What is the recommended treatment for trichomoniasis?

Treatment for Trichomoniasis

The recommended first-line treatment for trichomoniasis is metronidazole 2g orally in a single dose, which has a cure rate of 90-95% according to CDC guidelines. 1

First-line Treatment Options

• Metronidazole 2g orally in a single dose (preferred regimen) 2, 1
• Alternative regimen: Metronidazole 500mg twice daily for 7 days 2, 1

Recent evidence suggests that the 7-day regimen may be more effective than the single-dose treatment, with treatment failure rates of 11% versus 19% for the single-dose regimen 1, 3. A 2018 randomized controlled trial found that patients in the 7-day dose group were less likely to be T. vaginalis positive at test-of-cure than those in the single-dose group (11% vs 19%) 3.

Partner Treatment

• Sexual partners must be treated simultaneously to prevent reinfection 2, 1, 4
• Patients should avoid sexual activity until both they and their partners complete treatment and are asymptomatic 1

Follow-up Recommendations

• Routine test-of-cure is not necessary for patients who become asymptomatic after treatment 2, 1
• Retesting is recommended 3 months after treatment, regardless of whether sex partners were treated 1
• For pregnant women, retesting should be done 3-4 weeks after treatment 1

Management of Treatment Failures

If treatment failure occurs with the initial regimen:

1. First failure: Re-treat with metronidazole 500mg twice daily for 7 days 2, 1
2. Persistent failure: Administer metronidazole 2g once daily for 3-5 days 1
3. For resistant cases: Consider consultation with a specialist for susceptibility testing 1

Special Populations

Pregnant Women

• Metronidazole 2g orally in a single dose is safe after the first trimester 1
• Retesting 3-4 weeks after treatment is recommended 1

HIV-Positive Patients

• Same treatment regimen as HIV-negative patients 2, 1

Important Caveats

• Topical metronidazole gel is NOT recommended for trichomoniasis as it has <50% efficacy compared to oral preparations 1
• Tinidazole is an alternative medication approved for trichomoniasis treatment 5, 6, but metronidazole remains the first-line therapy
• Trichomoniasis has been associated with adverse pregnancy outcomes including premature rupture of membranes, preterm delivery, and low birthweight 2, 1
• Some T. vaginalis strains have diminished susceptibility to metronidazole but usually respond to higher doses 2, 1

Diagnosis Confirmation

Diagnosis should be confirmed through:

• Wet mount microscopy (60-70% sensitivity) 1
• Culture (most sensitive commercially available method) 1
• Nucleic acid amplification tests when available

Remember that trichomoniasis is a sexually transmitted infection that can lead to serious reproductive morbidity and amplified HIV transmission if left untreated 7. Proper treatment of both the patient and their sexual partners is essential for cure and prevention of reinfection.