eMedicine Specialties > Infectious Diseases > Parasitic Infections
Trichomoniasis: Treatment & Medication
Updated: Jan 5, 2010
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
- Prompt trichomoniasis diagnosis is important for eliminating infection in the patient and sexual partners.
- Treatment of sexual partners is thought to increase cure rates.2
- Systemic treatment is important to ensure a cure, as trichomoniasis is an infection of multiple sites (eg, vaginal epithelium, Skene glands, Bartholin glands, urethra).
- Oral metronidazole is the treatment of choice and has been demonstrated in multiple studies to offer efficacy that is superior to that of intravaginal treatment.
- Treatment with oral metronidazole is not associated with preterm birth and is protective in women diagnosed with trichomoniasis at 35 weeks’ gestation or later.13
- Drug resistance is rare, despite the prevalent use of nitroimidazole drugs in the treatment of trichomoniasis. Treatment failures may require a higher dose metronidazole regimen or the use of a different nitroimidazole.1
- In clinical practice, repeat testing is rarely performed unless symptoms do not improve with drug treatment. Theoretically, repeat testing at 5-7 and 30 days is recommended.1
- Routine screening for trichomoniasis in asymptomatic pregnant women is not currently recommended.2
Diet
Instruct the patient to avoid alcohol while taking metronidazole, tinidazole, or other nitroimidazole drugs. The interaction of the drugs and alcohol may cause a disulfiramlike reaction.
Activity
Patients should avoid sex until drug therapy is completed and all symptoms have disappeared.2 Treatment of the patient’s partner is crucial to avoid reinfection.
Medication
The 5-nitroimidazole group of drugs includes antiprotozoal agents (metronidazole, tinidazole, nimorazole, carnidazole) used for the treatment of trichomoniasis. In the Cochrane treatment review, metronidazole and other nitroimidazole group drugs were found to have comparable efficacy in treating trichomoniasis.1 The mechanism of action is not well understood; however, anaerobic organisms preferentially reduce the 5-nitro group, and active metabolites likely interact with anaerobic bacterial and protozoal DNA.
Resistance to these drugs is rare despite their widespread use in the treatment of trichomoniasis and is typically solved by increasing the dose or switching to another nitroimidazole.1 When standard treatment regimens fail, metronidazole or tinidazole at 2 g PO for 5 days should be considered.2
Drugs may also be applied locally in the vagina or rectum, although oral treatment is usually preferred. Local intravaginal medications include clotrimazole, povidone-iodine, and nonoxynol-9 (N-9). Metronidazole may also be applied vaginally or rectally to reach therapeutic concentrations in the blood. Topical drugs other than nitroimidazoles yield low cure rates (<50%).
Antiprotozoal agents
Therapy must be comprehensive and should cover all likely pathogens in the context of this clinical setting.
Metronidazole (Flagyl)
This medication is available PO, IV, and as intravaginal suppository gel. Highly effective in the treatment of many anaerobic bacterial and protozoal infections. Cure rates for trichomoniasis have been reported at 90-95% by the CDC.
Adult
2 g PO as single dose or 500 mg PO bid for 7 d
Pediatric
15 mg/kg/d PO tid for 7 d
Inhibits metabolism of warfarin and potentiates the anticoagulant effect; causes an intolerance to alcohol similar to disulfiram (therefore, avoid alcohol during treatment and for 24 h after administration); abdominal cramps, nausea, vomiting, headaches, and flushing occur when co-ingested with alcohol; cimetidine prolongs the plasma clearance by inhibiting metabolic enzymes; conversely, drugs that induce liver enzymes (eg, phenobarbital) may increase the elimination of metronidazole
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Usually well tolerated; commonly encountered adverse effects are nausea, vomiting, anorexia, and a metallic taste in the mouth; most serious adverse effects involve the nervous system and are manifested as convulsions and peripheral neuropathy, which are rare unless large doses are administered for a prolonged period; drug is slowly impaired in patients with reduced hepatic function; reduce dose in patients with reduced hepatic function to prevent toxic levels from building in the plasma
Tinidazole (Tindamax)
Nitroimidazole antiprotozoal agent. Nitro group is reduced by cell extract of Trichomonas. The free nitro radical generated is thought to be responsible for antiprotozoal activity against T vaginalis. Indicated to treat trichomoniasis caused by T vaginalis in both males and females. Cure rates for trichomoniasis have been reported at 86-100% by the CDC.
Adult
Treat individual and sexual partner: 2 g PO in a single dose with food
Pediatric
50 mg/kg PO once; 2 g maximum
Limited data exist; interaction information based on experience with other nitroimidazole derivatives (ie, metronidazole); may prolong PT when coadministered with warfarin; avoid alcoholic beverages and preparations containing ethanol or propylene glycol during and 3 d following administration (may cause disulfiramlike reaction); may increase serum levels of lithium, phenytoin, cyclosporine, tacrolimus, and fluorouracil; CYP450 inducers (eg, phenobarbital, rifampin, phenytoin) may increase elimination; CYP450 inhibitors (eg, cimetidine, ketoconazole) may decrease elimination; concurrent administration with cholestyramine may decrease oral bioavailability; oxytetracycline may antagonize effect
Documented hypersensitivity; first trimester of pregnancy
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Carcinogenicity has been observed in mice and rats treated chronically with metronidazole (another nitroimidazole), although not observed with tinidazole, use cautiously; seizures and peripheral neuropathy have been reported; caution with history of blood dyscrasia; may cause metallic/bitter taste, nausea, anorexia, vomiting, weakness, fatigue, dizziness, or headache; if administered on day of hemodialysis, administer additional dose equivalent to one-half of recommended dose following dialysis
More on Trichomoniasis |
| Overview: Trichomoniasis |
| Differential Diagnoses & Workup: Trichomoniasis |
 Treatment & Medication: Trichomoniasis |
| Follow-up: Trichomoniasis |
| Multimedia: Trichomoniasis |
| References |
| Further Reading |
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References
Forna F, Gülmezoglu AM. Interventions for treating trichomoniasis in women. Cochrane Database Syst Rev. 2003;CD000218. [Medline].
[Guideline] Centers for Disease Control and Prevention (CDC), Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep. Aug 4 2006;55:1-94. [Medline].
Soper D. Trichomoniasis: under control or undercontrolled?. Am J Obstet Gynecol. Jan 2004;190(1):281-90. [Medline].
Gerbase AC, Rowley JT, Mertens TE. Global epidemiology of sexually transmitted diseases. Lancet. 1998;351 Suppl 3:2-4. [Medline].
Sobel JD. What's new in bacterial vaginosis and trichomoniasis?. Infect Dis Clin North Am. Jun 2005;19(2):387-406. [Medline].
Miller M, Liao Y, Gomez AM, Gaydos CA, D'Mellow D. Factors associated with the prevalence and incidence of Trichomonas vaginalis infection among African American women in New York city who use drugs. J Infect Dis. Feb 15 2008;197(4):503-9. [Medline].
Patel SR, Wiese W, Patel SC, Ohl C, Byrd JC, Estrada CA. Systematic review of diagnostic tests for vaginal trichomoniasis. Infect Dis Obstet Gynecol. 2000;8(5-6):248-57. [Medline].
Huppert JS. Trichomoniasis in teens: an update. Curr Opin Obstet Gynecol. Oct 2009;21(5):371-8. [Medline].
Laga M, Manoka A, Kivuvu M, et al. Non-ulcerative sexually transmitted diseases as risk factors for HIV-1 transmission in women: results from a cohort study. AIDS. Jan 1993;7(1):95-102. [Medline].
Moodley P, Wilkinson D, Connolly C, et al. Trichomonas vaginalis is associated with pelvic inflammatory disease in women infected with human immunodeficiency virus. Clin Infect Dis. Feb 15 2002;34(4):519-22. [Medline].
Grodstein F, Goldman MB, Ryan L, et al. Relation of female infertility to consumption of caffeinated beverages. Am J Epidemiol. Jun 15 1993;137(12):1353-60. [Medline].
Shafir SC, Sorvillo FJ, Smith L. Current issues and considerations regarding trichomoniasis and human immunodeficiency virus in African-Americans. Clin Microbiol Rev. Jan 2009;22(1):37-45, Table of Contents. [Medline].
Mann JR, McDermott S, Zhou L, Barnes TL, Hardin J. Treatment of trichomoniasis in pregnancy and preterm birth: an observational study. J Womens Health (Larchmt). Apr 2009;18(4):493-7. [Medline].
[Guideline] ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologists, Number 72, May 2006: Vaginitis. Obstet Gynecol. May 2006;107(5):1195-1206. [Medline].
Burtin P, Taddio A, Ariburnu O, et al. Safety of metronidazole in pregnancy: a meta-analysis. Am J Obstet Gynecol. Feb 1995;172(2 Pt 1):525-9. [Medline].
Guenthner PC, Secor WE, Dezzutti CS. Trichomonas vaginalis-induced epithelial monolayer disruption and human immunodeficiency virus type 1 (HIV-1) replication: implications for the sexual transmission of HIV-1. Infect Immun. Jul 2005;73(7):4155-60. [Medline]. [Full Text].
Nanda N, Michel RG, Kurdgelashvili G, et al. Trichomoniasis and its treatment. Expert Rev Anti Infect Ther. Feb 2006;4(1):125-35. [Medline].
Radonjic IV, Dzamic AM, Mitrovic SM, Arsic Arsenijevic VS, Popadic DM, Kranjcic Zec IF. Diagnosis of Trichomonas vaginalis infection: The sensitivities and specificities of microscopy, culture and PCR assay. Eur J Obstet Gynecol Reprod Biol. May 1 2006;126(1):116-20. [Medline].
Further Reading
ACOG Committee on Practice Bulletins--Gynecology. ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologists, Number 72, May 2006: Vaginitis. Obstet Gynecol. May 2006;107(5):1195-1206.
Abramowicz M (ed.). Drugs for Parasitic Infections. The Medical Letter. Aug 2004.
Burtin P, Taddio A, Ariburnu O. Safety of metronidazole in pregnancy: a meta-analysis. ALYSIS. Feb 1995;172(2 Pt 1):525-9.
Guenthner PC, Secor WE, Dezzutti CS. Trichomonas vaginalis-induced epithelial monolayer disruption and human immunodeficiency virus type 1 (HIV-1) replication: implications for the sexual transmission of HIV-1. Infect Immun. Jul 2005;73(7):4155-60. [Full Text].
Nanda N, Michel RG, Kurdgelashvili G, Wendel KA. Trichomoniasis and its treatment. Expert Rev Anti Infect Ther. Feb 2006;4(1):125-35.
Keywords
trichomoniasis, Trichomonas vaginalis, T vaginalis, vaginal trichomoniasis, trichomonads, Trichomonas tenax, T tenax, nongonococcal nonchlamydial urethritis, prostatitis, epididymitis, urethral stricture disease, pelvic inflammatory disease, colpitis macularis, vaginal discharge, vaginitis, cervicitis, dyspareunia, dysuria
