International Journal of STD & AIDS http://std.sagepub.com/ United Kingdom National Guideline on the Management of Trichomonas vaginalis 2014 Jackie Sherrard, Cathy Ison, Judith Moody, Emma Wainwright, Janet Wilson and Ann Sullivan Int J STD AIDS 2014 25: 541 originally published online 10 March 2014 DOI: 10.1177/0956462414525947 The online version of this article can be found at: http://std.sagepub.com/content/25/8/541 Published by: http://www.sagepublications.com Additional services and information for International Journal of STD & AIDS can be found at: Email Alerts: http://std.sagepub.com/cgi/alerts Subscriptions: http://std.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav >> Version of Record - Jun 11, 2014 OnlineFirst Version of Record - Mar 10, 2014 What is This? Downloaded from std.sagepub.com at Imperial College London Library on October 17, 2014 Guidelines International Journal of STD & AIDS 2014, Vol. 25(8) 541–549 ! The Author(s) 2014 United Kingdom National Guideline Reprints and permissions: sagepub.co.uk/journalsPermissions.nav on the Management of Trichomonas DOI: 10.1177/0956462414525947 std.sagepub.com vaginalis 2014 Jackie Sherrard1, Cathy Ison2, Judith Moody3, Emma Wainwright4, Janet Wilson5 and Ann Sullivan6 Abstract The main objective is to assist practitioners in managing men and women diagnosed with Trichomonas vaginalis (TV) infection. This guideline offers recommendations on the diagnostic tests, treatment regimens and health promotion principles needed for the effective management of TV, covering the management of the initial presentation, as well as how to prevent transmission and future infection. Keywords Trichomoniasis (Trichomonas vaginalis), protozoal disease, diagnosis, epidemiology, treatment, sexually transmitted infection, guideline Date received: 1 February 2014; accepted: 4 February 2014 New in the 2014 guidelines: Updated section on diagno- development and assessment’’ at http://www.bash- sis incorporating information on nucleic acid amplifica- h.org/guidelines. The 2014 guideline updates the 2007 tion tests and management of infection refractory to guideline by searching PubMed 2006–2012 for first-line treatment. Trichomonas vaginalis or trichomoniasis and limited to ‘‘human’’ and ‘‘English’’. The Cochrane database was searched for Introduction and methodology Trichomonas vaginalis. The European (IUSTI/WHO) Scope and purpose guideline on the management of vaginal discharge, 2011, and the 2010 US CDC guidelines for the treat- It is aimed primarily at people aged 16 years or older ment of Sexually Transmitted Diseases were reviewed. (see specific guidelines for those under 16) presenting to health care professionals, working in departments offer- 1Consultant GU Physician, Oxford University Hospitals, NHS Trust, ing specialist care in sexually transmitted infection Oxford, UK (STI) management within the United Kingdom. 2Head of the Sexually Transmitted Bacteria Reference Unit (STBRU), However, the principles of the recommendations Public Health England, Colindale, London, UK should be adopted across all levels (non-specialist ser- 3HIV Specialist Pharmacist, Oxford University Hospitals, NHS Trust, vices may need to develop, where appropriate, local Oxford, UK 4GUM Specialty Registrar, Oxford University Hospitals NHS Trust, care pathways). For levels or recommendations, see Oxford, UK appendix 2. 5Leeds Teaching Hospitals, NHS Trust, Leeds, UK 6Clinical Effectiveness Group, British Association for Sexual Health and HIV, Chelsea and Westminster NHS Foundation Trust, London, UK Search strategy Corresponding author: This document was produced in accordance with the Jackie Sherrard, Consultant GU Physician, Oxford University Hospitals, guidance set out in the Clinical Effectiveness Group’s NHS Trust, Oxford, UK. (CEG) document ‘‘Framework for guideline Email: [email protected] Downloaded from std.sagepub.com at Imperial College London Library on October 17, 2014 542 International Journal of STD & AIDS 25(8) A general search was performed on the NHS evidence Males4–6 search engine as well as a Google Scholar and the BNF September 2012. 15 to 50% of men with TV are asymptomatic and usually present as sexual partners of infected women. Piloting and consultation, including public and patient . The commonest presentation in symptomatic men is involvement with urethral discharge and/or dysuria. Other symptoms include urethral irritation and urin- The initial draft of the guideline, including the patient ary frequency. information leaflet (PIL), was piloted for validation by . Rarely the patient may complain of a copious puru- the CEG and a number of BASHH pilot sites. A stan- lent urethral discharge, or complications such as dardised feedback form was completed by each pilot prostatitis. site for the PIL. The final draft guideline was then reviewed by the CEG using the AGREE instrument before posting it on the BASHH website for external Signs peer review for a two-month period. Concurrently it was reviewed by the BASHH Public and Patient Females1–3 Panel. Comments received were collated by the CEG editor and sent to the guideline chair for review and . Vaginal discharge in up to 70% – varying in consist- action. The final guideline was approved by the CEG ency from thin and scanty to profuse and thick; the and a review date agreed before publication on the classical frothy yellow discharge occurs in 10–30% BASHH website. of women. Vulvitis and vaginitis are associated with trichomoniasis. Aetiology . Approximately 2% of patients will have strawberry Causative organism cervix appearance to the naked eye. Higher rates are seen on colposcopic examination. Trichomonas vaginalis (TV) is a flagellated protozoon. 5–15% of women will have no abnormalities on In women the organism is found in the vagina, urethra examination. and paraurethral glands. Urethral infection is present in 90% of infected women, although the urethra is the sole Males4–6 site of infection in less than 5% of cases. In men infec- tion is usually of the urethra, although trichomonads . Urethral discharge (20–60% men) – usually small or have been isolated from the subpreputial sac and moderate amounts only, and or dysuria. lesions of the penis. No signs, even in the presence of symptoms suggest- ing urethritis: one recent prospective study of Transmission infected TV contacts found 77.3% were asymptomatic. In adults transmission is almost exclusively through . Rarely balanoposthitis. sexual intercourse. Due to site specificity, infection can only follow intravaginal or intraurethral inocula- tion of the organism. Complications There is increasing evidence that TV infection can have Clinical features (Evidence level III) a detrimental outcome on pregnancy and is associated Symptoms with preterm delivery and low birth weight. (Evidence level III).7–9 However, further research is needed to Females1–3 confirm these associations and to prove that the asso- ciation is causal. TV infection at delivery may predis- . 10–50% are asymptomatic. pose to maternal postpartum sepsis.10 . The commonest symptoms include vaginal dis- Some studies have shown treatment of TV infection charge, vulval itching, dysuria, or offensive odour, in pregnancy to have a negative impact on the preg- but these are not specific for TV. nancy11–13 but others have shown no association . Occasionally the presenting complaint is of low between treatment for TV and pre-term delivery or abdominal discomfort or vulval ulceration. low birth weight.14 Screening of asymptomatic Downloaded from std.sagepub.com at Imperial College London Library on October 17, 2014 Sherrard et al. 543 individuals for TV infection is therefore not currently trichomonads in these women indicates the presence recommended. (Evidence Level I & II, Grade A) of infection. However, the sensitivity is reported to be Multiple reports support an epidemiological associ- as low as 45–60% in women20,21,24,26–29 in some studies ation between HIV and trichomoniasis. There is grow- and lower in men,29,30 and so a negative result should ing evidence that trichomonas infection may enhance be interpreted with caution. The specificity with trained HIV transmission15–18 and there may be an increased personnel is high. risk of TV infection in those that are HIV positive.19 Detection of TV by staining dead organisms with acridine orange can give a higher sensitivity than wet 31,32 Diagnosis microscopy but is not widely used. Testing for TV should be undertaken in women com- Point of care tests Level of evidence: IIb, B plaining of vaginal discharge or vulvitis, or found to have evidence of vulvitis, and/or vaginitis on examin- A number of point of care tests that have the advan- ation. Testing in men is recommended for TV contacts, tages of microscopy have been described29,30,33 of and should be considered in those with persistent which the OSOM Trichomonas Rapid Test (Genzyme urethritis. Diagnostics, USA) has demonstrated a high sensitivity and specificity.29,30 The sensitivity and specificity has Sites sampled been reported to be 80–94% and greater than 95%, respectively, depending on the comparator.27,28,34,35 Females (Evidence level III, Grade B).1,2,20,21 This test requires no instrumentation and provides a result within 30 min and is a suitable alternative to cul- . Swab taken from the posterior fornix at the time of ture or molecular testing. Although these tests are more speculum examination. sensitive than those requiring