eMedicine Specialties > Dermatology > Bacterial Infections
Granuloma Inguinale (Donovanosis): Treatment & Medication
Updated: Feb 5, 2010
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
The recommended antibiotic for granuloma inguinale is either trimethoprim/sulfamethoxazole7 or doxycycline. Alternatives include ciprofloxacin, erythromycin, or azithromycin.8 The antibiotic should be given for at least a 3-week course and continued until reepithelialization of the ulcer occurs and any signs of the disease have resolved. If the granuloma inguinale ulcers do not respond within the first days of therapy, add an aminoglycoside (eg, gentamicin at 1 mg/kg IV q8h). Relapse of granuloma inguinale may occur up to 18 months after treatment. In some countries, tetracycline is no longer recommended, owing to bacterial resistance.9
Special considerations
Pregnancy is a relative contraindication for the use of sulfonamides. In pregnant and lactating women with granuloma inguinale, the Centers for Disease Control and Prevention10 recommends erythromycin with or without a parenteral aminoglycoside; however, recent data suggest erythromycin may increase the risk of congenital malformation.11 Doxycycline and ciprofloxacin are contraindicated in pregnancy.
HIV-associated granuloma inguinale may take longer to heal, and the addition of a parenteral aminoglycoside to the regimen is highly recommended.12
Sexual contacts within 60 days prior to the onset of the patient's symptoms of granuloma inguinale should be examined and offered therapy.
A clinical guideline summary is available from the US Centers for Disease Control and Prevention: Diseases characterized by genital ulcers. Sexually transmitted diseases treatment guidelines 2006.13
Surgical Care
Once granuloma inguinale is healed, disfiguring genital swellings may need to be surgically corrected.
Medication
The goal of pharmacotherapy for granuloma inguinale is to reduce morbidity and to prevent complications.
Antibiotics
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
Trimethoprim/sulfamethoxazole (Bactrim IV, Bactrim SS, Bactrim DS, Septra)
Sulfamethoxazole inhibits bacterial synthesis of dihydrofolic acid. Trimethoprim reversibly inhibits dihydrofolate reductase and blocks the production of tetrahydrofolic acid from dihydrofolic acid.
Adult
One DS tab (800 mg/160 mg) PO bid for at least 3 wk
Pediatric
<2 months: Contraindicated
>2 months: 15-20 mg/kg/d (based on TMP) PO divided q6-8h for at least 3 wk
May increase PT when used with warfarin (perform coagulation tests and adjust dose accordingly); coadministration of diuretics, primarily thiazides, increases incidence of thrombocytopenia purpura in elderly persons; phenytoin levels may increase with coadministration; sulfonamides may increase free methotrexate concentrations; TMP-SMZ may interfere with Jaffe alkaline picrate reaction for creatinine, causing overestimation of creatinine value
Documented hypersensitivity; megaloblastic anemia due to folate deficiency; pregnant patients; nursing mothers; age <2 mo
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
Discontinue at first appearance of rash or sign of adverse reaction; Stevens-Johnson syndrome, toxic epidermal necrolysis, fulminant hepatic necrosis, agranulocytosis, aplastic anemia, and other blood dyscrasias have rarely occurred; pseudomembranous colitis caused by Clostridium difficile has been reported; sulfonamide hypersensitivity reactions may cause cough, shortness of breath, and pulmonary infiltrates
Give with caution to patients with impaired renal or hepatic function, possible folate deficiency (elderly persons, alcoholic patients, anticonvulsant therapy, malabsorption, malnutrition) and those with severe allergies or bronchial asthma; dose-related hemolysis may occur in patients with G-6-PD deficiency
Obtain CBC count frequently and discontinue therapy if significant hematologic changes occur; may cause bone marrow suppression (if signs occur, give 5-15 mg/d leucovorin); patients with AIDS may not tolerate or respond to TMP-SMZ in same manner as non-AIDS patients; give fluids to prevent crystalluria and stone formation
Give with caution to patients with impaired renal or hepatic function, possible folate deficiency (elderly, alcoholic, anticonvulsant therapy, malabsorption, malnutrition) and those with severe allergies or bronchial asthma; dose-related hemolysis may occur in patients with G-6-PD deficiency
Obtain CBC count frequently and discontinue therapy if significant hematologic changes occur; may cause bone marrow suppression (if signs occur, give 5-15 mg/d leucovorin); patients with AIDS may not tolerate or respond to TMP-SMZ in same manner as non-AIDS patients; give fluids to prevent crystalluria and stone formation
Doxycycline (Adoxa, Doryx, Vibramycin, Periostat)
Bacteriostatic tetracycline antibiotic that inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria.
Adult
100 mg PO bid for at least 3 wk
Pediatric
<8 years: Not recommended
>8 years and <45 kg: 2.2 mg/kg PO/IV bid for at least 3 wk; not to exceed 200 mg/d
>8 years and >45 kg: 100 mg PO bid for at least 3 wk
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; depresses plasma prothrombin activity (anticoagulant dosage may need to be decreased); decreases effect of penicillin; barbiturates, carbamazepine, and phenytoin decrease half-life; concurrent use with methoxyflurane has resulted in fatal renal toxicity; concurrent use with oral contraceptives may render them less effective
Documented hypersensitivity
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; caution in patients with hepatic or renal insufficiency; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; use during tooth development (last half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines; as with all antibiotics, risk of superinfection exists; bulging fontanels in infants and benign intracranial hypertension in adults may occur (these resolve upon discontinuation)
Ciprofloxacin (Cipro)
Bactericidal fluoroquinolone antibiotic that inhibits the bacterial enzymes topoisomerase II (DNA gyrase) and topoisomerase IV, which are required for bacterial DNA replication, transcription, repair, and recombination.
Adult
750 mg PO bid for at least 3 wk
Pediatric
<18 years: Not recommended
>18 years: Administer as in adults
Multivalent cation-containing products such as magnesium/aluminum antacids, sucralfate, didanosine, other highly buffered drugs or products containing calcium, iron, or zinc may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; phenytoin serum levels may be altered (increased or decreased); probenecid may increase serum concentrations; may increase toxicity of theophylline, caffeine, tizanidine, glyburide, methotrexate, cyclosporine, and digoxin (monitor theophylline and digoxin levels); may increase effects of warfarin (monitor PT); metoclopramide accelerates absorption of oral ciprofloxacin; NSAIDs (but not acetyl salicylic acid) with very high doses of fluoroquinolones may provoke convulsions
Documented hypersensitivity; use with tizanidine
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
In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections with drug-resistant bacteria may occur with prolonged or repeated antibiotic therapy; avoid excessive sunlight due to risk of phototoxicity; crystalluria may occur if urine is alkaline or concentrated; CNS may be affected, resulting in nervousness, agitation, insomnia, anxiety, nightmares, or paranoia
Erythromycin (E-Mycin, Ery-Tab, Eryc)
Macrolide antibiotic that inhibits bacterial protein synthesis by binding to 50S ribosomal subunits of susceptible organisms; may be bacteriocidal or bacteriostatic depending on concentration and type of microorganism.
Adult
500 mg PO qid for at least 3 wk
Pediatric
30-50 mg/kg/d PO divided q6-8h for at least 3 wk
Coadministration may increase toxicity of theophylline and digoxin; may potentiate anticoagulant effects of oral anticoagulants; because erythromycin is an inhibitor of cytochrome P450 3A (CYP3A), the following drug levels may rise, causing increased risk of toxicity: ergotamine, dihydroergotamine, benzodiazepines (eg, triazolam, alprazolam, midazolam), HMG-CoA reductase inhibitors (eg, lovastatin, simvastatin), sildenafil, cyclosporine, carbamazepine, tacrolimus, alfentanil, disopyramide, rifabutin, quinidine, methylprednisolone, cilostazol, vinblastine, and bromocriptine; additional drug interactions exist with hexobarbital, phenytoin, valproate, terfenadine, and astemizole
When coadministered with cisapride, terfenadine, or astemizole, rare cases of serious cardiovascular adverse events, including ECG QT/QTc interval prolongation, cardiac arrest, torsades de pointes, and other ventricular arrhythmias, have been observed and fatalities have been reported
Documented hypersensitivity; coadministration of terfenadine, astemizole, pimozide, or cisapride
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution with impaired hepatic function; estolate formulation may cause cholestatic jaundice; adverse gastrointestinal effects are common; discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occur; risk of superinfection; may aggravate weakness in patients with myasthenia gravis; possible increased risk of infantile hypertrophic pyloric stenosis in infants that have consumed erythromycin
Azithromycin (Zithromax)
Azalide antibiotic (subclass of macrolide antibiotics) that inhibits bacterial protein synthesis by binding 50S ribosomal subunits of susceptible organisms; may be bacteriocidal or bacteriostatic depending on concentration and type of microorganism.
Adult
1 g PO qwk for at least 3 wk
Pediatric
<16 years: Not established
>16 years: Administer as in adults
Effects are reduced with coadministration of aluminum- and/or magnesium-containing antacids; nephrotoxicity and neurotoxicity may occur when coadministered with cyclosporine; coadministration with nelfinavir may effect a levels of both drugs (no dosage adjustment required but monitoring for azithromycin toxicity is warranted, ie, liver enzyme abnormalities and hearing impairment); efavirenz may increase peak plasma concentrations
Monitor theophylline level and PT when coadministered with theophylline and warfarin, respectively, because pharmacokinetics have not been determined; azithromycin studies with the following drugs have not been performed; however, interactions with other macrolides have been established: digoxin, ergotamine, dihydroergotamine, triazolam, carbamazepine, cyclosporine, hexobarbital, and phenytoin
Known hypersensitivity to azithromycin, erythromycin, or any macrolide antibiotic
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 with prolonged antibiotic use; may increase hepatic enzymes and cholestatic jaundice; caution in patients with impaired hepatic function; caution advised in patients with renal impairment (azithromycin not tested in this population); because other macrolides may prolonged cardiac repolarization and QT interval, causing cardiac arrhythmia and torsades de pointes (possible that azithromycin may have similar effect)
More on Granuloma Inguinale (Donovanosis) |
| Overview: Granuloma Inguinale (Donovanosis) |
| Differential Diagnoses & Workup: Granuloma Inguinale (Donovanosis) |
 Treatment & Medication: Granuloma Inguinale (Donovanosis) |
| Follow-up: Granuloma Inguinale (Donovanosis) |
| Multimedia: Granuloma Inguinale (Donovanosis) |
| References |
| « Previous Page | Next Page » |
References
Carter JS, Bowden FJ, Bastian I, Myers GM, Sriprakash KS, Kemp DJ. Phylogenetic evidence for reclassification of Calymmatobacterium granulomatis as Klebsiella granulomatis comb. nov. Int J Syst Bacteriol. Oct 1999;49 Pt 4:1695-700. [Medline].
Anderson K. The Cultivation From Granuloma Inguinale of a Microorganism Having the Characteristics of donovan bodiesin the yolk sac of chick embryos. Science. Jun 18 1943;97(2529):560-561. [Medline].
Velho PE, Souza EM, Belda Junior W. Donovanosis. Braz J Infect Dis. Dec 2008;12(6):521-5. [Medline].
Barroso LF, Wispelwey B. Donovanosis presenting as a pelvic mass mimicking ovarian cancer. South Med J. Jan 2009;102(1):104-5. [Medline].
Taneja S, Jena A, Tangri R, Sekhon R. Case report. MR appearance of cervical donovanosis mimicking carcinoma of the cervix. Br J Radiol. Jun 2008;81(966):e170-2. [Medline].
[Guideline] British Association for Sexual Health and HIV (BASHH). Donovanosis (granuloma inguinale). In: Sexually transmitted infections: UK national screening and testing guidelines. National Guidelines Clearinghouse. Aug 2006.
Sulfamethoxazole and trimethoprim [package insert]. Irvine, Calif: Sicor Pharmaceuticals; 2003.
Bowden FJ, Savage J. Azithromycin for the treatment of donovanosis. Sex Transm Infect. Feb 1998;74(1):78-9. [Medline].
Rosen T, Vandergriff T, Harting M. Antibiotic use in sexually transmissible diseases. Dermatol Clin. Jan 2009;27(1):49-61. [Medline].
Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2002. Centers for Disease Control and Prevention. MMWR Recomm Rep. May 10 2002;51:1-78. [Medline].
Kallen BA, Otterblad Olausson P, Danielsson BR. Is erythromycin therapy teratogenic in humans?. Reprod Toxicol. Jul-Aug 2005;20(2):209-14. [Medline].
Manders SM, Baxter JD. Granuloma inguinale and HIV: a unique presentation and novel treatment regimen. J Am Acad Dermatol. Sep 1997;37(3 Pt 1):494-6. [Medline].
[Guideline] Centers for Disease Control and Prevention. Diseases characterized by genital ulcers. Sexually transmitted diseases treatment guidelines 2006. MMWR Morb Mortal Wkly Rep. Aug 4 2006;55(RR-11):14-30.
Bowden FJ. Donovanosis in Australia: going, going... Sex Transm Infect. Oct 2005;81(5):365-6. [Medline].
Sardana K, Garg VK, Arora P, Khurana N. Malignant transformation of donovanosis (granuloma inguinale) in a HIV-positive patient. Dermatol Online J. 2008;14(9):8. [Medline].
Chandra Gupta TS, Rayudu T, Murthy SV. Donovanosis with auto-amputation of penis in a HIV-2 infected person. Indian J Dermatol Venereol Leprol. Sep-Oct 2008;74(5):490-2. [Medline].
Sardana K, Garg VK, Arora P, Khurana N. Malignant transformation of donovanosis (granuloma inguinale) in a HIV-positive patient. Dermatol Online J. Sep 15 2008;14(9):8. [Medline].
Further Reading
Keywords
granuloma inguinale, donovanosis, sexually transmitted disease, STD, venereal disease, VD, Donovan bodies, genital lesions,
