Managing Prevalent & Problematic
Sexually Transmitted Infections:
Trichomoniasis in Pregnancy
Reviewed for ARHP by:
Charlo...
Case Study: Carly

• 28-ye
ar-old G
3
P1102
Photo of
pregnant
• 30 w
eeks woman
• Malo
dorous
dischar
ge
• G ood
fetal
mov...
Carly: Obstetric and
Gynecologic History
• 1 term & 1 preterm delivery
• Last Pap test 1 year ago
• Trichomoniasis 2 years...
Carly: Physical Exam
• Moderate amount of
vaginal discharge
• Redness of vaginal
mucosa and cervix
• Normal fetal heartbea...
Carly: Lab Results
• Vaginal pH: 5.0
• Microscopic ferning: negative
• Fetal fibronectin: negative
• Wet prep shows many w...
Carly: Differential Diagnosis
• Yeast infection
• Trichomoniasis
• Bacterial vaginosis
• Normal vaginal discharge associat...
What is the annual incidence of
trichomoniasis in the US?
A. 2 to 4 million
B. 5 to 7 million
C. 10 to 12 million
Trichomonas vaginalis

Seattle STD/HIV Prevention Training Center. The practitioner’s handbook for the
management of sexua...
Trichomoniasis Testing Options

Bachmann LH. Clin Infect Dis. 2011; Gaydos CA. 29th Clinical Virology Symposium. 2013;
Gin...
Comparison of Testing Options
Method
Wet prep

Sensitivity

Specificity

55–65%

100%

Culture

75%

100%

POCT

>83%

>97...
Carly: Test Result
• Vaginal swab NAAT positive for
T. vaginalis
Who Should Be Tested?
• Symptomatic women
• Asymptomatic women at risk:
▪
▪
▪
▪
▪

New partner
Multiple partners
History o...
Rationale for Treating
Trichomoniasis
Relieve symptoms
Reduce risk of preterm labor and low
birth weight
Reduce HIV sheddi...
Treatment of Trichomoniasis
Metronidazole, 500 mg; four tablets in a single
dose
Tinidazole, 500 mg po; four tablets in a ...
Trichomoniasis Treatment in
Pregnancy and Breastfeeding
• Metronidazole:
▪
▪

2 g in single dose
Withhold breastfeeding
du...
Trichomoniasis: Partner Treatment
• Partners must be treated
• Metronidazole, 2 g, in a
single dose
• Abstain from sex unt...
Role of Rescreening
119 women tested positive for T. vaginalis at
baseline; of the 100 tested 3 months later,

16.5%
teste...
Carly: Follow-up
Completed treatment
Healthy female child delivered at 39 weeks
Rescreening at 3 months is negative

CDC. ...
Managing Prevalent & Problematic
Sexually Transmitted Infections
Full slide set with two additional cases
available for fr...
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Trichomoniasis in Pregnancy - Clinical Education for Providers

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This case-based curriculum is the product of an expert consensus meeting convened to identify practice gaps in STI management and offers guidance beyond the CDC’s STD treatment guidelines. This presentation highlights the case of Carly, a 28-year-old woman, G3 P1102, who is 30 weeks pregnant. She presents at her routine prenatal visit reporting malodorous discharge and mild vaginal irritation. Review this case to get the latest expert guidance on best practices in trichomoniasis screening and treatment.

For more evidence-based, peer reviewed slides on reproductive health topics, visit www.arhp.org/CORE. Review a free, on-demand webinar on managing prevalent & problematic STIs and earn CME at www.arhp.org/STIwebinar.

Published in: Health & Medicine, Education
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  • Talking Points
    This presentation may include information that is not on FDA-required product labels.
    - - -
    Original content for this slide submitted by ARHP’s Clinical Advisory Committee for the Managing Prevalent and Problematic Sexually Transmitted Infections program in May 2013. Original funding received from Hologic, Inc. through an educational grant. Last reviewed/updated by the Managing Prevalent and Problematic Sexually Transmitted Infections Clinical Advisory Committee in May 2013. This slide is available at www.arhp.org/core.
  • Talking Points
    Carly is a 28-year-old woman, G3 P1102, who is 30 weeks pregnant.
    She presents at her routine prenatal visit reporting vaginal discharge, which she describes as thin and malodorous, and mild vaginal irritation.
    Pregnancy has been uncomplicated to date, and all prenatal laboratory test results are normal.
    There is good fetal movement.
    - - -
    Original content for this slide submitted by ARHP’s Clinical Advisory Committee for the Managing Prevalent and Problematic Sexually Transmitted Infections program in May 2013. Original funding received from Hologic, Inc. through an educational grant. Last reviewed/updated by the Managing Prevalent and Problematic Sexually Transmitted Infections Clinical Advisory Committee in May 2013. This slide is available at www.arhp.org/core.
  • Talking Points
    Obstetric history includes non-surgical vaginal delivery of a full-term female infant, 6 pounds 11 ounces (5.8 kg), 7 years ago and preterm delivery at 34 weeks of a male infant, 4 pounds 11 ounces (4.9 kg) 3 years ago.
    She states that she has not had any abnormal Pap tests; her last Pap test was performed 1 year ago.
    She states that she has no history of sexually transmitted infections (STIs) except for a bout of trichomoniasis 2 years ago.
    Prior to her current pregnancy, she used oral contraceptives but desires a copper intrauterine device (IUD) postpartum.
    - - -
    Original content for this slide submitted by ARHP’s Clinical Advisory Committee for the Managing Prevalent and Problematic Sexually Transmitted Infections program in May 2013. Original funding received from Hologic, Inc. through an educational grant. Last reviewed/updated by the Managing Prevalent and Problematic Sexually Transmitted Infections Clinical Advisory Committee in May 2013. This slide is available at www.arhp.org/core.
  • Talking Points
    You perform a sterile speculum exam and observe a moderate amount of vaginal discharge. The vaginal mucosa and cervix have an inflammatory appearance (redness, “strawberry spots”).
    Fetal heartbeat is normal.
    Exam is otherwise unremarkable.
    - - -
    Original content for this slide submitted by ARHP’s Clinical Advisory Committee for the Managing Prevalent and Problematic Sexually Transmitted Infections program in May 2013. Original funding received from Hologic, Inc. through an educational grant. Last reviewed/updated by the Managing Prevalent and Problematic Sexually Transmitted Infections Clinical Advisory Committee in May 2013. This slide is available at www.arhp.org/core.
  • Talking Points
    The results of your examination show:
    Vaginal pH is usually elevated in symptomatic trichomoniasis, but if it is above 4.2, this could also reflect premature rupture of membranes (PROM).
    Microscopic ferning test is negative, ruling out PROM.
    Fetal fibronectin is negative, ruling out preterm labor.
    Yeast is absent, reducing the likelihood of candidiasis, but not ruling it out.
    Clue cells are universally present in bacterial vaginosis but are also common in trichomoniasis.
    Motile trichomonads are not observed.
    Can trichomoniasis be ruled out?
    References
    Riedewald S, Kreutzmann IM, Heinze T, et al. Vaginal and cervical pH in normal pregnancy and pregnancy complicated by preterm labor. J Perinat Med. 1990;18(3):181-6.
    - - -
    Original content for this slide submitted by ARHP’s Clinical Advisory Committee for the Managing Prevalent and Problematic Sexually Transmitted Infections program in May 2013. Original funding received from Hologic, Inc. through an educational grant. Last reviewed/updated by the Managing Prevalent and Problematic Sexually Transmitted Infections Clinical Advisory Committee in May 2013. This slide is available at www.arhp.org/core.
  • Talking Points
    Your differential diagnosis could include:
    Yeast infection
    Trichomoniasis
    Bacterial vaginosis
    Normal vaginal discharge associated with pregnancy
    You must rule out preterm labor and preterm PROM (PPROM).
    Because both bacterial vaginosis and trichomoniasis have been associated with preterm labor and have similar symptoms, it is important to distinguish between the two and to treat appropriately.
    References
    ACOG Committee on Practice Bulletins—Gynecology. ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologists, Number 72, May 2006: Vaginitis. Obstet Gynecol. 2006;107(5):1195-206.
    Cotch MF, Pastorek JG, Nugent RP, et al. Trichomonas vaginalis associated with low birth weight and preterm delivery. The Vaginal Infections and Prematurity Study Group. Sex Transm Dis. 1997;24:353-60.
    Moodley P, Wilkinson D, Connolly C, et al. Trichomonas vaginalis is associated with pelvic inflammatory disease in women infected with human immunodeficiency virus. Clin Infect Dis. 2002;34:519-22.
    Schwebke JR, Burgess D. Trichomoniasis. Clin Microbiol Rev. 2004;17:794-803.
    - - -
    Original content for this slide submitted by ARHP’s Clinical Advisory Committee for the Managing Prevalent and Problematic Sexually Transmitted Infections program in May 2013. Original funding received from Hologic, Inc. through an educational grant. Last reviewed/updated by the Managing Prevalent and Problematic Sexually Transmitted Infections Clinical Advisory Committee in May 2013. This slide is available at www.arhp.org/core.
  • Talking Points
    Polling Question A: The annual incidence of trichomoniasis in the United States is:
    2 to 4 million
    5 to 7 million (Correct Answer)
    10 to 12 million
    - - -
    Original content for this slide submitted by ARHP’s Clinical Advisory Committee for the Managing Prevalent and Problematic Sexually Transmitted Infections program in May 2013. Original funding received from Hologic, Inc. through an educational grant. Last reviewed/updated by the Managing Prevalent and Problematic Sexually Transmitted Infections Clinical Advisory Committee in May 2013. This slide is available at www.arhp.org/core.
  • Talking Points
    Trichomoniasis is caused by the protozoa Trichomonas vaginalis and is one of the most common STIs. Its annual incidence in the United States is 5 to 7 million.
    Symptoms in women include a diffuse, malodorous, yellow-green vaginal discharge with vulvar irritation, although many women are asymptomatic.
    Men are generally asymptomatic but may develop urethritis.
    Recent evidence collected with newer forms of testing suggest that one-third of infections in women may be asymptomatic.
    References
    Van der Pol B. Trichomonas vaginalis infection: the most prevalent nonviral sexually transmitted infection receives the least public health attention. Clin Infect Dis. 2007;44(1):23-5.
    Weinstock H, Berman S, Cates W. Sexually transmitted diseases among American youth: incidence and prevalence estimates, 2000. Perspect Sex Reprod Health. 2004; 36:6-10.
    Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep. 2010;59(RR-12):1-116.
    Seattle STD/HIV Prevention Training Center. The practitioner’s handbook for the management of sexually transmitted diseases. 2013. Available from: http://depts.washington.edu/handbook/index.html.
    - - -
    Original content for this slide submitted by ARHP’s Clinical Advisory Committee for the Managing Prevalent and Problematic Sexually Transmitted Infections program in May 2013. Original funding received from Hologic, Inc. through an educational grant. Last reviewed/updated by the Managing Prevalent and Problematic Sexually Transmitted Infections Clinical Advisory Committee in May 2013. This slide is available at www.arhp.org/core.
  • Talking Points
    The options for testing in women include:
    Wet prep
    Requires immediate reading
    Culture
    Was the gold standard in the past
    Urine sample is less sensitive than vaginal secretions
    Results take several days
    Point-of-care tests (POCT)
    Rapid antigen tests, such as OSOM (manufactured by Genzyme Diagnostics, Cambridge, MA), which uses immunochromatographic capillary flow dipstick technology and provides results in about 10 minutes
    Nucleic acid probe tests, such as Affirm VP III (manufactured by Becton Dickenson, San Jose, CA) that evaluates for T. vaginalis, Gardnerella vaginalis, and Candida albicans, with results in about 45 minutes
    Nucleic acid amplification tests (NAATs), which use one of two technologies:
    Polymerase chain reaction (PCR)
    Transcription-mediated amplification (TMA)
    Options for men:
    No POCT is available for men.
    NAATs have not been cleared by the US Food and Drug Administration (FDA) for men; wet prep and culture are the only options for testing.
    References
    Bachmann LH, Hobbs MM, Seña AC, et al. Trichomonas vaginalis genital infections: progress and challenges. Clin Infect Dis. 2011;53(Suppl 3):S160-72.
    Gaydos CA, Williams JA, Quinn N, et al. Performance of a new amplified DNA assay on the BD Viper™ system in extracted mode for the detection of Trichomonas vaginalis in women from cervical, vaginal, and urine specimens. Poster T-76. 29th Clinical Virology Symposium. Pan American Society for Clinical Virology and American Society for Microbiology. Daytona Beach, FL. 26 April–1 May 2013.
    Ginocchio CC, Chapin K, Smith JS, et al. Trichomonas vaginalis prevalence and STI coinfection using the APTIMA® Trichomonas vaginalis assay. J Clin Microbiol. 2012;50:2601-8.
    Schwebke JR, Hobbs MM, Taylor SN, et al. Molecular testing for Trichomonas vaginalis in women: results of a pivotal US clinical trial. J Clin Microbiol. 2011;49:4106-11.
    Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep. 2010;59(RR-12):1-116.
    - - -
    Original content for this slide submitted by ARHP’s Clinical Advisory Committee for the Managing Prevalent and Problematic Sexually Transmitted Infections program in May 2013. Original funding received from Hologic, Inc. through an educational grant. Last reviewed/updated by the Managing Prevalent and Problematic Sexually Transmitted Infections Clinical Advisory Committee in May 2013. This slide is available at www.arhp.org/core.
  • Talking Points
    This table compares the sensitivity and specificity of the various testing options.
    Wet prep (of vaginal secretions)
    Culture (of vaginal secretions)
    POCT
    Rapid antigen tests, such as OSOM
    Nucleic acid probe tests, such as Affirm VP III
    NAATs
    TMA, such as APTIMA (manufactured by Hologic Gen-Probe Inc. San Diego, CA) is a NAAT
    References
    Briselden AM, Hillier SL. Evaluation of Affirm VP Microbial Identification Test for Gardnerella vaginalis and Trichomonas vaginalis. J Clin Microbiol. 1994;32:148-52.
    Demeo LR, Draper DL, McGregor JA, et al. Evaluation of a deoxyribonucleic acid probe for the detection of Trichomonas vaginalis in vaginal secretions. Am J Obstet Gynecol. 1996;174:1339-42.
    Huppert JS, Batteiger BE, Braslins P, et al. Use of an immunochromatographic assay for rapid detection of Trichomonas vaginalis in vaginal specimens. J Clin Microbiol. 2005;43:684-7.
    Nye MB, Schwebke JR, Body BA. Comparison of APTIMA Trichomonas vaginalis transcription-mediated amplification to wet mount microscopy, culture, and polymerase chain reaction for diagnosis of trichomoniasis in men and women. Am J Obstet Gynecol. 2009;200:188.e1-7.
    - - -
    Original content for this slide submitted by ARHP’s Clinical Advisory Committee for the Managing Prevalent and Problematic Sexually Transmitted Infections program in May 2013. Original funding received from Hologic, Inc. through an educational grant. Last reviewed/updated by the Managing Prevalent and Problematic Sexually Transmitted Infections Clinical Advisory Committee in May 2013. This slide is available at www.arhp.org/core.
  • Talking Points
    Carly’s test results include the following:
    Vaginal swab NAAT for T. vaginalis is positive.
    Your working diagnosis is trichomoniasis; you prescribe metronidazole, 2 g orally (po), in a single dose.
    You counsel Carly regarding condom use.
    Reference
    Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep. 2010;59(RR-12):1-116.
    - - -
    Original content for this slide submitted by ARHP’s Clinical Advisory Committee for the Managing Prevalent and Problematic Sexually Transmitted Infections program in May 2013. Original funding received from Hologic, Inc. through an educational grant. Last reviewed/updated by the Managing Prevalent and Problematic Sexually Transmitted Infections Clinical Advisory Committee in May 2013. This slide is available at www.arhp.org/core.
  • Talking Points
    Women presenting with vaginal discharge should be screened for trichomoniasis.
    In addition, asymptomatic women at high risk for infection should be considered for screening.
    Risk factors for trichomoniasis include:
    New or multiple partners
    History of STIs
    History of transactional sex
    Injection drug use
    Because T. vaginalis has not been found to infect oral sites, screening of extragenital sites is not recommended.
    References
    Bachmann LH, Hobbs MM, Seña AC, et al. Trichomonas vaginalis genital infections: progress and challenges. Clin Infect Dis. 2011;53(Suppl 3):S160-72.
    Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep. 2010;59(RR-12):1-116.
    - - -
    Original content for this slide submitted by ARHP’s Clinical Advisory Committee for the Managing Prevalent and Problematic Sexually Transmitted Infections program in May 2013. Original funding received from Hologic, Inc. through an educational grant. Last reviewed/updated by the Managing Prevalent and Problematic Sexually Transmitted Infections Clinical Advisory Committee in May 2013. This slide is available at www.arhp.org/core.
  • Talking Points
    At one time, trichomoniasis was considered just a nuisance infection, but evidence now suggests that it is associated with symptoms and negative sequelae.
    Trichomoniasis has been shown to increase the risk of preterm labor and low birth weight.
    It also appears to increase the risk of HIV transmission in exposed women.
    In addition, treatment of trichomoniasis has been shown to reduce the risk of HIV shedding in HIV-positive individuals, possibly decreasing the risk of HIV transmission.
    References
    Coleman JS, Gaydos CA, Witter F. Trichomonas vaginalis: vaginitis in obstetrics and gynecology practice: new concepts and controversies. Obstet Gynecol Survey. 2013;68:43-50.
    Cotch MF, Pastorek JG, Nugent RP, et al. Trichomonas vaginalis associated with low birth weight and preterm delivery. Sex Transm Dis. 1997;24(6):353-60.
    Kissinger P, Amedee A, Clark RA, et al. Trichomonas vaginalis treatment reduces vaginal HIV-1 shedding. Sex Transm Dis. 2009;36(1):11-6.
    Kissinger P, Adamski A. Trichomoniasis and HIV interactions: a review. Sex Transm Infect. 2013. Available at: http://sti.bmj.com/content/early/2013/04/19/sextrans-2012-051005.abstract.
    Van der Pol B, Kwok C, Pierre‐Louis B, et al. Trichomonas vaginalis infection and human immunodeficiency virus acquisition in African women. J Infect Dis. 2008;197(4):548-54.
    - - -
    Original content for this slide submitted by ARHP’s Clinical Advisory Committee for the Managing Prevalent and Problematic Sexually Transmitted Infections program in May 2013. Original funding received from Hologic, Inc. through an educational grant. Last reviewed/updated by the Managing Prevalent and Problematic Sexually Transmitted Infections Clinical Advisory Committee in May 2013. This slide is available at www.arhp.org/core.
  • Talking Points
    Metronidazole and tinidazole are available in the United States and has been approved by the FDA for the treatment of trichomoniasis.
    In randomized clinical trials, recommended metronidazole regimens have resulted in cure rates of approximately 90–95%, and the recommended tinidazole regimen has resulted in cure rates of approximately 86–100%. These cure rates might be higher with appropriate treatment of partners. The 7-day course of metronidazole may be more effective than the single-dose regimen in patients who can adhere to it.
    Use of topically applied antimicrobials (e.g., metronidazole gel) is not recommended.
    Recommended regimens:
    Metronidazole, 500 mg po; four tablets (2 g total) as single dose
    Tinidazole, 500 mg po; four tablets (2 g total) as single dose
    Metronidazole, 500 mg po; 1 tablet twice daily for 7 days
    Patients should be advised to avoid the consumption of alcohol while taking either drug and for 24 hours after completing metronidazole or 72 hours after completing tinidazole.
    Note that both drugs are nitroimidazoles and may cause allergic cross-reactivity; there is no evidence that tinidazole can be safely used in patients with metronidazole allergy.
    See Centers for Disease Control and Prevention (CDC) guidelines for specific information: http://www.cdc.gov/std/treatment/2010/.
    References
    ACOG Committee on Practice Bulletins—Gynecology. ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologists, Number 72, May 2006: Vaginitis. Obstet Gynecol. 2006;107(5):1195-206.
    Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep. 2010;59(RR-12):1-116.
    - - -
    Original content for this slide submitted by ARHP’s Clinical Advisory Committee for the Managing Prevalent and Problematic Sexually Transmitted Infections program in May 2013. Original funding received from Hologic, Inc. through an educational grant. Last reviewed/updated by the Managing Prevalent and Problematic Sexually Transmitted Infections Clinical Advisory Committee in May 2013. This slide is available at www.arhp.org/core.
  • Talking Points
    According to CDC guidelines, women can be treated with 2 g of metronidazole in a single dose at any stage of pregnancy.
    Multiple studies and meta-analyses have shown no association between metronidazole use during pregnancy and teratogenic or mutagenic effects in infants. The safety of tinidazole in pregnancy has not been well evaluated.
    Regarding breastfeeding, the CDC recommends that lactating women taking metronidazole should withhold breastfeeding during treatment and for 12–24 hours after the last dose. CDC recommends that lactating women taking tinidazole withhold breastfeeding during treatment and for 3 days after the last dose.
    Some trials have suggested the possibility of an increased risk of prematurity or low birth weight after metronidazole treatment, but these studies were limited and do not allow for definitive conclusions regarding these risks.
    CDC recommends that clinicians counsel patients about the potential risks and benefits of treatment and give asymptomatic pregnant women the option of deferring therapy until after 37 weeks of gestation.
    See CDC guidelines for specific information: http://www.cdc.gov/std/treatment/2010/.
    References
    Burtin P, Taddio A, Ariburnu O, et al. Safety of metronidazole in pregnancy: a meta-analysis. Am J Obstet Gynecol. 1995;172(2 Pt 1):525-9.
    Caro-Paton T, Carvajal A, Martin D, et al. Is metronidazole teratogenic? A meta-analysis. Br J Clin Pharmacol. 1997;44:179-82.
    Kigozi GG, Brahmbhatt H, Wabwire-Mangen F, et al. Treatment of Trichomonas in pregnancy and adverse outcomes of pregnancy: a subanalysis of a randomized trial in Rakai, Uganda. Am J Obstet Gynecol. 2003;189:1398-400.
    Klebanoff MA, Carey JC, Hauth JC, et al. Failure of metronidazole to prevent preterm delivery among pregnant women with asymptomatic Trichomonas vaginalis infection. N Engl J Med. 2001;345:487–93.
    Piper JM, Mitchel EF, Ray WA. Prenatal use of metronidazole and birth defects: no association. Obstet Gynecol. 1993;82:348-52.
    Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep. 2010;59(RR-12):1-116.
    - - -
    Original content for this slide submitted by ARHP’s Clinical Advisory Committee for the Managing Prevalent and Problematic Sexually Transmitted Infections program in May 2013. Original funding received from Hologic, Inc. through an educational grant. Last reviewed/updated by the Managing Prevalent and Problematic Sexually Transmitted Infections Clinical Advisory Committee in May 2013. This slide is available at www.arhp.org/core.
  • Talking Points
    You counsel Carly that her partner needs to be treated and arrange for him to be prescribed metronidazole, 2 g po, in a single dose.
    Note that tinidazole (2 g po in a single dose) is also an option.
    You instruct Carly to abstain from sex until she and her partner have both completed therapy and are no longer asymptomatic.
    References
    Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep. 2010;59(RR-12):1-116.
    - - -
    Original content for this slide submitted by ARHP’s Clinical Advisory Committee for the Managing Prevalent and Problematic Sexually Transmitted Infections program in May 2013. Original funding received from Hologic, Inc. through an educational grant. Last reviewed/updated by the Managing Prevalent and Problematic Sexually Transmitted Infections Clinical Advisory Committee in May 2013. This slide is available at www.arhp.org/core.
  • Talking Points
    The recurrence rate of trichomoniasis is relatively high.
    In one study of women visiting an STI clinic, 119 tested positive for T. vaginalis at baseline. Of the 100 tested 3 months later, 16.5% tested positive for T. vaginalis; a total of 23% tested positive for at least one infection (T. vaginalis, C. trachomatis, or N. gonorrhoeae).
    Although most recurrent T. vaginalis infections are thought to result from reinfection due to exposure to an untreated partner, in some cases reduced susceptibility to metronidazole may result in persistent infection.
    CDC recommends rescreening in 3 months for women with documented trichomoniasis to detect reinfection.
    Low-level metronidazole resistance has been identified in 2–5% of cases of vaginal trichomoniasis, but high-level resistance occurs only rarely.
    Low-level resistance will usually respond to either a short course of tinidazole or to an extended course of metronidazole (the same regimen typically used to treat bacterial vaginosis).
    References
    Bachmann LH, Hobbs MM, Seña AC, et al. Trichomonas vaginalis genital infections: progress and challenges. Clin Infect Dis. 2011;53(Suppl 3):S160-72.
    Peterman TA, Tian LH, Metcalf CA, et al. High incidence of new sexually transmitted infections in the year following a sexually transmitted infection: a case for rescreening. Ann Intern Med. 2006;145:564-72.
    Schmid G, Narcisi E, Mosure D, et al. Prevalence of metronidazole-resistant Trichomonas vaginalis in a gynecology clinic. J Reprod Med. 2001;46:545-9.
    Schwebke JR, Barrientes FJ. Prevalence of Trichomonas vaginalis isolates with resistance to metronidazole and tinidazole. Antimicrob Agents Chemother. 2006;50:4209-10.
    Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep. 2010;59(RR-12):1-116.
    - - -
    Original content for this slide submitted by ARHP’s Clinical Advisory Committee for the Managing Prevalent and Problematic Sexually Transmitted Infections program in May 2013. Original funding received from Hologic, Inc. through an educational grant. Last reviewed/updated by the Managing Prevalent and Problematic Sexually Transmitted Infections Clinical Advisory Committee in May 2013. This slide is available at www.arhp.org/core.
  • Talking Points
    Carly and her partner each completed the single-dose regimen of metronidazole, 2 g po.
    Carly delivered a healthy female child at 39 weeks.
    You perform screening at 3 months (4 weeks postpartum), which is negative.
    References
    Centers for Disease Control and Prevention. Update to CDC's U.S. Medical Eligibility Criteria for Contraceptive Use, 2010: revised recommendations for the use of contraceptive methods during the postpartum period. MMWR Morb Mortal Wkly Rep. 2011;60(26):878-83.
    - - -
    Original content for this slide submitted by ARHP’s Clinical Advisory Committee for the Managing Prevalent and Problematic Sexually Transmitted Infections program in May 2013. Original funding received from Hologic, Inc. through an educational grant. Last reviewed/updated by the Managing Prevalent and Problematic Sexually Transmitted Infections Clinical Advisory Committee in May 2013. This slide is available at www.arhp.org/core.
  • Trichomoniasis in Pregnancy - Clinical Education for Providers

    1. 1. Managing Prevalent & Problematic Sexually Transmitted Infections: Trichomoniasis in Pregnancy Reviewed for ARHP by: Charlotte Gaydos, DrPH, MPH, MS H. Hunter Handsfield, MD Beth Kruse, MS, CNM, ARNP Jeanne Marrazzo, MD, MPH, FACP, FIDSA
    2. 2. Case Study: Carly • 28-ye ar-old G 3 P1102 Photo of pregnant • 30 w eeks woman • Malo dorous dischar ge • G ood fetal movem en t more… more…
    3. 3. Carly: Obstetric and Gynecologic History • 1 term & 1 preterm delivery • Last Pap test 1 year ago • Trichomoniasis 2 years ago
    4. 4. Carly: Physical Exam • Moderate amount of vaginal discharge • Redness of vaginal mucosa and cervix • Normal fetal heartbeat
    5. 5. Carly: Lab Results • Vaginal pH: 5.0 • Microscopic ferning: negative • Fetal fibronectin: negative • Wet prep shows many white blood cells and a few clue cells; negative for yeast and trichomonas Riedewald S. J Perinat Med. 1990
    6. 6. Carly: Differential Diagnosis • Yeast infection • Trichomoniasis • Bacterial vaginosis • Normal vaginal discharge associated with pregnancy ACOG. Obstet Gynecol. 2006; Cotch MF. Sex Transm Dis. 1997; Moodley P. Clin Infect Dis. 2002; Schwebke JR. Clin Microbiol Rev. 2004.
    7. 7. What is the annual incidence of trichomoniasis in the US? A. 2 to 4 million B. 5 to 7 million C. 10 to 12 million
    8. 8. Trichomonas vaginalis Seattle STD/HIV Prevention Training Center. The practitioner’s handbook for the management of sexually transmitted diseases. 2013.
    9. 9. Trichomoniasis Testing Options Bachmann LH. Clin Infect Dis. 2011; Gaydos CA. 29th Clinical Virology Symposium. 2013; Ginocchio CC. J Clin Microbiol. 2012; Schwebke JR. J Clin Microbiol. 2011; CDC. MMWR Recomm Rep. 2010.
    10. 10. Comparison of Testing Options Method Wet prep Sensitivity Specificity 55–65% 100% Culture 75% 100% POCT >83% >97% TMA 97% 100% Briselden AM. J Clin Microbiol. 1994; Demeo LR. Am J Obstet Gynecol. 1996; Huppert JS. J Clin Microbiol. 2005; Nye MB. Am J Obstet Gynecol. 2009.
    11. 11. Carly: Test Result • Vaginal swab NAAT positive for T. vaginalis
    12. 12. Who Should Be Tested? • Symptomatic women • Asymptomatic women at risk: ▪ ▪ ▪ ▪ ▪ New partner Multiple partners History of sexually transmitted infections (STIs) Sex work Injection drug use CDC. MMWR Recomm Rep. 2010; Bachmann LH. Clin Infect Dis. 2011
    13. 13. Rationale for Treating Trichomoniasis Relieve symptoms Reduce risk of preterm labor and low birth weight Reduce HIV shedding in HIVinfected women Coleman JS. Obstet Gynecol Survey. 2013; Cotch MF. Sex Transm Dis. 1997; Kissinger P. Sex Transm Dis. 2009; Kissinger P. Sex Transm Infect. 2013; Van der Pol B. J Infect Dis. 2008.
    14. 14. Treatment of Trichomoniasis Metronidazole, 500 mg; four tablets in a single dose Tinidazole, 500 mg po; four tablets in a single dose Metronidazole, 500 mg po; one tablet twice daily for 7 days* *Also effective for bacterial vaginosis ACOG. Obstet Gynecol. 2006; CDC. MMWR Recomm Rep. 2010.
    15. 15. Trichomoniasis Treatment in Pregnancy and Breastfeeding • Metronidazole: ▪ ▪ 2 g in single dose Withhold breastfeeding during treatment and 12–24 h after dose • Tinidazole: ▪ Withhold breastfeeding during treatment and 3 days after dose Burtin P. Am J Obstet Gynecol. 1995; Caro-Paton T. Br J Clin Pharmacol. 1997; Kigozi GG. Am J Obstet Gynecol. 2003; Klebanoff MA. N Engl J Med. 2001; Piper JM. Obstet Gynecol. 1993; CDC. MMWR Recomm Rep. 2010.
    16. 16. Trichomoniasis: Partner Treatment • Partners must be treated • Metronidazole, 2 g, in a single dose • Abstain from sex until therapy is completed and both partners are asymptomatic CDC. MMWR Recomm Rep. 2010. Photo of man
    17. 17. Role of Rescreening 119 women tested positive for T. vaginalis at baseline; of the 100 tested 3 months later, 16.5% tested positive for T. vaginalis Bachmann LH. Clin Infect Dis. 2011; Peterman TA. Ann Intern Med. 2006; Schmid G. J Reprod Med. 2001; Schwebke JR. Antimicrob Agents Chemother. 2006; CDC. MMWR Recomm Rep. 2010.
    18. 18. Carly: Follow-up Completed treatment Healthy female child delivered at 39 weeks Rescreening at 3 months is negative CDC. MMWR Morb Mortal Wkly Rep. 2011.
    19. 19. Managing Prevalent & Problematic Sexually Transmitted Infections Full slide set with two additional cases available for free at CORE: www.arhp.org/core View archived webinar at ARHP.org: www.arhp.org/STIwebinar

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