What is the treatment for Trichomoniasis?

Treatment of Trichomoniasis

The first-line treatment for trichomoniasis is oral metronidazole 2g as a single dose, with cure rates of approximately 90-95%. 1, 2

First-Line Treatment Options

• Metronidazole 2g orally in a single dose is the recommended first-line treatment for trichomoniasis in both males and females 1, 2
• An alternative regimen is metronidazole 500mg orally twice daily for 7 days, which may be considered when medication adherence is not a concern 1, 3
• Recent evidence suggests that the 7-day regimen may be more effective than single-dose therapy (11% vs 19% treatment failure rates) 4
• Tinidazole is an FDA-approved alternative that can be used for trichomoniasis treatment 5

Management of Sexual Partners

• All sexual partners should be treated simultaneously to prevent reinfection 1, 3
• Patients should abstain from sexual activity until both they and their partners complete treatment and are asymptomatic 6, 3
• Asymptomatic partners should be treated even if diagnostic testing is negative or not performed, as they may still harbor the infection 2

Follow-Up Recommendations

• Routine follow-up is unnecessary for patients who become asymptomatic after treatment 3
• If symptoms persist after treatment, consider reinfection or resistant infection 6, 3

Treatment Failure Management Algorithm

1. For first treatment failure:

   • Re-treat with metronidazole 500mg twice daily for 7 days 3, 1

2. For second treatment failure:

   • Administer metronidazole 2g once daily for 3-5 days 3

3. For persistent failure:

   • Consider susceptibility testing of T. vaginalis to metronidazole 7
   • Consult with infectious disease specialist 6
   • Consider tinidazole as an alternative, which may be effective against some metronidazole-resistant strains 8

Important Clinical Considerations

• Topical metronidazole gel is NOT effective for trichomoniasis (efficacy <50%) and should not be used 3, 1
• Metronidazole can cause a disulfiram-like reaction when combined with alcohol, which may include nausea, vomiting, flushing, headache, and abdominal cramps 6
• Patients should be advised to avoid alcohol during treatment and for at least 24 hours after completing metronidazole therapy 6
• Common side effects include nausea (23%), headache (7%), and vomiting (4%) 4

Special Situations

Pregnancy

• Metronidazole 2g single dose is recommended for symptomatic pregnant women after the first trimester 3, 6
• Multiple studies have not demonstrated consistent association between metronidazole use during pregnancy and teratogenic effects 3

Metronidazole Allergy

• For patients with an immediate-type allergy to metronidazole, desensitization may be required 3
• Topical therapy with drugs other than nitroimidazoles can be attempted, but cure rates are low (<50%) 3
• High-dose intravaginal metronidazole combined with miconazole has shown promise in small studies (80% efficacy) but is not standard of care 9

HIV Infection

• Patients with HIV should receive the same treatment regimen as those without HIV 3, 1

Common Pitfalls and Caveats

• Failure to treat sexual partners is a common cause of recurrent infection 1, 10
• Metronidazole resistance is emerging and should be considered in cases of treatment failure 7
• Trichomoniasis is associated with adverse pregnancy outcomes and increased HIV transmission risk 10
• Asymptomatic infection is common in both men and women, highlighting the importance of screening high-risk individuals 10