Trichomoniasis medical therapy

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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. 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

• 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. 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

• 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.

Treatment of Sexual Partners

• Sexual partners of patients with trichomoniasis should be treated.
• 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.
• Data are insufficient to support retesting men after treatment.

References

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