Chancroid is a sexually-transmitted infectious disease caused by a small bacterial organism Haemophilus ducreyi and an important cause of genital ulceration syndrome in many parts of the world.
Ulcerations present in the infected individuals are usually accompanied by regional inflammation of lymph nodes and bubo formation.
As laboratory diagnosis is often neither sensitive nor swift, treatment should be initiated as soon as chancroid is suspected on clinical grounds. Patients should be informed that this bacterial infection is sexually-transmitted and that it may act as a co-factor for the transmission of human immunodeficiency virus (HIV); thus, sexual partners should also be examined and treated.
Antibiotic Treatment and Resistance Patterns
According to the Centers for Disease Control and Prevention (CDC), currently recommended first-line treatment approach for chancroid should be one of the following four regimens: a single dose of azithromycin (1 gram), a single intramuscular dose of ceftriaxone (250 milligrams), oral ciprofloxacin (500 milligrams two times per day) for a total of three days, or oral erythromycin (500 milligrams three times per day) for a total of seven days.
Azithromycin and ceftriaxone have the advantage of a single-dose approach, although multiple day regimens are warranted for HIV-positive individuals. Ciprofloxacin should not be given to pregnant or lactating women, as well as to children or adolescents younger than 18 years of age.
Successful treatment of chancroid should result in evidently reduced tenderness, lack of purulence, with at least some epithelialization of ulcers when they are evaluated seven days after therapy was initiated. It must be noted that healing might be slower for uncircumcised men and HIV-infected patients.
Practically all strains of Haemophilus ducreyi carry a beta-lactamase and a tetracycline-resistance determinant on their plasmids (extrachromosomal DNA), which deems them inherently resistant to penicillins and tetracyclines. Furthermore, it was shown that resistance to trimethoprim and sulphonamides exceed 50 percent in many areas of sub-Saharan Africa and Asia, which is why they should not be prescribed.
Syndromic Management Approach
The World Health Organization (WHO) has proposed a comprehensive syndromic approach for the treatment of genital ulcers. This type of management is intended for settings without adequate laboratory support, thus the antimicrobial treatment is based on local epidemiological patterns and antibiotic sensitivity.
The underlying principle of a syndromic approach is to treat the patients at the first visit by combining different antimicrobials to cover probable etiological infectious agents present in that area. This process does not necessitate clinical description of the ulcer or exact laboratory identification.
Syndromic management approach has resulted in more success than just relying on clinical diagnoses or hierarchical algorithms. It has also been credited with near elimination of chancroid (but also syphilis) from certain countries in sub-Saharan Africa.
Experience of chancroid outbreak control in non-endemic areas has provided important insight into modalities of eliminating this infection and preventing its reappearance. Some interventions that have proved successful are targeted prevention and treatment efforts for commercial sex workers, peer interventions in order to preserve high level of preventive behavior, as well as adequate syndromic management of ulcers.
Other potentially efficacious interventions should also be investigated, such as more accurate and affordable diagnostics, as well as post-exposure male hygiene. Currently there are no vaccines available. In any case, research endeavors should be principally operational and focus on adjusting strategies to local surroundings.
In conclusion, the ongoing persistence of chancroid reflects an emendable imbalance. The prime condition that is necessary for chancroid preservation in a specific population is a commercial sex environment that exposes a sufficient number of women to increased numbers of sexual partners, as well as the lack of basic curative and preventive control measures. Its eradication should be seen as a priority for preventing infection with HIV, but also general control of sexually-transmitted infections.
Reviewed by Afsaneh Khetrapal Bsc (Hons)