I have a referred patient of 62 with extremely difficult to eradicate Trichomonas vaginalis. I tried all possible oral an vaginal, high dose, and different anti-parasitic medication, like metronidazole, tinidazole, probiotics, ornidazole, iso-betadine vaginal rinsings, paromomycin.....As infections were diagnosed with microscopy and PCR, I don't have resistance testing at the moment.
Two questions: 1) anybody knows what coud be a next step to treat? 2) anybody any information whether resistance pattern and/or treatment preference are specific for that area in the world?
Thanking you all for your advice and information!
Hai Gilbert,
We hebben er ooit 'ns een publicatie aan gewijd in Rotterdam, d.w.z. aan zeer moeilijk te behandelen T. vaginalis. Eerste auteur Robin van der Weiden, gynaecoloog in het st. Franciscus Gasthuis in Rotterdam. Misschien, het is al lang geleden, staat daar nog wat nuttigs in.
Groet,
Wim
Hello Gilbert
Maybe you could try with Nifuratel. Nifuratel displays a strong antiprotozoarian and antibacterial activity and is provided with certain fungicidal effect, but it is not active against the physiologic flora.
(Clinical effects of nifuratel in vulvovaginal infections. A meta-analysis of metronidazole-controlled trials.
Mendling W1, Poli A, Magnani P. Klinik für Frauenheilkunde und Geburtsmedizin, VIVANTES-Klinika am Urban und im Friedrichshain, Berlin, Germany)
Happy New Year Gilbert,
There are various reasons why TV may appear not to respond to standard treatment:
1. Genuine resistance to anti-trichomonal agents
2. Poor absorption of drug (blood levels needed for that)
3. Breakdown of drug in the vagina by other 'splitting' bacteria
4. Don't forget reinfection; has the partner been seen/treated?
In the good old days when metronidazole was still under patent, M&B (the British manufacturers) provided a free service which answered the first three of these, if one sent them the TV in question, a sample of blood 1/2 hour after ingestion of MTZ and a sample of vaginal flora. These tests should still be available, at a price!
To counter the bacterial splitting, we occasionally had success by giving a broad-spectrum antibiotic along with the MTZ or tinidazole.
Finally, I have never had a failure, once genuine resistance has been established, with Acetarsol pessaries although they themselves occasionally cause quite a vaginitis. (M Y Chen, N A Smith, E F Fox, J S Bingham, David Barlow (1999)
Acetarsol pessaries in the treatment of metronidazole-resistant Trichomonas vaginalis, Int. J. STD & AIDS; 10:277-280).
There have been anecdotal reports of success with tea-tree oil....
DON'T FORGET THE PARTNER!!!!
Dear David,
Thank you for the extensive answer, I appreciate it enormously. Acetarsol pesaaries are completely new to me and I will certainly check it out. Let there be no doubt that there is NO partner involved in this case as patient is copletely celebatary since the single encounter where she atrapped the disease. Also it is not even possible to have intercourse, so bad is this infection!
Also the hypothesis of malabsorption is no issue as I gave MTZ vaginally in high doses and even intraveneously in subtoxic doses, but without result!
The theory of the splitting bacteria requiring other antibiotics seems a little odd to me, but i will try.
To be honnest I am really out of options and quite desperate in this patient!
Gilbert
Thank you, Gilbert.
I don't have any recent references but inactivation of MTZ by other bacteria was an accepted fact of life back in the 1970s. I have located one article, the full text of which is available on Researchgate:
https://www.researchgate.net/publication/22434324_Inactivation_of_metronidazole_by_anaerobic_and_aerobic_bacteria
Hope this helps but I suspect you will need the acetarsol
David
Article Inactivation of Metronidazole by Anaerobic and Aerobic Bacteria
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