An incremental dosing protocol for women with severe vaginal trichomoniasis and adverse reaction to metronidazole

British Association for Sexual Health and HIV (BASHH) United Kingdom national guideline on the management of Trichomonas vaginalis 2021

The main objective of this guideline is to assist practitioners in managing individuals diagnosed with Trichomonas vaginalis (TV). It offers recommendations on the diagnostic tests, treatment regimens and health promotion principles needed for the effective management of TV. It covers the management of the initial presentation, as well as how to prevent transmission and future re-infection. It is aimed primarily at people aged 16 years or older presenting to health care professionals, working in departments offering specialist care in sexually transmitted infection (STI) management within the United Kingdom. However, the principles of the recommendations are applicable across all levels of STI care providers (N.B. non-specialist services may need to develop, where appropriate, local care pathways).

Immediate and Delayed Hypersensitivity Reactions to Antibiotics: Aminoglycosides, Clindamycin, Linezolid, and Metronidazole

Hypersensitivity reactions including IgE-mediated and delayed cell-mediated reactions to aminoglycosides, clindamycin, linezolid, and metronidazole are rare. For aminoglycosides, allergic contact dermatitis is the most frequent reaction for which patch testing can be a useful step in evaluation. For clindamycin, delayed maculopapular exanthems are the most common reactions. There are case reports of clindamycin associated with drug rash with eosinophilia and systemic symptoms (DRESS), acute generalized exanthematous pustulosis (AGEP), acute febrile neutrophilic dermatosis, and symmetrical drug-related intertriginous and flexural exanthema (SDRIFE). For linezolid, cases of hypersensitivity were exceedingly rare and included urticaria, angioedema, anaphylaxis, delayed rashes, and DRESS. For metronidazole, only rare cases were found across a broad spectrum of reactions including allergic contact dermatitis, fixed drug eruption, angioedema, anaphylaxis, serum sickness-like reaction, SJS/TEN, AGEP, SDRIFE, and a possible case of DRESS. IgE-mediated reactions and anaphylaxis to these types of antibiotics are uncommon, and reports of skin testing concentrations and desensitization protocols are largely limited to case reports and series. Non-irritating skin testing concentrations have been reported for gentamycin, tobramycin, and clindamycin. Published desensitization protocols for intravenous and inhaled tobramycin, oral clindamycin, intravenous linezolid, and oral and intravenous metronidazole have also been reported and are reviewed.

Failure of a single day metronidazole desensitization protocol, and success of a modified two-day protocol in an outpatient setting

Background

True allergy to metronidazole, a common anti-infective in clinical practice, is rarely reported in the literature. In the case of Trichomonas, there are few alternatives to the nitrimidazole class of drugs, and the alternatives that do exist are associated with worse clinical outcomes. Accordingly, for the rare patients with Type 1 hypersensitivity reactions to metronidazole but compelling need, desensitization protocols have been adapted previously. Reactions during these protocols appear common. Patients in previous regimens have required higher level care for observation, which is costly and resource-intensive.

Case presentation

We report here on a successful outpatient two-day regimen for metronidazole desensitization. Our patient had compelling indication for metronidazole, but reacted after receiving the very first dose of a previously described desensitization protocol. Accordingly, the protocol was adapted further. Despite this, she went on to develop objective hives prior to reaching the full intended dose. With appropriate symptom management and pre-medication on the second day in clinic, she was successfully desensitized and able to complete a week of full-dose metronidazole. No acute care resources were needed.

Conclusion

We propose this two-day desensitization regimen for patients who react during the previously described desensitization protocols. This regimen was effective and safe, and did not necessitate the use of acute-care resources. Two-day desensitization protocols while relatively uncommon, can be successful.

Management of Trichomoniasis in the Setting of 5-Nitroimidazole Hypersensitivity

ABSTRACT

Metronidazole and other 5-nitroimidazoles are the mainstay of Trichomonas vaginalis treatment, with few efficacious and safe treatment options available outside of this class. Patients with trichomoniasis and a history of a clinically confirmed hypersensitivity reaction to 5-nitroimidazoles present a management challenge for clinicians. The first step in managing such patients is metronidazole desensitization. In situations where this cannot be performed or tolerated, treatment with alternative regimens outside of the 5-nitroimidazole class, such as intravaginal boric acid or paromomycin, may be possible.

Recent advances in the epidemiology, diagnosis, and management of Trichomonas vaginalis infection

Trichomonas vaginalis is the most common, curable non-viral sexually transmitted infection (STI) worldwide. Despite this burden of disease, it is not currently a reportable disease in the United States. Recent advances in the epidemiology, diagnosis, and management of T. vaginalis infection are described in this article. This includes updated global and U.S. prevalence data in women and men as well as recent epidemiological data in HIV-infected individuals and pregnant women. Advances in molecular diagnostics are also reviewed, as are data from recent clinical trials regarding the treatment of trichomonas in women.

Increased intracellular Cl- concentration mediates Trichomonas vaginalis-induced inflammation in the human vaginal epithelium

Trichomonas vaginalis is a primary urogenital parasite that causes trichomoniasis, a common sexually transmitted disease. As the first line of host defense, vaginal epithelial cells play critical roles in orchestrating vaginal innate immunity and modulate intracellular Cl^- homeostasis via the cystic fibrosis transmembrane conductance regulator (CFTR), an anion channel that plays positive roles in regulating nuclear factor-κB (NF-κB) signalling. However, the association between T. vaginalis infection and intracellular Cl^- disequilibrium remains elusive. This study showed that after T. vaginalis infection, CFTR was markedly down-regulated by cysteine proteases in vaginal epithelial cells. The intracellular Cl^- concentration ([Cl^-]_i) was consequently elevated, leading to NF-κB signalling activation via serum- and glucocorticoid-inducible kinase-1. Moreover, heightened [Cl^-]_i and activated NF-κB signalling could be sustained in a positive feedback regulatory manner resulting from decreased intracellular cAMP through NF-κB-mediated up-regulation of phosphodiesterase 4. The results conclusively revealed that the intracellular Cl^- of the human vaginal epithelium could be dynamically modulated by T. vaginalis, which contributed to mediation of epithelial inflammation in the human vagina.

Antiparasitic activity of synthetic curcumin monocarbonyl analogues against Trichomonas vaginalis

Trichomoniasis is a parasitic infection caused by Trichomonas vaginalis and it is considered to be the most common non-viral sexually transmitted infection in the world. Since the 1960s, nitroimidazoles such as metronidazole are the drugs of choice for the treatment of trichomoniasis, but many adverse effects and allergic reactions may result from their use. Reports of metronidazole-resistant infections also highlight the importance for the search of new anti-T. vaginalis agents. Considering this, herein we report the anti-T. vaginalis evaluation of 21 synthetic monocarbonyl analogues of curcumin, which itself has been reported to possess antiparasitic potential. From the in vitro analysis of the synthetic molecules, untreated trophozoites, and metronidazole at 100 μM, it was observed that three curcumin analogues (3a, 3e, and 5e) exhibited anti-T. vaginalis activity comparable to metronidazole (no significant statistical difference). Optimal antiparasitic concentrations were determined to be 80 μM and 90 μM for propanone derivatives 3a and 3e, respectively, and 200 μM for cyclohexanone derivative 5e. Kinetic growth curves showed that, after 24 h, the trophozoites were completely inhibited. At the tested concentrations, natural curcumin did not significantly inhibit the growth of trophozoites, therefore demonstrating that the designed synthetic molecules not only have better chemical stability, but also higher anti-T. vaginalis potential. Cytotoxicity analysis, performed on VERO cells, demonstrated low, moderate and high cytotoxic effects for analogues 3e, 5e and 3a, respectively. This study suggests that these analogues possess chemical features of interest to be further explored as alternatives for the treatment of trichomoniasis.

2018 European (IUSTI/WHO) International Union against sexually transmitted infections (IUSTI) World Health Organisation (WHO) guideline on the management of vaginal discharge

Four common pathological conditions are associated with vaginal discharge: bacterial vaginosis, aerobic vaginitis, candidosis, and the sexually transmitted infection, trichomoniasis. Chlamydial or gonococcal cervical infection may result in vaginal discharge. Vaginal discharge may be caused by a range of other physiological and pathological conditions including atrophic vaginitis, desquamative inflammatory vaginitis, cervicitis, and mucoid ectopy. Psychosexual problems may present with recurrent episodes of vaginal discharge and vulval burning. These need to be considered if tests for specific infections are negative. Many of the symptoms and signs are non-specific and a number of women may have other conditions such as vulval dermatoses or allergic and irritant reactions.

Trichomoniasis - are we giving the deserved attention to the most common non-viral sexually transmitted disease worldwide?

ETIOLOGY

Trichomonas vaginalis is the etiologic agent of trichomoniasis, the most common non-viral sexually transmitted disease (STD) in the world. Transmission: Trichomoniasis is transmitted by sexual intercourse and transmission via fomites is rare. Epidemiology, incidence and prevalence: The WHO estimates an incidence of 276 million new cases each year and prevalence of 187 million of infected individuals. However, the infection is not notifiable. Pathology/Symptomatology: The T. vaginalis infection results in a variety of clinical manifestations - in most cases the patients are asymptomatic, but some may develop signs typically associated to the disease. Importantly, the main issue concerning trichomoniasis is its relationship with serious health consequences such as cancer, adverse pregnancy outcomes, infertility, and HIV acquisition. Molecular mechanisms of infection: To achieve success in parasitism trichomonads develop a complex process against the host cells that includes dependent- and independent-contact mechanisms. This multifactorial pathogenesis includes molecules such as soluble factors, secreted proteinases, adhesins, lipophosphoglycan that culminate in cytoadherence and cytotoxicity against the host cells. Treatment and curability: The treatment with metronidazole or tinidazole is recommended; however, cure failures remain problematic due to noncompliance, reinfection and/or lack of treatment of sexual partners, inaccurate diagnosis, or drug resistance. Therefore, new therapeutic alternatives are urgently needed. Protection: Strategies for protection including sexual behavior, condom usage, and therapy have not contributed to the decrease on disease prevalence, pointing to the need for innovative approaches. Vaccine development has been hampered by the lack of long-lasting humoral immunity associated to the absence of good animal models.

United Kingdom National Guideline on the Management of Trichomonas vaginalis 2014

The main objective is to assist practitioners in managing men and women diagnosed withTrichomonas vaginalis(TV) infection. This guideline offers recommendations on the diagnostic tests, treatment regimens and health promotion principles needed for the effective management of TV, covering the management of the initial presentation, as well as how to prevent transmission and future infection.

Modified oral metronidazole desensitization protocol

The Center for Disease Control guidelines recommend desensitization to metronidazole in patients with trichomoniasis and hypersensitivity to metronidazole. There is only one published oral metronidazole desensitization protocol. The purpose of this study was to design a new, more gradual oral desensitization protocol to decrease systemic reactions that may occur when using the previously published protocol. We present two patients with presumed IgE-mediated allergy to metronidazole who underwent oral desensitization using our modified protocol. Case 1 was a 65-year-old woman with trichomoniasis who presented for metronidazole desensitization with a history of intraoperative anaphylaxis and positive skin tests to metronidazole. The patient tolerated six doses of the modified desensitization but developed systemic symptoms of nasal congestion and diffuse pruritus after the 25- and 100-mg doses. Both reactions were treated with intravenous (i.v.) antihistamines. Because of gastrointestinal irritation, the desensitization was completed at a dose of 250 mg orally every 6 hours. Case 2 was a 42-year-old woman with trichomoniasis and a history of hives immediately after administration of i.v. metronidazole who presented for desensitization. The patient had negative skin-prick and intradermal testing to metronidazole. She developed lip tingling and pruritus on her arms 15 minutes after the 10-mg dose. Fexofenadine at 180 mg was given orally and symptoms resolved. She tolerated the rest of the protocol without reaction and received a total dose of 2 g of metronidazole. Our oral metronidazole desensitization for presumed IgE-mediated reactions offers a second option for physicians wishing to use a more gradual escalation in dose.

European (IUSTI/WHO) guideline on the management of vaginal discharge, 2011

Three common infections are associated with vaginal discharge: bacterial vaginosis, trichomoniasis and candidiasis, of which trichomoniasis is a sexually transmitted infection (STI). This guideline covers the presentation and clinical findings of these infections and outlines the differential diagnoses. Recommendations for investigation and management based on currently available evidence are made, including the management of persistent and recurrent infections.

Symptomatic Trichomonas vaginalis infection in the setting of severe nitroimidazole allergy: successful treatment with boric acid

This report describes a patient with symptomatic Trichomonas vaginalis infection who was unable to tolerate nitroimidazole drugs because of severe hypersensitivity, for which desensitisation was not possible. Use of intravaginal clotrimazole, intravaginal paromomycin, intravaginal furazolidone, povidone–iodine douches, and oral nitazoxanide were unsuccessful in eradicating the patient’s T. vaginalis infection. A 2-month course of intravaginal topical boric acid subsequently achieved a complete symptomatic cure and the patient remained T. vaginalis wet prep- and culture-negative 60 days after treatment.

Refractory Trichomoniasis in HIV-positive and HIV-negative Subjects

Trichomonas vaginalis, a common pathogen, remains widely unknown to the public. Its clinical consequences include upper genital tract infection, increased risk of preterm delivery, and increased risk of HIV transmission. Diagnostic tests, especially in men, have historically had low sensitivity, but the recent development of rapid, reliable point-of-care testing is a step toward improved detection. Reliable treatments for trichomoniasis are limited to the nitroimidazoles, and options for cases with either hypersensitivity or resistance remain limited. In select resistant cases, alternatives, most notably paromomycin, may play a role. A complex interaction exists between T. vaginalis and HIV, whereby women with trichomoniasis are at increased risk for HIV and vice versa. It is hoped that diagnosis and treatment of trichomoniasis in women at high risk for HIV may help to lower the incidence of both infections.

Management of trichomonas vaginalis in women with suspected metronidazole hypersensitivity

BACKGROUND/OBJECTIVE

Standard treatment for Trichomonas vaginalis is metronidazole or tinidazole. Hypersensitivity to these drugs has been documented but is poorly understood. Desensitization is an option described in limited reports of women with hypersensitivity to nitroimidazoles. The purpose of this analysis is to improve documentation of management for trichomonas infections among women with metronidazole hypersensitivity.

STUDY DESIGN

Clinicians who consulted Centers for Disease Control and Prevention concerning patients with suspected hypersensitivity to metronidazole were provided with treatment options and asked to report outcomes.

RESULTS

From September 2003-September 2006, complete information was obtained for 59 women. The most common reactions were urticaria (47%) and facial edema (11%). Fifteen of these women (25.4%) were treated with metronidazole desensitization and all had eradication of their infection. Seventeen women (28.8%) were treated with alternative intravaginal drugs, which were less successful; 5 of 17 infections (29.4%) were eradicated.

CONCLUSION

Metronidazole desensitization was effective in the management of women with nitroimidazole hypersensitivity.

Trichomoniasis and its treatment

Trichomonas vaginalis has long been recognized as a cause of infectious vaginitis in women. More recently, studies have demonstrated a significant burden of disease in men with urethritis or men at high risk for sexually transmitted diseases. There is increasing interest in this pathogen as more data accumulates linking it to HIV transmission and perinatal morbidity. New diagnostic methods have emerged that may increase sensitivity of diagnosis or improve point-of-care access to testing. Nitroimidazoles remain the mainstay of therapy. Metronidazole and tinidazole are highly effective as single-dose therapy. Unfortunately, despite the link between T. vaginalis infection and perinatal morbidity, nitroimidazole therapy during pregnancy remains controversial. Although metronidazole resistance is currently uncommon, pharmacological features and nitroimidazole resistance patterns suggest that tinidazole may be more effective in treating patients with metronidazole treatment failure. Alternatives to nitroimidazole therapy are few, and most have limited efficacy and significant toxicity.

Trichomoniasis

Trichomoniasis is perhaps the most common curable sexually transmitted disease worldwide, yet few resources are devoted to its control. It is associated with potentially serious complications such as preterm birth and human immunodeficiency virus acquisition and transmission. The immunology of a related organism, Tritrichomonas foetus, which causes disease in cattle, has been investigated to some extent, but more work is needed for the human strain, Trichomonas vaginalis. In addition, although trichomoniasis is easily treated with oral metronidazole, there is concern that the number of strains resistant to this antibiotic are increasing, and currently no alternative is licensed in the United States. As more is appreciated concerning the important public health implications of this common infection, more work will need to be done in understanding the diagnosis, treatment, and immunology of this organism.

Public health issues related to infection in pregnancy and cerebral palsy

Cerebral palsy is the most common neuromotor developmental disability of childhood, affecting as many as 8,000 to 12,000 children born in the U.S. each year (corresponding to a prevalence rate of between 2 and 3 per 1000 children). Recent improvements in neonatal care have not resulted in a decline in the overall prevalence of cerebral palsy and, in fact, greater numbers of very preterm/very low birth weight infants are surviving with cerebral palsy and other developmental problems. Infection in pregnancy may be an important cause of the disorder. In preterm infants, there appears to be about a 2-fold increased risk for cerebral palsy from chorioamnionitis, and in term infants the estimated increased risk is about 4-fold. Provisionally, chorioamnionitis might account for 12% of spastic cerebral palsy in term infants and 28% of cerebral palsy in preterm infants. Studies of biochemical markers of fetal inflammation typically associated with infection also suggest that an inflammatory response may be an important independent etiologic factor. If a substantial proportion of cerebral palsy is attributable to acute amnionitis infection and/or neonatal sepsis, cerebral palsy should have decreased in the United States after administration of intrapartum antibiotics became widespread in response to publication of public health consensus guidelines for Group B streptococcus in 1996. However, failure to detect declines could have a number of explanations and these explanations illustrate the many public health challenges related to intrauterine infection and cerebral palsy. Given the gaps in our current knowledge about intrauterine infection and cerebral palsy, public health recommendations for timely and specific prevention activities are limited at this time.

Antimicrobial agents: pharmacology and clinical application in obstetric, gynecologic, and perinatal infections

The pharmacology of selective antimicrobial agents and their role in the treatment of obstetric, gynecologic, and neonatal infections is the focus of this clinical review. Defining and refining the use of antimicrobial therapy is significant on both an individual and a global level because the emergence of resistant organisms is a public health concern. Heath care providers must be knowledgeable about the risks and benefits of initiating pharmacologic treatment based on clinical evidence with regard to an agent's spectrum of activity, efficacy, and side effects.

Managing Resistant Trichomonas Vaginitis

Vaginal trichomoniasis is a sexually transmitted disease of worldwide importance that is commonly treated with metronidazole. Although surprisingly uncommon, resistance to metronidazole has nevertheless been widely reported. Patients with suspected resistant trichomoniasis should have the diagnosis confirmed either by visualization of motile trichomonads on saline microscopy or by culture. In addition, reinfection from a partner must be ruled out through a careful history. Data regarding treatment of metronidazole-resistant trichomoniasis are mainly limited to case reports or series. Most cases can be treated successfully with increasing doses of oral metronidazole. Other promising options include oral tinidazole and topical paromomycin cream.

Vaginitis in the adolescent patient

For any clinician involved in the health care of women, vaginitis remains an unavoidable problem. Vaginitis accounts for an estimated 10 million office visits each year, and it remains the most common reason for patient visits to obstetrician-gynecologists. Despite extensive self-diagnosis and self-treatment for vaginal symptoms in all age groups, important questions persist about the accuracy of such an approach. This article addresses these questions and approaches.

Current evaluation and management of vulvovaginitis

There are many problems in the diagnosis and treatment of vaginitis. Often, the patient is not examined (telephone treatment) or examined improperly with lack of attention to the wet prep. In patients with recurrent vaginitis, it should not be assumed that the current infection is the same as a previous infection without a thorough examination. At times, there is an overuse of topical steroids for all vulvar symptoms or use of antifungals for all vulvar symptoms. The various abnormalities in vulvovaginitis have unique physical findings, laboratory tests, and treatments. It should be remembered that unusual conditions of the vagina and vulva may resemble vulvovaginitis. Many vulvar conditions must be considered when a patient reports discharge and itching. It is important to remember that if the treatment is not working, reconsider the diagnosis.