Resistant trichomoniasis

[lisamush1]

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

[trichyissues]

From what I have read, every case study with this sort of outrageously resistant trich has been in men, not women.  Makes me think the infection may be in her urethra as well as vaginal.  Are you certain that she isn't being reinfected w/ an untreated partner and is not comfortable stating as such?  Has she been given the megadose of 2g Flagyl?  My s.o. of many, many years strayed and gave me a nasty trich that likely brewed for over a year and created very distressing urinary tract symptoms (since I was in a long-term monogamous relationship, I never even thought about std's).  Here's what worked:  2g Flagyl, followed by 500 mg bid X 14 days, followed w/ another 2g after 14 days.  Partner treatment was essential as well.  This was augmented by a good bit of "natural" remedies, including high potency multivitamin, an additional B complex, an additional 100 mg vitamin C 4 X/day, new zealand colostrum, calendula, blue cohosh, acidophylus (sic?), abdominal castor oil packs (w/ the flannel and heat nonsense) for 1 hour/day.  This cured the dreadful stuff.  Here's some additional "natural" stuff that may augment traditional medical treatment.  My goals were to boost my immune system, make my body a very unpleasant place for any super-trich, and let the medications swoop in for cleanup.  I did not try these douches, but the ethanol extract ****** looks interesting.  
Sample douches:
One teaspoon of Melaleuca alternifolia (tea tree) oil in two cups of water.
two week treatment regime using Betadine preparations. These can be purchased pre diluted or one can be made from 1/2 tablespoon of a standard solution (povidone-iodine 10%) to 2 cups of water.
An ethanol extract of propolis (150mcg per ml) has been shown to have a 100% lethal effect in tests on Trichomonas vaginalis after 24 hours of contact. This extract has also been shown to decrease the inflammation associated with trichomonal vaginitis.
Essential oils have well-demonstrated antimicrobial action. Many possess strong antitrichomonal properties. Mentha piperita (peppermint) and Lavandula angustifolia (lavender) had the fastest killing action.

[stib]

A related discussion, how long will it take before I know if the antibiotic is working was started.