Trichomoniasis Treatment & Management
- Author: Darvin Scott Smith, MD, MSc, DTM&H; Chief Editor: Michael Stuart Bronze, MD more...
Trichomoniasis is not a nationally mandated reported sexually transmitted disease, although other sexually transmitted disease reporting requirements vary by state. Evaluation is typically conducted in the outpatient setting.
Treatment should be instituted immediately and, whenever possible, in conjunction with all sexual partners. Patient-delivered partner therapy is a safe and effective means of treating the sexual partners of patients diagnosed with trichomoniasis. Both patient and partner should abstain from sex until pharmacological treatment has been completed and they have no symptoms.
Patients undergoing pharmacotherapy should be advised to avoid alcohol consumption during the course of treatment and for an appropriate amount of time after the completion of their medication.
Because trichomoniasis is an infection of multiple sites (eg, vaginal epithelium, Skene glands, Bartholin glands, and urethra), systemic treatment is needed. Because of the high rate of coinfection with other sexually transmitted infections (STIs), the healthcare provider should consider empiric treatment of gonorrhea and chlamydia. Patients should also be offered counseling and testing for HIV.
In clinical practice, repeat testing is rarely performed unless symptoms do not improve with drug treatment. However, the CDC recommends rescreening at 3 months post therapy for sexually active women, as they have a high rate of reinfection. Currently, no data are available on rescreening men.
Inpatient therapy is usually not required but may be indicated when resistance is present and intravenous (IV) therapy is indicated. For patients in whom treatment fails and in whom reinfection is ruled out, consultation with experts from the CDC may be advisable (770-488-4115). Consultation with an infectious diseases specialist, a gynecologist, or both may be helpful.
Patients who are HIV positive should generally receive the same treatment as those who are HIV negative. The notable exception is that the multiday treatment drug regimen (metronidazole 500 mg twice daily for 7 days) was recently shown to be more effective in treating T vaginalis in HIV-positive women than a single-dose treatment (metronidazole 2 g single dose). Thus, the CDC recommends considering the multidose treatment in HIV-positive women with trichomoniasis.
The CDC recommends rescreening at 3 months after the completion of therapy for HIV-positive women due to the likelihood of recurrent or persistent infection and the increased risk of HIV transmission with comorbid trichomonal infection.[9, 38, 85, 86]
Failure to treat trichomoniasis during pregnancy may result in preterm birth, low birth weight, and other adverse fetal outcomes. Accordingly, pregnant women should seek prompt treatment during pregnancy. Routine screening for trichomoniasis in asymptomatic pregnant women is not currently recommended.
The CDC recommends that infected symptomatic pregnant women be considered for treatment, as metronidazole has not been definitively shown to be harmful during pregnancy and may prevent transmission to the newborn.[87, 88] Infected asymptomatic pregnant women may wish to defer treatment to after 37 weeks’ gestation. Pregnant women should be treated with 2 g metronidazole in a single dose, according to the CDC. The safety of tinidazole in pregnancy is not known.
Transmission of trichomoniasis from an infected mother during delivery is rare, but respiratory or genital infection of the newborn is possible. An infected infant may present with fever.
In breastfeeding women, the CDC recommends stopping breastfeeding during the course of metronidazole treatment and for 12-24 hours after the last day. For treatment with tinidazole, the CDC recommends stopping breastfeeding for the course of treatment and for 3 days after the last dose.
T vaginalis infection in a pediatric patient may suggest child abuse. Young girls may present with vaginal discharge.
5-Nitroimidazole drugs are used for the treatment of trichomoniasis. In the United States, metronidazole and tinidazole are FDA-approved. In a Cochrane review, metronidazole and other nitroimidazoles had comparable efficacy in treating trichomoniasis. Randomized clinical trials comparing single 2-g doses have also shown metronidazole and tinidazole to be equally effective. With recommended dosages, the expected cure rate of trichomoniasis is 95%. Treating the patient’s sexual partners to prevent reinfection further improves the cure rate.
The mechanism of action is not well understood. Target organisms preferentially reduce the 5-nitro group, and active metabolites likely disrupt the helical structure of the DNA within them, preventing nucleic acid synthesis and eventually leading to cell death.
The advantages of single-dose therapy of metronidazole or tinidazole for trichomoniasis are better patient compliance, lower total dose, and, possibly, decreased subsequent candidal vaginitis.
For both metronidazole and tinidazole, patients should not consume alcohol during the course of treatment. For those on metronidazole therapy, abstinence should continue for 24 hours after the last dose. For those on tinidazole therapy, abstinence should continue for 72 hours after completion of the medication.
Despite the widespread use of nitroimidazoles in the treatment of trichomoniasis, resistance to these drugs is rare and is typically solved by increasing the dose or switching to another nitroimidazole. The CDC has reported incidents of trichomoniasis resistant to metronidazole that were susceptible to tinidazole.[89, 90] When standard treatment regimens fail, a regimen of 2 g of oral metronidazole or tinidazole for 5 days may be considered. Inpatient intravenous (IV) therapy may be indicated when resistance is present.
For patients in whom treatment fails and in whom reinfection is ruled out, consultation with experts from the CDC may be advisable (770-488-4115). Consultation with an infectious diseases specialist, a gynecologist, or both may be helpful.
Because trichomoniasis is an infection of multiple sites, systemic (oral) treatment is needed. Topical medications should are not recommended by the CDC, as they are unlikely to reach therapeutic levels. Topical metronidazole and other antimicrobials yield low cure rates (under 50%).
Patients allergic to this class of drug should be referred to an allergist for desensitization.
Metronidazole is the treatment of choice for trichomoniasis. Single-dose therapy with 2 g orally is as effective as prolonged therapy with 500 mg twice daily for 7 days. Single-dose therapy increases drug adherence.
Treatment failure with metronidazole increased from 0.4% to 3.5% between 1999 and 2002. Reports now describe resistance to metronidazole approaching 5-10%. If standard treatment with either single-dose or multidose therapy fails, a regimen of 2 g of oral metronidazole or tinidazole for 5 days may be considered.
Metronidazole gel is effective in less than 50% of trichomoniasis cases and is not recommended to treat trichomoniasis.
Patients should not consume alcohol during the course of treatment or during the 24 hours after the completion of the medication.
Metronidazole crosses the placenta in pregnancy and is a pregnancy Class B agent. A number of clinical trials and meta-analyses have not shown it to have teratogenic effects.[92, 93] However, it may prevent transmission of T vaginalis to the newborn. The CDC currently recommends that infected symptomatic pregnant females be treated with 2 g metronidazole in a single dose. Infected asymptomatic pregnant women may wish to defer treatment to after 37 weeks’ gestation.
In lactating women, the CDC recommends that breastfeeding be withheld during treatment and until 12-24 hours after the last dose to reduce exposure to the infant.
The National Institute of Child Health and Human Development Maternal Fetal Medicine Units Network presented data suggesting that metronidazole treatment of asymptomatic carriers of T vaginalis increased the risk of preterm birth.[94, 95] This was a controversial conclusion in that the investigators treated T vaginalis infection with 4 doses of 2 g metronidazole, which is significantly more than what is standard practice. The women included in the study were between 16 and 23 weeks’ gestational age, suggesting a significant delay in treatment. A subsequent study by Mann et al showed no increased risk of preterm birth with the use of metronidazole for the treatment of trichomoniasis.
Tinidazole has a longer half-life (12-14 h) than metronidazole (6-7 h). Single-dose therapy consists of 2 g taken with food. Cure rates range from 86-100%. Randomized clinical trials comparing single 2-g doses have shown metronidazole and tinidazole to be equally effective. For resistant infections, some recommend using 2 g twice daily for 14 days. In a case series by Hager et al, all 3 patients who failed 3 regimens of metronidazole therapy were cured by tinidazole.
Patients on tinidazole therapy should not consume alcohol during therapy or for 72 hours after completion of the medication.
Tinidazole is a pregnancy class C agent; animal studies have demonstrated adverse effects on fetal development. Its use is not recommended in pregnant women.
In lactating women, it is recommended that breastfeeding be withheld during treatment and for 3 days after the last dose.
The CDC does not currently recommend the use of clotrimazole for treatment of trichomoniasis. Clotrimazole vaginal tablets have been used in the past. In a study by duBouchet et al, the cure rate was only 11% with this mode of therapy.
Some medical practitioners consider clotrimazole suppositories for patients with trichomoniasis who are in the first trimester of pregnancy. Clotrimazole mainly offers symptomatic treatment but may cure as many as 50% of infections. If this initial treatment fails, a single 2-g dose of metronidazole may be given during the second or third trimester of pregnancy.
Diet and Activity
Patients should be instructed to avoid alcohol while taking metronidazole, tinidazole, or other nitroimidazole drugs. The interaction of these drugs with alcohol may cause a disulfiramlike reaction.
Modifying sexual behavior helps reduce the incidence of infection. Patients should avoid sex until drug therapy is completed and all symptoms have disappeared. Treatment of the patient’s partner is crucial for minimizing reinfection. Thereafter, consistent use of condoms and other barrier contraceptives reduces the chance of infection.
Abstinence from sexual intercourse prevents trichomoniasis. Limiting the number of sexual partners decreases the risk of trichomoniasis. Male condoms can protect against the transmission of trichomoniasis. Although the efficacy of female condoms is undefined, they may also provide some protection. Diaphragms have been shown to protect against trichomoniasis but should not be used as the primary source of protection against HIV.
Spermicides that contain nonoxynol-9 are not recommended for the prevention of sexually transmitted diseases. Frequent use is associated with disruption of the genital epithelium, which may be associated with an increased risk of HIV infection and other sexually transmissible agents.
Infected women who are sexually active have a high rate of reinfection and, thus, rescreening at 3 months post treatment should be considered.
Because trichomoniasis has a high rate of comorbidity with other STIs, providers should consider empiric treatment of infections that frequently coexist with trichomoniasis. Patients should be advised to follow up on results of other studies performed.
If symptoms persist despite pharmacotherapy, patients should follow up with their primary care providers. Persistent treatment failures may require metronidazole susceptibility testing through the CDC.
Sexual partners of patients infected with trichomoniasis must be treated to prevent reinfection. Patient and sexual partners should abstain from sexual intercourse until they have both completed therapy and are asymptomatic.
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