Antimicrobial therapy is the standard of care for trichomoniasis in both genders once the diagnosis has been confirmed. The symptoms of trichomoniasis among infected men may disappear within a few weeks even without treatment, but asymptomatic men may continue to be infectious and should therefore be treated. Antimicrobial therapy generally includes either metronidazole or tinidazole 2 g PO in a single dose. Prolonged therapy for 7 days is indicated among patients who fail to respond to the initial course of therapy. Following successful treatment, individuals may still be susceptible to re-infection.

Antimicrobial therapy is the standard of care for trichomoniasis in both genders once the diagnosis has been confirmed.^[1][2][3] The symptoms of trichomoniasis in infected men may disappear within a few weeks even without treatment, but asymptomatic men may continue to be infectious and should therefore be treated.

• 1. T. vaginalis infection in women

• Preferred regimen: Metronidazole 500 mg PO bid for 7 days
• Alternative regimen: Tinidazole 2 g PO in a single dose
• Note: Patients should avoid sexual contact until they are fully cured of trichomoniasis
• Note: Testing for other STIs, including HIV, syphilis, gonorrhea, and chlamydia, should be performed for persons with T. vaginalis.

2. T. vaginalis infection in men

• Preferred regimen: Metronidazole 2 g PO in a single dose
• Alternative regimen: Tinidazole 2 g PO in a single dose
• Note: Patients should avoid sexual contact until they are fully cured of trichomoniasis
• Note: Testing for other STIs, including HIV, syphilis, gonorrhea, and chlamydia, should be performed for persons with T. vaginalis.

• 2. T. vaginalis infection in pregnant and lactating Women

• 2.1 Pregnant women

• Preferred regimen: Metronidazole 2 g PO in a single dose

• 2.2 Post-partum and Breastfeeding

• Preferred regimen (1): Metronidazole 500 mg PO bid for 7 days
• Preferred regimen (2): Tinidazole 2 g PO in a single dose
• Note (1): Do not breastfeed for 12-24 hrs following Metronidazole and 72 hrs following Tinidazole
• Note (2): Symptomatic pregnant women, regardless of pregnancy stage, should be tested and considered for treatment.^[4] Pregnant women should be advised of the risk and benefits to treatment as infection (definitely) and treatment (possibly)
• Note (3): Pregnant women with HIV who are treated for T. vaginalis infection should be retested 3 months after treatment.

• 3. T. vaginalis infection in patients with HIV

• Preferred regimen: Metronidazole 500 mg PO bid for 7 days

• 4. Persistent or recurrent trichomoniasis^[5]

• 4.1 Treatment failure:
  • 4.1.1 In a woman after completing a regimen and has been re-exposed to an untreated partner
    • Preferred regimen: Metronidazole 500 mg PO bid for 7 days
  • 4.1.2 In a woman after completing a regimen and no re-exposure has occurred:
    • Preferred regimen (1): Metronidazole 2 g PO for 7 days
    • Preferred regimen (2): Tinidazole 2 g PO for 7 days
  • 4.1.3 In men after completing a regimen and has been re-exposed to an untreated partner
    • Preferred regimen: Metronidazole single 2-g dose.
  • 4.1.4 In men after completing a regimen and no re-exposure has occurred:
  • Preferred regimen (1): Metronidazole 500 mg PO BID for 7 days.
• 4.2 Nitroimidazole-resistant T. vaginalis
• Antibiotic susceptibility testing recommended
• Preferred regimen: Tinidazole or metronidazole 2 g daily for 7 days
• Alternative regimen (1): high-dose oral tinidazole 2 g daily plus tinidazole 500 mg BID intravaginal for 14 days
• Alternative regimen (2): If the first failed, high-dose oral tinidazole 1 g TID plus paromomycin 4 g of 6.25% intravaginal paromomycin cream nightly for 14 days.

• Sexual partners of patients with trichomoniasis should be treated.^[3][6]
• Patients and their sexual partners should avoid sexual contact until they are fully cured of trichomoniasis.

• Patients should be re-evaluated at the end of the antimicrobial therapy regimen to determine whether therapy has been successful.
• Patients should be instructed that they are still susceptible to re-infection.
• Retesting is recommended for sexually active women within 3 months of treatment for initial infection. If retesting at 3 months is not possible, clinicians should retest whenever persons next seek medical care <12 months after initial treatment. ^[7]
• Data are insufficient to support retesting men after treatment.

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