Warning:

This document is being maintained for historical purposes, but is now out of date. To view current guidelines please visit:

• STD Treatment Guidelines   at http://www.cdc.gov/STD/treatment

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1993 Sexually Transmitted Diseases Treatment Guidelines

09/24/1993

SUGGESTED CITATION
Centers for Disease Control and Prevention. 1993 Sexually
transmitted diseases treatment guidelines. MMWR 1993;42(No. RR-14):
{inclusive page numbers}.

CIO Responsible for this publication:
National Center for Prevention Services,
Division of Sexually Transmitted Diseases and HIV Prevention

Chancroid
     
     Chancroid is endemic in many areas of the United States and
also occurs in discrete outbreaks. Chancroid has been well
established as a co-factor for HIV transmission and a high rate of
HIV infection among patients with chancroid has been reported in
the United States and in other countries. As many as 10% of
patients with chancroid may be coinfected with T. pallidum or HSV.

     Definitive diagnosis of chancroid requires identification of
H. ducreyi on special culture media that are not commercially
available; even using these media, sensitivity is no higher than
80% and is usually lower. A probable diagnosis, for both clinical
and surveillance purposes, may be made if the person has one or
more painful genital ulcers, and a) no evidence of T. pallidum
infection by darkfield examination of ulcer exudate or by a
serologic test for syphilis performed at least 7 days after onset
of ulcers, and b) either the clinical presentation of the ulcer(s)
is not typical of disease caused by HSV or the HSV test results are
negative. The combination of a painful ulcer with tender inguinal
adenopathy (which occurs among one-third of patients) is suggestive
of chancroid, and when accompanied by suppurative inguinal
adenopathy is almost pathognomonic.

Treatment
     Successful treatment cures infection, resolves clinical
symptoms, and prevents transmission to others. In extensive cases,
scarring may result despite successful therapy.

Recommended Regimens
     Azithromycin 1 g orally in a single dose
                      or
     Ceftriaxone 250 mg intramuscularly (IM) in a single dose
                      or
     Erythromycin base 500 mg orally 4 times a day for 7 days.

     All three regimens are effective for the treatment of
chancroid among patients without HIV infection. Azithromycin and
ceftriaxone offer the advantage of single-dose therapy.
Antimicrobial resistance to ceftriaxone and azithromycin has not
been reported. Although two isolates resistant to erythromycin were
reported from Asia a decade ago, similar isolates have not been
reported.

Alternative Regimens
     Amoxicillin 500 mg plus clavulanic acid 125 mg orally 3 times
     a day for 7 days,
                           or
     Ciprofloxacin 500 mg orally 2 times a day for 3 days.

NOTE: Ciprofloxacin is contraindicated for pregnant and
lactating women, children, and adolescents less than or equal to 17
years of age.

     These regimens have not been evaluated as extensively as the
recommended regimens; neither has been studied in the United
States.

Other Management Considerations
     Patients should be tested for HIV infection at the time of
diagnosis. Patients also should be tested 3 months later for both
syphilis and HIV, if initial results are negative.

Follow-Up
     Patients should be re-examined 3-7 days after initiation of
therapy. If treatment is successful, ulcers improve symptomatically
within 3 days and improve objectively within 7 days after therapy.
If no clinical improvement is evident, the clinician must consider
whether a) the diagnosis is correct, b) coinfection with another
STD agent exists, c) the patient is infected with HIV, d) treatment
was not taken as instructed, or e) the H. ducreyi strain causing
infection is resistant to the prescribed antimicrobial. The time
required for complete healing is related to the size of the ulcer;
large ulcers may require greater than or equal to 2 weeks. Clinical
resolution of fluctuant lymphadenopathy is slower than that of
ulcers and may require needle aspiration through adjacent intact
skin -- even during successful therapy.


Management of Sex Partners
     Persons who had sexual contact with a patient who has
chancroid within the 10 days before onset of the patient's symptoms
should be examined and treated. The examination and treatment
should be administered even in the absence of symptoms.

Special Considerations

Pregnancy -
     The safety of azithromycin for pregnant and lactating women
has not been established. Ciprofloxacin is contraindicated during
pregnancy. No adverse effects of chancroid on pregnancy outcome or
on the fetus have been reported.

HIV Infection -
     Patients coinfected with HIV should be closely monitored.
These patients may require courses of therapy longer than those
recommended in this report. Healing may be slower among
HIV-infected persons and treatment failures do occur, especially
after shorter-course treatment regimens. Since data on therapeutic
efficacy with the recommended ceftriaxone and azithromycin regimens
among patients infected with HIV are limited, those regimens should
be used among persons known to be infected with HIV only if
follow-up can be assured. Some experts suggest using the
erythromycin 7-day regimen for treating HIV-infected persons.

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