Canadian Guidelines on Sexually Transmitted Infections
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Section 5 - Management and Treatment of Specific Infections
- Genital ulcer disease (GUD) due to Haemophilus
ducreyi or chancroid. H. ducreyi is a fastidious Gram-negative rod.
- Chancroid has been widespread in areas of the
world where sexually transmitted infection (STI) control is inadequate.
Vulnerable females (particularly sex workers with limited access to care) who
have multiple partners in spite of genital ulceration are the usual reservoir.
Chancroid can only remain endemic in this context.,
- Reintroduction into societies in which chancroid
has been eliminated occasionally occurs with travel. Clusters can occur around
an index case (has been described in Canada).
- It is readily eliminated with control activities
directed toward sex workers, treatment of men with genital ulcers and enhanced
attention to STI-control efforts.
- Chancroid is transmitted only by individuals
with ulcerations; no latent reservoir of transmissible chancroid without active
disease is known.
- The attack rate following intercourse with
contacts who have not used protection is substantial (probably >50% of
exposed men or women); incubation period is 5–14 days.
- In endemic areas, as many as 10% of chancroid
patients may have concomitant herpes simplex virus (HSV) infection. Treponema
pallidum may also co-exist with H. ducreyi.
- Chancroid gained significance as an important
STI when its role in the transmission of HIV became apparent during the 1980s.
- Accelerated increases in HIV prevalence have
occurred in societies in which chancroid was endemic.
- The risk of HIV transmission increases by
10–50-fold following sexual exposure to an individual with concomitant H.
ducreyi and HIV infection., As a result, extensive research has been directed toward H.
ducreyi and chancroid.
- Control can be achieved in most societies with
limited infrastructure and resources.
- Has been essentially eliminated during the past
decade from many areas of the world in which it was previously endemic,
including much of eastern and southern Africa.
- Importation into other countries where it has
already been eliminated will likely occur with reduced frequency.
Prevention and Control
- Conventional STI-control measures are very
effective: reducing the number of partners, the promotion and use of condoms
for all high-risk sexual activities and early diagnosis in countries where
chancroid is endemic.
- Female sex workers need to be trained to recognize
genital ulceration and should have access to medical care.
- In an outbreak, microbiological diagnosis,
enhanced education of sex workers and clients, and syndromic treatment of
ulcers have together been very successful at limiting spread and eliminating H.
ducreyi infection locally.
- Male circumcision also reduces susceptibility to H. ducreyi infection; chancroid has been shown not to spread in
populations where all men are circumcised.
- A papule develops following exposure, and this rapidly
progresses to one or more pustular lesions. These rupture to form painful,
purulent, shallow ulcers with a granulomatous base that readily bleeds.
- In males, lesions occur on the prepuce, coronal
sulcus and shaft of the penis.
- In females, lesions can occur widely on the
external genitalia but are rarely seen in the vagina or on the cervix.
- Multiple ulcers are common, particularly in
- Painful inguinal lymphadenitis occurs in 30% of
patients, and lymph nodes may suppurate, become fluctuant and spontaneously
- Chancroid can mimic other genital ulcer
diseases, particularly syphilis; however, chancroid lesions are usually
painful, and classic primary syphilis chancres are generally painless.
- Chancroid rarely spreads from the genital tract
and does not cause systemic disease.
- Clinical etiologic diagnosis is frequently
erroneous; in Canada, careful etiologic investigation of an ulcer should be
carried out, since chancroid is not known to be endemic.
- Should include, wherever possible, culture for H.
ducreyi using specialized culture or transport media; these vary by
location (check with your local laboratory for more information).
- Other causes of GUD should be ruled out by
performing either a dark-field analysis, direct/indirect fluorescent antibody
(DFA/IFA) or nucleic acid amplification testing (NAAT, e.g., PCR) for T.
pallidum for primary syphilis and a culture for HSV.
- There are no useful serologic tests for
diagnosis of H. ducreyi. Gram stain with Gram-negative coccobacilli in a
“school of fish” pattern may be useful.
- Culture for H. ducreyi requires
specialized media. In Kenya, the use of both gonococcal and Mueller
Hinton agar facilitated the growth of most strains in prospective studies. Specimens
should be collected from the base of ulcers into thioglycolate hemin–based
transport media, as this can permit bacterial survival (2–3 days at 4ºC) while
the medium is being prepared. H. ducreyi grow optimally at
32ºC in a humid atmosphere containing 5% carbon dioxide.
- Nucleic acid amplification tests (NAATs)
including a multiplex polymerase chain reaction (M-PCR) technique that
identifies H. ducreyi, T. pallidum and HSV can be used but are
not available in most laboratories.
- Syndromic management is used globally for the
immediate treatment of GUD at first contact with the health care system; it has
been particularly effective at controlling both syphilis and chancroid.
Intermittent, careful investigation should be performed in most societies to
determine which microbial etiologies require syndromic management.
- Outbreak investigation and control should be
routine in all countries in which syphilis and chancroid have been
“eliminated”. A rapid-response mode should be available to immediately address
the appearance of either of these ulcerative diseases, with strategies to
achieve effective re-establishment of regions “free” of both H. ducreyi and T. pallidum.
- All patients diagnosed with chancroid should
undergo testing to rule out co-infection with other STIs, including HIV.
- Syndromic treatment for chancroid consists of a
single oral dose of 500 mg of ciprofloxacin, which has a cure rate of
- A 1-week course of erythromycin, 500 mg
PO tid, also provides an excellent cure rate of >90% but is
associated with poorer compliance [A-l].
- Another macrolide, azithromycin, has
cured over 90% of patients when prescribed as a single oral 1 g dose [A-l].–
- Ceftriaxone 250
mg IM has been successful, but failures have commonly occurred in HIV
co-infected individuals [A-l].,,
- Treatment failures should be carefully evaluated
with respect to both the etiology and the possible co-existence of other
pathogens. Buboes should be aspirated or incised to relieve pain and prevent
Reporting and Partner Notification
- All individuals who had sexual exposure to the
index patient during the 2 weeks prior to the date of initial symptoms should
be empirically treated with a quinolone or another antibacterial known
to be effective for index case(s) regardless of clinical findings and without
waiting for test results.
- The length of time for the trace-back period
should be extended:
- to include additional time up to the date of
- if the index case states that there were no partners during the
recommended trace-back period, then the last partner should be notified
- if all partners traced (according to recommended trace-back
period) test negative, then the partner prior to the trace-back period should
Consideration for Other STIs
- Patients suspected of having chancroid should
also be considered for the following STIs:
- Lymphogranuloma venereum
- Donovanosis (granuloma inguinale)
- All patients with presumed chancroid should also
be tested for syphilis and HIV infection at presentation and 3 months later.
Patients should also be tested appropriately for gonorrhea.
- Immunization for hepatitis B should be offered
to non-immune patients.
- The opportunity to provide safer-sex counselling
should not be missed.
- Discuss HPV vaccine with women as per the
recommendations outlined in the Canada Communicable Disease Report, Volume 33
ACS-2, (2007) National Advisory Committee on Immunization (NACI) statement
on Human papillomavirus vaccine.
- Repeat diagnostic testing for the detection of H. ducreyi is not routinely indicated if
a recommended treatment is given and taken AND symptoms and signs disappear AND
there is no re-exposure to an untreated partner.
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