What is the management of chancroid?

Management of Chancroid

Treat chancroid with azithromycin 1 g orally as a single dose, ceftriaxone 250 mg intramuscularly as a single dose, ciprofloxacin 500 mg orally twice daily for 3 days, or erythromycin base 500 mg orally four times daily for 7 days. 1

First-Line Treatment Regimens

The CDC provides four equally effective first-line options for chancroid treatment: 1

• Azithromycin 1 g orally as a single dose 1, 2
• Ceftriaxone 250 mg intramuscularly as a single dose 1
• Ciprofloxacin 500 mg orally twice daily for 3 days 1
• Erythromycin base 500 mg orally four times daily for 7 days 1

Azithromycin and ceftriaxone offer the critical advantage of single-dose therapy, which ensures compliance and allows treatment at first presentation. 1 This is particularly important given that chancroid is a cofactor for HIV transmission and early treatment reduces onward transmission. 1

Important Contraindications and Warnings

• Ciprofloxacin is absolutely contraindicated in pregnant women, lactating women, and persons under 18 years of age. 1
• Azithromycin safety has not been established in pregnant and lactating women, though no adverse fetal effects have been reported. 1
• Worldwide isolates with intermediate resistance to ciprofloxacin and erythromycin have been reported, though resistance to azithromycin and ceftriaxone has not been documented. 1, 3

Essential Concurrent Testing

At the time of chancroid diagnosis, the following testing is mandatory: 1

• HIV testing (chancroid is a significant cofactor for HIV transmission) 1
• Serologic test for syphilis (10% of chancroid patients have co-infection with T. pallidum or HSV) 1
• HSV culture or antigen test to exclude herpes 1, 4
• Repeat testing at 3 months for HIV and syphilis if initial results were negative 1

Follow-Up Protocol

Re-examine patients 3-7 days after initiating therapy to assess treatment response. 1, 5

Expected Clinical Response

• Symptomatic improvement should occur within 3 days 1, 6
• Objective improvement should occur within 7 days 1, 6
• Large ulcers may require more than 2 weeks for complete healing 1
• Healing is slower in uncircumcised men with ulcers under the foreskin 1

Treatment Failure Considerations

If no clinical improvement is evident at 3-7 days, consider the following: 1, 5

• Incorrect diagnosis (25% of genital ulcers have no laboratory-confirmed diagnosis even after complete evaluation) 1, 4, 5
• Co-infection with another STD (10% of chancroid patients have T. pallidum or HSV co-infection) 1, 4
• HIV infection (HIV-positive patients have slower healing and higher treatment failure rates) 1, 6
• Non-adherence to treatment 1
• Antimicrobial resistance 1

Special Populations

HIV-Infected Patients

HIV-infected patients require close monitoring and may need longer courses of therapy than HIV-negative patients. 1

• All four standard regimens are effective in HIV-infected patients, but healing is slower and treatment failures occur with any regimen 1
• Some experts recommend the erythromycin 7-day regimen for HIV-infected persons to ensure adequate treatment duration 1
• Azithromycin and ceftriaxone should only be used in HIV-infected patients if follow-up can be ensured 1
• Uncircumcised HIV-infected patients may not respond as well to treatment 1

Pregnant Women

• Erythromycin base 500 mg orally four times daily for 7 days is the preferred regimen 1
• Ciprofloxacin is contraindicated 1
• Azithromycin safety has not been established, though no adverse pregnancy outcomes have been reported 1

Management of Lymphadenopathy

Fluctuant lymphadenopathy (buboes) resolves more slowly than ulcers and may require drainage even during otherwise successful therapy. 1, 5

• Needle aspiration through adjacent intact skin is the simpler procedure 1
• Incision and drainage may be preferred because of less need for subsequent drainage procedures 1

Sexual Partner Management

All sex partners who had sexual contact with the patient during the 10 days preceding symptom onset must be examined and treated, regardless of whether symptoms are present. 1, 5

This is critical to prevent reinfection and limit onward transmission of both chancroid and HIV. 1

Critical Diagnostic Pitfalls

• Clinical diagnosis alone is highly unreliable – classic presentations occur in only 31-35% of cases 4
• The combination of painful ulcer with tender inguinal adenopathy that progresses to suppurative adenopathy is almost pathognomonic for chancroid 1, 4
• Up to 25% of genital ulcers remain undiagnosed even after complete evaluation 1, 4, 5
• When diagnosis is uncertain and diagnostic capabilities are limited, treat empirically for both syphilis and chancroid if the patient resides in a community where H. ducreyi is prevalent 1, 4