What is the recommended treatment for trichomoniasis?

Treatment for Trichomoniasis

Metronidazole 500 mg orally twice daily for 7 days is the preferred treatment for trichomoniasis, achieving superior cure rates of 90-95% compared to single-dose therapy. 1, 2, 3

First-Line Treatment Regimen

• Metronidazole 500 mg orally twice daily for 7 days is the recommended regimen based on CDC guidelines, with demonstrated cure rates of 90-95%. 1, 2, 3

• While metronidazole 2 g as a single oral dose was historically recommended and remains FDA-approved 4, recent high-quality evidence shows the 7-day regimen is significantly more effective, with treatment failure rates of only 11% versus 19% for single-dose therapy (p<0.0001). 5

• The 7-day regimen should be prioritized despite the convenience of single-dose therapy, as the improved efficacy outweighs the minor adherence concerns. 5

Alternative Treatment Options

• Tinidazole 2 g orally as a single dose is an FDA-approved alternative nitroimidazole for trichomoniasis treatment. 6

• Metronidazole 2 g single dose may be considered when the 7-day regimen is not feasible, though it has lower efficacy. 7

Critical Management Principles

• All sexual partners must be treated simultaneously to prevent reinfection, which is the most common cause of treatment failure. 1, 2, 3

• Patients must abstain from sexual activity until both they and their partners complete treatment and are asymptomatic. 1, 2, 3

• Advise patients to avoid alcohol during treatment and for at least 24 hours after completing metronidazole therapy due to potential disulfiram-like reaction (nausea, vomiting, flushing, headache, abdominal cramps). 1

Common Pitfall to Avoid

• Never use topical metronidazole gel for trichomoniasis treatment—it has efficacy <50% and fails to achieve therapeutic levels in the urethra and perivaginal glands. 7, 1, 2

Treatment Failure Algorithm

• First treatment failure: Re-treat with metronidazole 500 mg twice daily for 7 days. 7, 1, 2, 3

• Second treatment failure: Administer metronidazole 2 g once daily for 3-5 days. 7, 1, 2, 3

• Persistent failure after excluding reinfection: Consult infectious disease specialist for possible resistant infection. 1, 3

Special Populations

Pregnancy

• Metronidazole is contraindicated in the first trimester. 2, 3

• After the first trimester, treat with metronidazole 2 g orally as a single dose (lower dose to minimize fetal exposure). 7, 3

• Treatment is important as trichomoniasis is associated with premature rupture of membranes and preterm delivery. 7, 3

HIV-Infected Patients

• Use the same treatment regimens as HIV-negative patients—no modification needed. 1, 2, 3

Metronidazole Allergy

• Effective alternatives are extremely limited; patients with immediate-type allergy may require desensitization. 3

Follow-Up Recommendations

• Routine follow-up is unnecessary for patients who become asymptomatic after treatment. 7, 1, 2, 3

• Re-evaluate only if symptoms persist, considering reinfection (most common) or resistant infection. 2, 3