Background/introduction Trichomonas vaginalis (TV) remains common in England, with 6475 cases reported in 2013.1 BASHH guidelines2 advocate first line TV treatment with metronidazole (2 g stat or 400 mg BD for five to seven days) or a single dose of tinidazole (2 g). Recalcitrant infections have been well documented and may be caused by inadequate therapy, re-infection or antibiotic resistance.3 In the US, up to 5% of isolates of TV demonstrate a degree of resistance.4 In the UK there remains no facility to test for TV resistance, leading to multiple ‘blind’ treatment approaches. We wished to evaluate the prevalence and clinical management of recalcitrant TV in our services.
Methods Clinic databases were used to identify patients with recalcitrant TV attending two sexual health services over a two year period.
Results A total of 1046 cases of TV were seen across the two services in the study period. Four female patients (0.4%) with recalcitrant TV requiring three or more treatments were identified. The patients were aged between aged 25 and 47 years. Two were black British, one white British and one white European. All four patients failed to respond to at least two five day courses of metronidazole; they required between three and eleven different courses of treatment, as per the table below:
During the courses of treatment all four patients were microscopy and culture negative at least once. However, symptoms persisted and tests were subsequently positive on at least one other occasion, despite no risk of reinfection. Three patients subsequently responded to fourteen days of tinidazole and one required acetarsol treatment. Three were eventually cured of TV, taking between 3–7 months to achieve cure and 5 and 12 clinic visits; one was lost to follow up, presumed cured.
Discussion Recalcitrant TV is rare, but for patients affected, the absence of a UK facility to detect TV resistance means that individuals who fail to respond to first line therapy undergo multiple attempts at TV treatment, recurrent clinic visits and investigations.
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