Treatment of Trichomoniasis
The recommended first-line treatment for trichomoniasis is metronidazole 500 mg orally twice daily for 7 days, which has cure rates of approximately 90-95%. 1
First-Line Treatment Options
- Metronidazole 500 mg orally twice daily for 7 days is the preferred regimen according to the Centers for Disease Control and Prevention (CDC) 1
- An alternative regimen is metronidazole 2 g orally in a single dose, though this has been shown to be less effective than the 7-day regimen 2, 3
- Tinidazole is also FDA-approved for trichomoniasis treatment and can be used as an alternative option 4, 5
Management of Sexual Partners
- All sexual partners should be treated simultaneously to prevent reinfection 1, 6
- Patients should abstain from sexual activity until both they and their partners complete treatment and are asymptomatic 1
- Treating asymptomatic partners is essential as trichomoniasis is a sexually transmitted disease that can be passed between partners 6
Special Populations
Pregnancy
- Metronidazole is contraindicated during the first trimester of pregnancy 1, 7
- After the first trimester, pregnant women can be treated with metronidazole 2 g orally in a single dose 7
- Treatment is important as trichomoniasis has been associated with adverse pregnancy outcomes, including premature rupture of membranes and preterm delivery 7
HIV Infection
- Patients with HIV infection should receive the same treatment regimen as HIV-negative individuals 1, 7
- Treatment is particularly important in this population as T. vaginalis infection may increase HIV transmission 8
Treatment Failure Management
- For first treatment failure, re-treat with metronidazole 500 mg twice daily for 7 days 2, 1
- For repeated failure, administer metronidazole 2 g once daily for 3-5 days 2, 1
- If treatment continues to fail and reinfection has been excluded, consult with an infectious disease specialist 1, 9
- Emerging resistance to metronidazole is a concern, with high-dose tinidazole being a potential option for resistant cases 9
Important Clinical Considerations
- Topical metronidazole gel is NOT effective for trichomoniasis (efficacy <50%) and should not be used 2, 10
- Asymptomatic infection is common in both men and women, making screening important in high-risk populations 8
- Follow-up is unnecessary for patients who become asymptomatic after treatment 2, 1
- Intravaginal options like metronidazole/miconazole suppositories may be considered for patients who cannot tolerate oral therapy, though these are not first-line treatments 11
Common Pitfalls and Caveats
- Failure to treat sexual partners is a common cause of recurrent infection 1, 8
- Mistaking treatment failure for reinfection (or vice versa) can lead to inappropriate management 1
- Using inadequate dosing or duration of therapy can contribute to treatment failure 3
- Alcohol should be avoided during treatment with metronidazole or tinidazole and for at least 24-72 hours afterward to prevent disulfiram-like reactions 6