Chancroid
Chancroid prevalence has declined in the United States (141). When infection does occur, it is usually associated with sporadic outbreaks. Worldwide, chancroid appears to have decreased as well, although infection might still occur in certain Africa regions and the Caribbean. Chancroid is a risk factor in HIV transmission and acquisition (197).
Diagnostic Considerations
A definitive diagnosis of chancroid requires identifying H. ducreyi on special culture media that is not widely available from commercial sources; even when these media are used, sensitivity is <80% (427). No FDA-cleared NAAT for H. ducreyi is available in the United States; however, such testing can be performed by clinical laboratories that have developed their own NAAT and have conducted CLIA verification studies on genital specimens.
The combination of one or more deep and painful genital ulcers and tender suppurative inguinal adenopathy indicates the chancroid diagnosis; inguinal lymphadenitis typically occurs in <50% of cases (428). For both clinical and surveillance purposes, a probable diagnosis of chancroid can be made if all of the following four criteria are met: 1) the patient has one or more painful genital ulcers; 2) the clinical presentation, appearance of genital ulcers and, if present, regional lymphadenopathy are typical for chancroid; 3) the patient has no evidence of T. pallidum infection by darkfield examination or NAAT (i.e., ulcer exudate or serous fluid) or by serologic tests for syphilis performed at least 7–14 days after onset of ulcers; and 4) HSV-1 or HSV-2 NAAT or HSV culture performed on the ulcer exudate or fluid are negative.
Treatment
Successful antimicrobial treatment for chancroid cures the infection, resolves the clinical symptoms, and prevents transmission to others. In advanced cases, genital scarring and rectal or urogenital fistulas from suppurative buboes can result despite successful therapy.
Azithromycin 1 gm orally in a single dose
OR
Ceftriaxone 250 mg IM in a single dose
OR
Ciprofloxacin 500 mg orally 2 times/day for 3 days
OR
Erythromycin base 500 mg orally 3 times/day for 7 days
Azithromycin and ceftriaxone offer the advantage of single-dose therapy (429). Worldwide, several isolates with intermediate resistance to either ciprofloxacin or erythromycin have been reported. However, because cultures are not routinely performed, and chancroid is uncommon, data are limited regarding prevalence of H. ducreyi antimicrobial resistance.
Other Management Considerations
Men who are uncircumcised and persons with HIV infection do not respond as well to treatment as persons who are circumcised or are HIV negative (430). Patients should be tested for HIV at the time chancroid is diagnosed. If the initial HIV test results were negative, the provider can consider the benefits of offering more frequent testing and HIV PrEP to persons at increased risk for HIV infection.
Follow-Up
Patients should be reexamined 3–7 days after therapy initiation. If treatment is successful, ulcers usually improve symptomatically within 3 days and objectively within 7 days after therapy. If no clinical improvement is evident, the clinician should consider whether the diagnosis is correct, another STI is present, the patient has HIV infection, the treatment was not used as instructed, or the H. ducreyi strain causing the infection is resistant to the prescribed antimicrobial. The time required for complete healing depends on the size of the ulcer; large ulcers might require >2 weeks. In addition, healing can be slower for uncircumcised men who have ulcers under the foreskin. Clinical resolution of fluctuant lymphadenopathy is slower than that of ulcers and might require needle aspiration or incision and drainage, despite otherwise successful therapy. Although needle aspiration of buboes is a simpler procedure, incision and drainage might be preferred because of reduced need for subsequent drainage procedures.
Management of Sex Partners
Regardless of whether disease symptoms are present, sex partners of patients with chancroid should be examined and treated if they had sexual contact with the patient during the 10 days preceding the patient’s symptom onset.
Special Considerations
Pregnancy
Data indicate ciprofloxacin presents a low risk to the fetus during pregnancy but has potential for toxicity during breastfeeding (431). Alternative drugs should be used if the patient is pregnant or lactating. No adverse effects of chancroid on pregnancy outcome have been reported.
HIV Infection
Persons with HIV infection who have chancroid infection should be monitored closely because they are more likely to experience chancroid treatment failure and to have ulcers that heal slowly (430,432). Persons with HIV might require repeated or longer courses of therapy, and treatment failures can occur with any regimen. Data are limited concerning the therapeutic efficacy of the recommended single-dose azithromycin and ceftriaxone regimens among persons with HIV infection.
Children
Because sexual contact is the major primary transmission route among U.S. patients, diagnosis of chancroid ulcers among infants and children, especially in the genital or perineal region, is highly suspicious of sexual abuse. However, H. ducreyi is recognized as a major cause of nonsexually transmitted cutaneous ulcers among children in tropical regions and, specifically, countries where yaws is endemic (433–435). Acquisition of a lower-extremity ulcer attributable to H. ducreyi in a child without genital ulcers and reported travel to a region where yaws is endemic should not be considered evidence of sexual abuse.