BACKGROUND: Resistant Trichomonas vaginalis infection is typically treated with increased doses of oral metronidazole. Because of side effects that limit compliance, such treatment may be ineffective. CASE: A young woman had an 8-year history of T vaginalis that was refractory to multiple courses of metronidazole, tinidazole and intravaginal paromomycin. After microscopic examination confirmed trichomonads, she began an extended, 14-day course of combined oral and vaginal metronidazole. Six weeks later her symptoms were unchanged, but microscopy revealed fewer trichomonads. After a 5% acetic acid vaginal wash and dilute silver nitrate bladder instillation, she was given the same treatment for 21 days. Symptoms and trichomonads resolved, and 3 years later she remained asymptomatic. CONCLUSION: Prolonged vaginal and oral metronidazole, in combination with bladder and vaginal irrigation, should be considered in women with refractory T vaginalis.
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