What is the treatment for trichomoniasis?

Treatment of Trichomoniasis

The recommended first-line treatment for trichomoniasis is metronidazole 2g orally in a single dose, which achieves cure rates of approximately 90-95%. 1, 2

First-Line Treatment Options

• Metronidazole 2g orally in a single dose is the preferred treatment regimen for trichomoniasis, with high efficacy rates 3, 1
• An alternative regimen is metronidazole 500mg orally twice daily for 7 days, which may be more effective but requires longer treatment duration 3, 4
• Recent research suggests that the 7-day regimen may have higher cure rates (89% vs 81%) compared to the single-dose regimen 4

Management of Sexual Partners

• All sexual partners should be treated simultaneously to prevent reinfection, as trichomoniasis is a sexually transmitted disease 3, 1
• Patients should abstain from sexual activity until both they and their partners complete treatment and are asymptomatic 1, 5
• Treating asymptomatic partners is essential as they can serve as reservoirs for reinfection 2

Follow-Up Recommendations

• Routine follow-up is unnecessary for patients who become asymptomatic after treatment 3, 1
• If symptoms persist after initial treatment, patients should be re-evaluated for potential reinfection or treatment failure 3, 5

Treatment Failure Management

• For first treatment failure, re-treat with metronidazole 500mg twice daily for 7 days 3
• For repeated failure, administer metronidazole 2g once daily for 3-5 days 3, 1
• If treatment continues to fail and reinfection has been excluded, consultation with an infectious disease specialist is recommended 3, 5
• Consider susceptibility testing of T. vaginalis to metronidazole in cases of persistent infection 3

Special Populations

Pregnancy

• Metronidazole is contraindicated during the first trimester of pregnancy 3, 5
• After the first trimester, pregnant women can be treated with metronidazole 2g orally in a single dose 3
• Treatment is important as trichomoniasis has been associated with adverse pregnancy outcomes, including premature rupture of membranes and preterm delivery 3, 5

HIV Infection

• Patients with HIV infection should receive the same treatment regimen as HIV-negative individuals 3, 1

Metronidazole Allergy

• For patients with true metronidazole allergy, options are limited as effective alternatives are not readily available 3, 6
• Desensitization may be required in these cases 1, 6

Important Clinical Considerations

• Topical metronidazole gel is NOT effective for trichomoniasis (efficacy <50%) and should not be used 1, 7
• Metronidazole can cause a disulfiram-like reaction when combined with alcohol, including nausea, vomiting, flushing, headache, and abdominal cramps 1
• Patients should be advised to avoid alcohol during treatment and for at least 24 hours after completing metronidazole therapy 1
• Secnidazole (2g single dose) has recently been approved as an alternative treatment option with favorable pharmacokinetics and good tolerability 8
• Tinidazole is also FDA-approved for trichomoniasis treatment and may be considered as an alternative 9

Treatment Algorithm

1. First-line: Metronidazole 2g orally in a single dose 3, 1
2. Alternative: Metronidazole 500mg orally twice daily for 7 days (consider when adherence is not a concern) 3, 4
3. For treatment failure: Metronidazole 500mg twice daily for 7 days 3
4. For repeated failure: Metronidazole 2g once daily for 3-5 days 3, 1
5. For persistent infection: Consult infectious disease specialist and consider susceptibility testing 3, 5