What is the recommended treatment for a sexually active adult presenting with chancroid symptoms?

Treatment of Chancroid

For a sexually active adult with chancroid symptoms, treat immediately with azithromycin 1 g orally as a single dose or ceftriaxone 250 mg intramuscularly as a single dose. 1

First-Line Treatment Options

The CDC recommends four equally effective regimens for chancroid 2, 1:

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

Azithromycin and ceftriaxone are strongly preferred because single-dose therapy ensures complete treatment at the first visit, eliminating compliance concerns. 1 This is critical because chancroid is a significant cofactor for HIV transmission, and immediate effective treatment reduces onward transmission of both infections. 2, 1

Critical Contraindication

Ciprofloxacin is absolutely contraindicated in pregnant women, lactating women, and persons under 18 years of age. 2 For these populations, use azithromycin, ceftriaxone, or erythromycin instead. 2, 1

Essential Concurrent Testing

Every patient with chancroid requires 2, 1:

• HIV testing - Chancroid significantly increases HIV transmission risk 2, 1
• Serologic test for syphilis - 10% of chancroid patients have coinfection with Treponema pallidum or HSV 2, 1
• HSV testing if available - To rule out herpes simplex virus coinfection 2

Mandatory Follow-Up Protocol

Re-examine the patient 3-7 days after initiating therapy. 1 Look for:

• Symptomatic improvement within 3 days 1
• Objective improvement of ulcers within 7 days 1

If no improvement occurs, consider treatment failure, HIV coinfection, or incorrect diagnosis. 1

Management of Inguinal Lymphadenopathy

Fluctuant buboes resolve more slowly than ulcers and may require drainage even during otherwise successful therapy. 1 Options include needle aspiration or incision and drainage. 1 Do not excise buboes, as this delays healing. 1

Partner Management Requirements

All sexual partners who had contact with the patient during the 10 days preceding symptom onset must be examined and treated, regardless of whether they have symptoms. 1 This prevents reinfection of the index patient and limits onward transmission of both chancroid and HIV. 1

Special Considerations for HIV-Infected Patients

HIV-infected patients require close monitoring and may need longer treatment courses than HIV-negative patients. 1 All four standard regimens remain effective, but healing is slower and treatment failures can occur with any regimen. 1 These patients warrant more frequent follow-up visits. 1

Pregnancy-Specific Recommendations

Pregnant women should be treated with erythromycin base 500 mg orally four times daily for 7 days. 1 Ciprofloxacin is contraindicated, and azithromycin safety has not been established in pregnancy for chancroid treatment. 1

Clinical Diagnosis Criteria

A probable diagnosis of chancroid can be made for clinical and surveillance purposes if 2, 1:

• The patient has one or more painful genital ulcers 2
• No evidence of T. pallidum infection by darkfield examination or serologic test performed at least 7 days after ulcer onset 2
• Clinical presentation is typical for chancroid and HSV test is negative 2

The combination of a painful ulcer with tender inguinal adenopathy (occurring in one-third of patients) strongly suggests chancroid; when accompanied by suppurative adenopathy, this is almost pathognomonic. 2

Common Pitfall to Avoid

Do not wait for culture confirmation before treating. 2 H. ducreyi culture requires special media not widely available commercially, and even with optimal media, sensitivity is ≤80%. 2 Treat based on clinical diagnosis and adjust if culture results indicate otherwise. 2