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We read with interest the recent review on trichomoniasis and would like to share our experience of a patient with clinically resistant infection, in whom various therapies were tried until we achieved a successful response.1
A 39 year old Irish female factory worker presented in April 2001, complaining of a copious malodorous vaginal discharge associated with vulval soreness following unprotected sexual intercourse with a casual male partner 4 months previously. On examination the vulva and groin were erythematous and there was a profuse frothy yellow vaginal discharge with a pH >4.5. Microscopy revealed Trichomonas vaginalis and she was treated with a 5 day course of oral metronidazole 400 mg twice daily as per the UK national guidelines.2 Screening for chlamydia and gonorrhoea was negative.
Over the next 10 months, she re-attended a further eight times with persistent symptoms and on each occasion denied any sexual contact or non-compliance with treatment. After her third visit, a management strategy was implemented on the basis of a literature review with a named clinician. In total, she received two courses of oral metronidazole (one preceded by oral amoxicillin2), three courses of metronidazole suppositories (used as pessaries), a single dose of tinidazole, and a course of acetarsol and nononxynol-9 pessaries. However, despite the planned treatments microscopy was repeatedly positive. She even had her intrauterine device removed in case this contributed to the problem.
Finally, in February 2002, she was treated with oral metronidazole 400 mg three times daily and metronidazole pessaries 1 g daily for 2 weeks following the recommendations of another consultant colleague in the region. Her symptoms had resolved and microscopy was negative when reviewed 3 weeks later. She did not experience side effects secondary to the high dose metronidazole and continued 1 g pessaries once every 2 weeks for 2 months as maintenance therapy. The frequency was then reduced to every 4 weeks for 2 months and, reassuringly, microscopy remained negative. Treatment was then stopped and she has not re-attended subsequently.
Management of patients with treatment failure is challenging as sensitivity testing is currently unavailable. A key factor in this woman was her frustration with multiple therapies, which resulted in erratic attendance. Acetarsol and nononxynol-9 pessaries have been used with varying results but in our patient both were unsuccessful.3–5 In persistent infection it is important to ascertain a patient’s compliance with therapy and any possibility of re-infection, both of which were excluded. The use of extended courses of treatment has also been suggested in the management of other vaginal infections such as candidiasis and bacterial vaginosis.2,6 Certainly, in our patient this approach was required.
The distressing symptoms associated with clinically resistant trichomoniasis cannot be underestimated, thus sharing anecdotal management experience is essential. Devising a treatment schedule and providing a named clinician to ensure continuity of care is invaluable for such patients. We would suggest that re-treating with a prolonged course of oral and vaginal metronidazole at an early stage can result in a favourable outcome and should be considered.
Source of funding: none.
Conflict of interest: none.
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