eMedicine Specialties > Dermatology > Bacterial Infections
Chancroid: Treatment & Medication
Updated: Aug 22, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
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Treatment
Medical Care
- Local therapy for chancroid includes gentle topical cleansing, soaks, and measures to reduce edema.
- Patients with nonfluctuant buboes respond well to antibiotics, and the chancroid lesions do not need to be drained.
- If appropriate chancroid therapy is provided and no clinical improvement is evident, the clinician must consider whether the diagnosis is correct, whether the patient is co-infected with another STD, whether the patient is infected with HIV, whether the treatment instructions were followed properly, and whether the H ducreyi strain is resistant to the prescribed antimicrobial.
- In resource-poor settings, where diagnostic facilities are not readily available, the World Health Organization advocates the use of a syndromic approach for the therapy of GUD.24,25,15,16
- The syndromic approach for the therapy of STDs delivers effective treatment quickly to people when they first come in for care and is focused on the most common STDs that can be cured, including syphilis, gonorrhea, chlamydia, chancroid, trichomoniasis, and candidiasis.
- The syndromic approach does not require the use of expensive tests, which often are not available. People who may have more than one STD infection are treated with the most effective drug available. In some undeveloped regions, 6 of every 10 patients with an STD have 2 or more different infections at the same time. This approach also emphasizes treatment during the first visit. Treating curable STDs as soon as possible limits the future spread of STDs, including HIV.
- STD syndromes that cause similar signs and symptoms are included in a simple flow chart to help health care workers use the syndromic approach to make a diagnosis and begin appropriate therapy.
- Using the syndromic approach is as follows:
- Men who present with a urethral discharge are treated for both gonorrhea and chlamydia.
- Women who present with lower abdominal pain are treated for gonorrhea, chlamydia, and other bacterial infections.
- Women who present with vaginal discharge and cervicitis are treated for gonorrhea and chlamydia.
- Women who present with vaginal discharge and vaginitis are treated for trichomoniasis and candidiasis.
- Men or women who present with genital ulcers are treated for syphilis, chancroid, and genital herpes.
- Treating people with STDs in this way is less expensive long term because more people are cured the first time they come for care and because the spread of STD may be limited.
- The recommended drugs for STDs should be selected based on cost, availability, and local resistance patterns.26,27
- A proper supply of STD drugs and training programs for health care workers are essential.
- With the syndromic approach, less emphasis is placed on identifying the cause of a particular STD. This may be difficult for some health care workers to accept when they have been trained to identify the specific cause of a disease before starting therapy. However, in a setting where rapid therapy is of utmost importance and sophisticated laboratories are not available, the syndromic approach provides effective treatment.
- Prompt, effective therapy and education of patients helps them decide to use condoms, change their risky sexual behavior, and convince their partner to seek treatment.
Surgical Care
- Fluctuant buboes should be drained with the patient under local anesthesia. Insert a large-gauge needle into the bubo, passing through normal tissue from the side or the top of the lesion rather than the bottom, thus avoiding continuous dependent drainage and fistula formation (see Media File 4).
- Incision and drainage is an effective method for treating fluctuant buboes and may be preferable to traditional needle aspiration, considering the frequency of required repeat aspirations in some studies.28
- If circumcision is needed, it should be completed after the patient successfully completes treatment with antibiotics.
Activity
Patients should refrain from sexual activity until ulcers are healed. Untreated chancroid ulcers may persist for 1-3 months. Chancroid ulcers treated with the appropriate antibiotic agent resolve within 7-14 days.
Medication
Guidelines for therapy are usually based on the presenting symptoms and the clinical distribution of infection. Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
Successful treatment for chancroid cures the infection, resolves the clinical symptoms, and prevents chancroid transmission to others. The US Centers for Disease Control and Prevention (CDC) recommends any one of the following treatments for chancroid:
- Azithromycin 1 g orally in a single dose
- Ceftriaxone 250 mg intramuscularly in a single dose
- Ciprofloxacin 500 mg orally twice a day for 3 days
- Erythromycin base 500 mg 3 times a day for 7 days
Ciprofloxacin is contraindicated for pregnant and lactating women. Azithromycin and ceftriaxone offer the advantage of single-dose therapy. Worldwide, several isolates with intermediate resistance to either ciprofloxacin or erythromycin have been reported.24,29
Uncircumcised men and patients who are infected with HIV do not respond to therapy as well as others. Chancroid relapses after antibiotic therapy in as many as 5% of patients, and relapses are more common in patients who are uncircumcised or are infected with HIV. If they are not infected with HIV, repeating the original therapy is usually effective.
Because chancroid treatment is often accompanied by treatment for gonococcal infections, it is important to be aware of changes to the CDC guidelines for STDs. In April 2007, the CDC updated treatment guidelines for gonococcal infection and associated conditions. Fluoroquinolone antibiotics are no longer recommended to treat gonorrhea in the United States. The recommendation was based on data from the CDC's Gonococcal Isolate Surveillance Project (GISP) published in the April 13, 2007, issue of the Morbidity and Mortality Weekly Report. This limits treatment of gonorrhea to drugs in the cephalosporin class (eg, ceftriaxone 125 mg intramuscularly once as a single dose). For more information see, the CDC's Antibiotic-Resistant Gonorrhea Web site; CDC Updated Gonococcal treatment recommendations (April 2007); or Medscape Medical News on CDC Issues - New Treatment Recommendations for Gonorrhea.
Antibiotic, Macrolide
Azithromycin (Zithromax)
Acts by binding to 50S ribosomal subunit of susceptible microorganisms and blocks dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Nucleic acid synthesis is not affected.
Concentrates in phagocytes and fibroblasts as demonstrated by in vitro incubation techniques. In vivo studies suggest that concentration in phagocytes may contribute to drug distribution to inflamed tissues.
Treats mild-to-moderate microbial infections. Plasma concentrations are very low, but tissue concentrations are much higher, giving it value in treating intracellular organisms. Has a long tissue half-life.
Adult
1 g PO single dose
Pediatric
<6 months: Not established
>6 months: 10 mg/kg PO once on day 1, not to exceed 500 mg/d; 5 mg/kg PO qd on days 2-5, not to exceed 250 mg/d
May increase toxicity of theophylline, warfarin, and digoxin; effects are reduced with coadministration of aluminum and/or magnesium antacids; nephrotoxicity and neurotoxicity may occur when coadministered with cyclosporine
Documented hypersensitivity; hepatic impairment; coadministration with pimozide
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Site reactions can occur with IV route; bacterial or fungal overgrowth may result from prolonged antibiotic use; may increase hepatic enzymes and cholestatic jaundice; caution in patients with impaired hepatic function or prolonged QT intervals
Erythromycin (E-Mycin, Eryc, Ery-Tab)
Recommended dosing schedule may result in GI upset, causing one to prescribe alternative macrolide or change to tid dosing. Covers most potential etiologic agents, including Mycoplasma species.
Less active against Haemophilus influenzae. Although 10 d seems to be standard course of treatment, treating until patient has been afebrile for 3-5 d seems more rational. Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Indicated for staphylococcal and streptococcal infections.
In children, age, weight, and severity of infection determine proper dosage. When bid dosing is desired, half-total daily dose may be taken q12h. For more severe infections, double the dose.
Has added advantage of being a good anti-inflammatory agent by inhibiting migration of polymorphonuclear leukocytes.
Adult
Erythromycin base 500 mg PO tid for 7 d
Pediatric
30-50 mg/kg/d (15-25 mg/lb/d) PO divided q6-8h; double dose for severe infection
Inhibits CYP450 1A2, 3A3/4 isoenzymes; coadministration may increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin increases risk of rhabdomyolysis; decreases metabolism of repaglinide, thus increasing serum levels and effects
Documented hypersensitivity; hepatic impairment
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in liver disease; estolate formulation may cause cholestatic jaundice; adverse GI effects are common (give doses pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occur
Antibiotic, Cephalosporin
Ceftriaxone (Rocephin)
Third-generation cephalosporin with broad-spectrum, gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Arrests bacterial growth by binding to 1 or more penicillin-binding proteins.
Adult
250 mg IM as single dose
Pediatric
>7 days: 25-50 mg/kg/d IV/IM; not to exceed 125 mg/d
Infants and children: 50-75 mg/kg/d IV/IM divided q12h; not to exceed 2 g/d
Probenecid may increase levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment; caution in breastfeeding and in persons allergic to penicillin
Antibiotic, Quinolone
Ciprofloxacin (Cipro)
Fluoroquinolone that inhibits bacterial DNA synthesis and, consequently, growth, by inhibiting DNA gyrase and topoisomerases, which are required for replication, transcription, and translation of genetic material. Quinolones have broad activity against gram-positive and gram-negative aerobic organisms. Has no activity against anaerobes. Continue treatment for at least 2 d (7-14 d typical) after signs and symptoms have disappeared.
Adult
500 mg PO bid for 3 d
Pediatric
<18 years: Not recommended
>18 years: Administer as in adults
Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; reduces therapeutic effects of phenytoin; probenecid may increase serum concentrations
May increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Dosage adjustments (adult adjustments)
CrCl <10 mL/min: 50% of PO or IV dose q12h
HD: 0.25-0.5 g PO or 0.2-0.4 g IV q12h
During peritoneal dialysis: 0.25-0.5 g PO or 0.2-0.4 g IV q8h
In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy
Not drug of first choice in pediatrics because of increased incidence of adverse events compared with controls, including arthropathy; no data available for pediatric dosing in renal impairment (ie, CrCl <50 mL/min)
More on Chancroid |
| Overview: Chancroid |
| Differential Diagnoses & Workup: Chancroid |
 Treatment & Medication: Chancroid |
| Follow-up: Chancroid |
| Multimedia: Chancroid |
| References |
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Further Reading
Keywords
chancroid, HIV transmission, soft chancre, genital ulcers, STD, genital ulcer disease, GUD, Haemophilus ducreyi, H ducreyi, sexually transmitted disease, genital ulcer, bubo
