Original Title: Infection confirmée à Trichomonas vaginalis : traitement pharmacologique

Authors' objectives: In Québec, many people present with a persistent or recurrent syndrome compatible with a sexually transmitted and blood-borne infection, for which tests for Chlamydia trachomatis and Neisseria gonorrhoeae have proved negative, and for which appropriate syndromic treatment has proved ineffective. It is important to consider, in these people, the possibility of the presence of chronic conditions or of other pathogens, including Mycoplasma genitalium and Trichomonas vaginalis. In light of these findings, and in response to growing demand from Québec healthcare professionals for a clinical tool on this subject, a new optimal usage guide on confirmed T. vaginalis infection has been developed.

Authors' results and conclusions: RESULTS (#1 ORAL NITROIMIDAZOLES ARE THE ONLY CLASS OF ANTIBIOTICS KNOWN TO BE EFFECTIVE AGAINST T. VAGINALIS INFECTION. IN QUEBEC, THE ONLY AGENT AVAILABLE IN THIS CLASS IS METRONIDAZOLE. TWO DIFFERENT DOSAGES OF METRONIDAZOLE CAN BE USED (500 MG PO BID X 7 DAYS OR 2 G PO AS A SINGLE DOSE). THE CHOICE OF ORAL METRONIDAZOLE DOSAGE SHOULD BE BASED ON THE NATURE OF THE PATIENT'S SYMPTOMS (SYMPTOMS OF VAGINITIS, CERVICITIS OR URETHRITIS): If vaginitis or cervicitis of confirmed T. vaginalis etiology is present, the efficacy of the multidose oral metronidazole regimen (500 mg PO BID x 7 days) would be superior to that of the single-dose oral regimen (2 g PO as a single dose). However, no studies comparing the efficacy of multidose and single-dose oral regimens of metronidazole have been conducted when T. vaginalis urethritis is present. The use of metronidazole vaginal gel is not recommended for the treatment of confirmed T. vaginalis infections. (#2 THE INFECTED PERSON'S MOST RECENT PARTNER AND REGULAR PARTNER(S) SHOULD RECEIVE EPIDEMIOLOGICAL TREATMENT FOR T. VAGINALIS WITH EITHER OF TWO DOSAGES OF ORAL METRONIDAZOLE (500 MG PO BID X 7 DAYS OR 2 G PO AS A SINGLE DOSE): The nucleic acid amplification test is the most sensitive test for detecting T. vaginalis. When T. vaginalis is detected by this test, depending on the clinician's judgement and the anticipated delay in obtaining the partner's laboratory results, it may be possible to wait for the partner's results before treating them, if they are motivated and able to obtain treatment in the event of a positive test result. (#3 DUE TO THE RISKS ASSOCIATED WITH T. VAGINALIS INFECTION ON PREGNANCY OUTCOMES, TREATMENT MUST BE ADMINISTERED. AS THERE IS NO OTHER OPTION, METRONIDAZOLE IS THE RECOMMENDED TREATMENT DURING ALL PREGNANCY TRIMESTERS. IT IS ALSO THE RECOMMENDED TREATMENT DURING BREAST-FEEDING): The recommended dosage of oral metronidazole for confirmed T. vaginalis infection during pregnancy or breastfeeding is 500 mg PO BID x 7 days. (#4 IF ALLERGY TO NITROIMIDAZOLES IS PRESENT, CONSULTATION WITH AN EXPERIENCED COLLEAGUE IS REQUIRED. A SYSTEMATIC TEST OF CURE (IF THERE ARE NO PERSISTENT OR RECURRENT SYMPTOMS) IS NOT RECOMMENDED): If symptoms persist or recur, microbiological tests for T. vaginalis should be repeated at least three weeks after the end of treatment, if performed using a nucleic acid amplification test. If the test is performed by other means (wet-mount microscopy, culture, antigenic test), the interval may be shorter. CONCLUSION: The development of the optimal usage guide is based on clinical practice recommendations, which were supplemented with the perspectives of the stakeholders consulted and contextualized for Québec practice. This tool should help enhance and harmonize the practice and contribute to the effective management of persons with a confirmed T. vaginalis infection and of their sexual partners. However, the enhancement and harmonization of the practice will depend on: • The dissemination of the optimal usage guide; • The adherence to the changes and the uptake of the recommendations by the health professionals concerned; • The availability of training, if needed; and • The promotion of this tool within the health and social services system.

Authors' recommendations: Following the iterative process with the advisory committee’s members, during which the clinical data and recommendations from the literature, the contextual information and the perspectives of the different stakeholders consulted were triangulated, a series of conclusions and recommendations were drawn up regarding the management of persons with a confirmed T. vaginalis infection. These recommendations appear in text boxes throughout this report and have been incorporated into the clinical tool stemming from this project (an optimal usage guide).

Authors' methods: In order to respond to the mandate, a systematic review of best clinical practices for the management of confirmed T. vaginalis infections was conducted, based on publications listed in bibliographic databases and other sources of information. The information was analyzed from the perspective of contextualizing the practice in Québec, based mainly on legislative, regulatory and organizational contextual elements specific to Québec, and on the perspectives of the various stakeholders consulted. An advisory committee made up of clinicians from various specialties and areas of expertise was set up to gather stakeholders' perspectives. Finally, the overall quality of the work, its acceptability and applicability were assessed by external readers specializing in the field of interest, as well as by future users who had not been involved in the work.

Authors' identified further research: The advisability of updating the recommendations will be determined in 4 years from the date of publication, on the basis of the advances in the scientific data, changes in clinical practices, any significant changes in additional background documents published for example by the Institut national de santé publique du Québec, and the health and social services system’s needs in terms of future work on the management of confirmed T. vaginalis infections.

Project Status: Completed

Year Published: 2025

URL for published report: https://www.inesss.qc.ca/fileadmin/doc/INESSS/Rapports/Usage_optimal/ITSS_Infection_Trichomonas_vaginalis_GN_INESSS.pdf

English language abstract: An English language summary is available

Publication Type: Other

Country: Canada

Province: Quebec

Organisation Name: Institut national d'excellence en sante et en services sociaux

Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369

Contact Name: demande@inesss.qc.ca

Contact Email: demande@inesss.qc.ca

Copyright: L'Institut national d'excellence en sante et en services sociaux (INESSS)