Treatment in Pregnancy
The CDC recommends consideration of treatment for trichomoniasis during pregnancy with the use of metronidazole 2 g in a single dose at any time during pregnancy.4 Avoidance of tinidazole is recommended due to limited studies of its use during pregnancy.4
Treatment During Breastfeeding
Metronidazole 2 g in a single dose is recommended during breastfeeding.4 Metronidazole is secreted in breast milk. Some clinicians advise women to defer breastfeeding for 12 to 24 hours following a single metronidazole dose.4,7 If a single dose of tinidazole 2 g is prescribed, breastfeeding should be deferred for 72 hours, according to the CDC.4
Partner Treatment for Trichomoniasis
Partners should be treated for trichomoniasis.4 The identification of the organism is not required before treatment.4,13 Health care providers may consider presumptive treatment of partners by expedited partner therapy, if available within the residing state.6,11 Testing should be offered to partners, as well.
Patient Counseling and Education
Patient education and counseling are essential to properly treating trichomoniasis and determining recurrent or resistant infections. Health care providers should properly educate patients on proper medication usage, abstention from sexual intercourse until a partner is treated, and retesting recommendations.
Persistent and Recurrent Trichomoniasis
Women who present with ongoing symptoms following treatment should be evaluated for recurrent (or persistent) trichomoniasis.4 Recurrent trichomoniasis stemming from treatment failure, which occurs in approximately 2% to 5% of patients, should be distinguished from reinfection, which is more common and reported to occur in up to 17% of women at 3 months.4,7 Reinfection may occur due to a lack of partner treatment, inadequate partner treatment, or infection by a new partner.4-6 There is no laboratory test to differentiate recurrent trichomoniasis and reinfection.
The CDC recommends metronidazole 500 mg twice daily for 7 days for women with recurrent infection following a metronidazole 2 g single dose.4 Partners should receive retreatment as well with the same drug regimen. If this regimen fails, the CDC recommends treatment with metronidazole or tinidazole at 2 g for 7 days for the patient and their partner.4
Resistant trichomoniasis should be suspected if a woman fails both treatment regimens for recurrent infection.4 The CDC recommends testing of the organism for metronidazole and tinidazole susceptibility and referral to a specialist.4,5 Health care providers should reach out to the CDC directly for assistance with suspected cases of treatment-resistant trichomoniasis (404-718-4141 or https://www.cdc.gov/laboratory/specimen-submission/detail.html?CDCTestCode=CDC-10239).4,5
For documented nitroimidazole-resistant infections, the CDC recommends tinidazole 2 to 3 g for 14 days, often in combination with intravaginal tinidazole 500 mg twice daily.4 Alternative regimens might be effective in eradicating the infection including compound intravaginal paromomycin in conjunction with tinidazole or intravaginal boric acid.4,5 However, these regimens have not been systemically evaluated. Health care providers should consult with an infectious disease specialist to determine if an alternative regimen is recommended.3
Trichomoniasis is a highly prevalent STI.1 It is essential for health care providers to be up to date on screening, clinical presentation, testing methods, and treatment options available for this common STI. With the emergence of recurrent and resistant infections, health care providers should have increased knowledge on how to distinguish and treat these types of infections. The CDC serves as a vital resource when caring for patients with resistant infections.
Shawana Moore, DNP, MSN, CRNP, WHNP-BC, is assistant professor and director of the Women’s Health-Gender Related Nurse Practitioner Program at Thomas Jefferson University, Jefferson College of Nursing in Philadelphia. She has a passion for providing women’s and reproductive health care to underserved populations. She actively maintains clinical practice by serving as a women’s health nurse practitioner at health care organizations in Pennsylvania and New Jersey. Dr. Moore serves on the Board of Directors as Chair-Elect of the National Association of Nurse Practitioners in Women’s Health.
- Centers for Disease Control and Prevention. Trichomoniasis — CDC Fact Sheet. Updated January 19, 2021. Accessed July 12, 2021. https://www.cdc.gov/std/trichomonas/stdfact-trichomoniasis.htm
- Kreisel KM, Spicknall IH, Gargano JW, Lewis FMT, Lewis RM, Markowitz LE, Roberts H, Johnson AS, Song R, St Cyr SB, Weston EJ, Torrone EA, Weinstock HS. Sexually transmitted infections among US women and men: prevalence and incidence estimates, 2018. Sex Transm Dis. 2021;48(4):208-214. doi:10.1097/OLQ.0000000000001355
- Flagg EW, Meites E, Phillips C, Papp J, Torrone EA. Prevalence of Trichomonas vaginalis among civilian, noninstitutionalized male and female population aged 14 to 59 years: United States, 2013 to 2016. Sex Transm Dis. 2019;46(10):e93-e96. doi:10.1097/OLQ.0000000000001013
- Workowski KA, Bolan GA. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015;64:1-137.
- Seña AC, Bachmann LH, Hobbs MM. Persistent and recurrent Trichomonas vaginalis infections: epidemiology, treatment and management considerations. Expert Rev Anti Infect Ther. 2014;12(6):673-685. doi:10.1586/14787210.2014.887440
- Alessio C, Nyirjesy P. Management of resistant trichomoniasis. Curr Infect Dis Rep. 2019;21(9):31. doi:10.1007/s11908-019-0687-4
- Kissinger P. Trichomonas vaginalis: a review of epidemiologic, clinical and treatment issues. BMC Infect Dis. 2015;15:307. doi:10.1186/s12879-015-1055-0
- Vaginitis in nonpregnant patients: ACOG Practice Bulletin, Number 215. Obstet Gynecol. 2020;135(1):e1-e17. doi:10.1097/AOG.0000000000003604
- Meites E, Gaydos CA, Hobbs MM, et al. A review of evidence-based care of symptomatic trichomoniasis and asymptomatic Trichomonas vaginalis infections. Clin Infect Dis. 2015;61 (suppl 8):S837-848. doi:10.1093/cid/civ738
- Miller JM, Binnicker MJ, Campbell S, et al. A guide to utilization of the microbiology laboratory for diagnosis of infectious diseases: 2018 update by the Infectious Diseases Society of America and the American Society for Microbiology. Clin Infect Dis. 2018;67(6):e1-e94. doi:10.1093/cid/ciy381
- Schumann JA, Plasner S. Trichomoniasis. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; Jan 2021. Available from: https://www.ncbi.nlm.nih.gov/books/NBK534826/
- Howe K, Kissinger PJ. Single-dose compared with multidose metronidazole for the treatment of trichomoniasis in women: a meta-analysis. Sex Transm Dis. 2017;44(1):29-34. doi:10.1097/OLQ.0000000000000537
- Seña AC, Miller WC, Hobbs MM, Schwebke JR, Leone PA, Swygard H, Atashili J, Cohen MS. Trichomonas vaginalis infection in male sexual partners: implications for diagnosis, treatment, and prevention. Clin Infect Dis. 2007;44(1):13-22. doi:10.1086/511144