Resistant trichomoniasis

Hello, Dr. Handsfield-

I don't know whether you are comfortable with specific patient questions, but I'm just looking for some guidance as to what other treatments to try, or where else i can go to find answers...
I'm a physician assistant in family planning. I have a woman patient with resistant trichomoniasis. She has been treated with:

1)Flagyl 500 mg PO bid x 7 days
2)Tindamax 500 mg 4 PO stat
3)Tindamax 500 mg 4 PO stat followed by Flagyl 500 mg PO bid x 14 days along with zinc sulfate douche 1% qd x 14 days
4) Vermox 100 mg PO bid x 3 days
5) Flagyl 500 mg 2 PO tid x 14 days along with MetroGel Vaginal 1 applicator qHS x 14 days

None have been effective. The last treatment regimen was the most effective, but not completely. The patient has not been sexually active since 8/04.

I have been attempting to search the medical literature and there does not seem to be a lot out there on any other alternatives. I've seen reference to paramomycin and to Vagisec suppositories, but apparently both have been removed from the market.  I've read reference to disulfiram, furazolidone, anisomycin and rifabutin, but nothing about dose or length of treatment. A pharmacist told me he found reference at one time to aminoglycosides being effective, but I have not been able to find any reference to these.  I've also read a case study where nonoxynol-9 worked, and have considered trying this.  

Do you have any recommendations as to what to try next or where to look for additional/more specific suggestions? I would truly appreciate it. Thank you!

Lisa S, PA-C

[H. Hunter Handsfield, M.D.]

Wow--not many cases will fail to respond to that barrage.  The next step may be parenteral (IV) therapy with metronidazole.  In theory, oral metronidazole gives blood levels about the same as IV, but some success has been reported with high dose IV therapy.  Fortunately, IV therapy usually no longer requires hospitalization for the entire treatment period.  But before proceding, I suggest getting a formal consult with an infectious disease-oriented gynecologist.  Such persons normally can be found in major medical centers.

Good luck--  HHH, MD