infants. Tinidazole is pregnancy category C (animal studies have demonstrated an adverse event, and no adequate, well-controlled studies in pregnant women have been conducted), and its safety in pregnant women has not been well-evaluated.  
*Retesting is recommended for sexually active women within 3 months of treatment for initial infection. If retesting at 3 months is not possible, clinicians should retest whenever persons next seek medical care <12 months after initial treatment. <ref>Van Der Pol, Barbara, et al. "Prevalence, incidence, natural history, and response to treatment of Trichomonas vaginalis infection among adolescent women." Journal of Infectious Diseases 192.12 (2005): 2039-2044.</ref>
 
*Data are insufficient to support retesting men after treatment.
In lactating women who are administered metronidazole, withholding [[breastfeeding]] during treatment and for 12–24 hours after the last dose will reduce the exposure of metronidazole to the infant. While using tinidazole, interruption of breastfeeding is recommended during treatment and for 3 days after the last dose.
 
====HIV Infection====
 
Patients who have trichomoniasis and also are infected with HIV should receive the same treatment regimen as those who are HIV negative. The [[incidence]],persistence, and recurrence of trichomoniasis in HIV-infected women are not correlated with immune status. [http://www.cdc.gov/std/trichomonas/STDFact-Trichomoniasis.htm][http://www.cdc.gov/std/treatment/2006/vaginal-discharge.htm#vagdis3]


==References==
==References==
{{reflist|2}}
{{Reflist|2}}


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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aysha Anwar, M.B.B.S[2] Nuha Al-Howthi, MD[3]

Overview

Antimicrobial therapy is the standard of care for trichomoniasis in both genders once the diagnosis has been confirmed. The symptoms of trichomoniasis among infected men may disappear within a few weeks even without treatment, but asymptomatic men may continue to be infectious and should therefore be treated. Antimicrobial therapy generally includes either metronidazole or tinidazole 2 g PO in a single dose. Prolonged therapy for 7 days is indicated among patients who fail to respond to the initial course of therapy. Following successful treatment, individuals may still be susceptible to re-infection.

Medical Therapy

Antimicrobial therapy is the standard of care for trichomoniasis in both genders once the diagnosis has been confirmed.[1][2][3] The symptoms of trichomoniasis in infected men may disappear within a few weeks even without treatment, but asymptomatic men may continue to be infectious and should therefore be treated.

Antimicrobial Regimen

  • 1. T. vaginalis infection in women
  • Preferred regimen: Metronidazole 500 mg PO bid for 7 days
  • Alternative regimen: Tinidazole 2 g PO in a single dose
  • Note: Patients should avoid sexual contact until they are fully cured of trichomoniasis
  • Note: Testing for other STIs, including HIV, syphilis, gonorrhea, and chlamydia, should be performed for persons with T. vaginalis.
2. T. vaginalis infection in men
  • Preferred regimen: Metronidazole 2 g PO in a single dose
  • Alternative regimen: Tinidazole 2 g PO in a single dose
  • Note: Patients should avoid sexual contact until they are fully cured of trichomoniasis
  • Note: Testing for other STIs, including HIV, syphilis, gonorrhea, and chlamydia, should be performed for persons with T. vaginalis.
  • 2. T. vaginalis infection in pregnant and lactating Women
  • 2.1 Pregnant women
  • 2.2 Post-partum and Breastfeeding
  • Preferred regimen (1): Metronidazole 500 mg PO bid for 7 days
  • Preferred regimen (2): Tinidazole 2 g PO in a single dose
  • Note (1): Do not breastfeed for 12-24 hrs following Metronidazole and 72 hrs following Tinidazole
  • Note (2): Symptomatic pregnant women, regardless of pregnancy stage, should be tested and considered for treatment.[4] Pregnant women should be advised of the risk and benefits to treatment as infection (definitely) and treatment (possibly)
  • Note (3): Pregnant women with HIV who are treated for T. vaginalis infection should be retested 3 months after treatment.
  • 3. T. vaginalis infection in patients with HIV
  • 4. Persistent or recurrent trichomoniasis[5]
  • 4.1 Treatment failure:
    • 4.1.1 In a woman after completing a regimen and has been re-exposed to an untreated partner
    • 4.1.2 In a woman after completing a regimen and no re-exposure has occurred:
    • 4.1.3 In men after completing a regimen and has been re-exposed to an untreated partner
    • 4.1.4 In men after completing a regimen and no re-exposure has occurred:
    • Preferred regimen (1): Metronidazole 500 mg PO BID for 7 days.
  • 4.2 Nitroimidazole-resistant T. vaginalis
  • Antibiotic susceptibility testing recommended
  • Preferred regimen: Tinidazole or metronidazole 2 g daily for 7 days
  • Alternative regimen (1): high-dose oral tinidazole 2 g daily plus tinidazole 500 mg BID intravaginal for 14 days
  • Alternative regimen (2): If the first failed, high-dose oral tinidazole 1 g TID plus paromomycin 4 g of 6.25% intravaginal paromomycin cream nightly for 14 days.

Treatment of Sexual Partners

  • Sexual partners of patients with trichomoniasis should be treated.[3][6]
  • Patients and their sexual partners should avoid sexual contact until they are fully cured of trichomoniasis.

Follow-up

  • Patients should be re-evaluated at the end of the antimicrobial therapy regimen to determine whether therapy has been successful.
  • Patients should be instructed that they are still susceptible to re-infection.
  • Retesting is recommended for sexually active women within 3 months of treatment for initial infection. If retesting at 3 months is not possible, clinicians should retest whenever persons next seek medical care <12 months after initial treatment. [7]
  • Data are insufficient to support retesting men after treatment.

References

  1. ↑ Cudmore SL, Delgaty KL, Hayward-McClelland SF, Petrin DP, Garber GE (2004). "Treatment of infections caused by metronidazole-resistant Trichomonas vaginalis". Clin Microbiol Rev. 17 (4): 783–93, table of contents. doi:10.1128/CMR.17.4.783-793.2004. PMC 523556. PMID 15489348.
  2. ↑ Coleman JS, Gaydos CA, Witter F (2013). "Trichomonas vaginalis vaginitis in obstetrics and gynecology practice: new concepts and controversies". Obstet Gynecol Surv. 68 (1): 43–50. doi:10.1097/OGX.0b013e318279fb7d. PMC 3586271. PMID 23322080.
  3. ↑ 3.0 3.1 http://www.cdc.gov/std/tg2015/trichomoniasis.htm, Accessed on September 13, 2016
  4. ↑ Trintis, J., et al. "Neonatal Trichomonas vaginalis infection: a case report and review of literature." International journal of STD & AIDS 21.8 (2010): 606-607.
  5. ↑ "www.cdc.gov" (PDF).
  6. ↑ Kissinger, Patricia, et al. "Patient-delivered partner treatment for Trichomonas vaginalis infection: a randomized controlled trial." Sexually transmitted diseases 33.7 (2006): 445-450.
  7. ↑ Van Der Pol, Barbara, et al. "Prevalence, incidence, natural history, and response to treatment of Trichomonas vaginalis infection among adolescent women." Journal of Infectious Diseases 192.12 (2005): 2039-2044.


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