Monitoring
Patient follow-up helps to check adherence to therapy, evaluate symptom improvement, confirm if contact tracing was done, and provide further counseling and sexual health education.
Trichomoniasis
Test of cure after oral Metronidazole therapy is not recommended. Perform retesting after 4 weeks if patient remains symptomatic or if treatment of partner is uncertain. Rescreening 3 months after initial infection should be considered in sexually active women with trichomoniasis. Studies have shown that 17% of women diagnosed with trichomoniasis were reinfected within 3 months. No evidence has been shown to support the need to rescreen men infected with T vaginalis. Recurrent T vaginalis infections are usually due to reinfection with an untreated or new partner or decreased susceptibility to Metronidazole; poor adherence or tolerance to therapy should also be ruled out. Two to five percent of cases of T vaginalis infection were identified to have low-level Metronidazole resistance. The majority respond to Tinidazole or higher doses of Metronidazole.
Treatment Failure
Rule out possible non-compliance, vomiting of Metronidazole, and re-infection from a new or untreated partner. Patients who do not respond to the initial single-dose treatment usually respond to oral Metronidazole using a 7-day regimen. If treatment still fails, higher doses of oral Tinidazole or Metronidazole given for 5-7 days should be considered. If none of the therapies were effective, the patient should be referred to a specialist, and susceptibility of T vaginalis to Metronidazole and Tinidazole should be determined.
Bacterial Vaginosis (BV)
A test of cure is not required. Patients who become asymptomatic after treatment need not return for a follow-up visit. The patient should return for re-evaluation if symptoms recur. Patients with first recurrent bacterial vaginosis may be offered a different treatment regimen but may retry the same or prior regimen. A repeat course of the standard topical regimen may also be done during the early stages of infection. Metronidazole gel for 4-6 months has been shown to reduce multiple recurrences, but the suppressive effect does not persist after discontinuation. Limited studies have shown the use of oral nitroimidazole followed by intravaginal Boric acid, suppressive Metronidazole gel or monthly oral Metronidazole plus Fluconazole, probiotics, and dendrimer gels for women with recurrent bacterial vaginosis.
Vulvovaginal Candidiasis (VVC)
Uncomplicated infections usually respond to treatment within a few days, while complicated infections may require up to 2 weeks of therapy. Test of cure is not required, and follow-up is needed only if symptoms persist or recur within 2 months of onset of initial symptoms. Recurrent vulvovaginal candidiasis occurs in 5% of women. Evaluate for predisposing factors (eg DM, STIs, immunosuppression) and treat accordingly. Request for culture to confirm the clinical diagnosis and to identify the infecting organism, as other non-albicans species (eg C glabrata) may be resistant to conventional antimycotic therapy. Long-term prophylactic treatment with 6 months of azoles may reduce relapse.