Guidelines 2016 – Chancroid
Guidelines for Nurse Practitioners in Gynecologic Settings 2016
I. DEFINITION
Chancroid is a bacterial infection of the genitourinary tract in which a rapidly growing ulcerated lesion forms on external genitalia. Definitive diagnosis requires the identification of Haemophilus ducreyi using special culture media. Even with the use of these media, sensitivity is less than 80%. Diagnosis is usually based on clinical findings.
II. ETIOLOGY
A. Causative agent is H. ducreyi, a short, gram-negative bacillus with rounded ends, usually found in chains and groups.
B. Incubation period is 4 to 7 days after exposure (rarely < 3 or > 10 days); lesion appears 3 to 14 days after exposure.
III. HISTORY
A. What the patient may present with
1. History of one to three painful macules on the external genitalia, which rapidly change to a pustule and then to an ulcerated lesion; may have “kissing ulcers” from autoinoculation; can also be painless
2. Enlarged inguinal nodes
3. Abscess in inguinal region
4. A sinus formed over the healed lesion
5. New lesions forming when exposed to lesions already present
6. Pain on voiding or defecating
7. Rectal bleeding
8. Dyspareunia
B. Additional information to be obtained
1. History of STI or PID
2. Previous vaginal infections; diagnosis, treatment
3. Previous urinary tract infections
4. Sexually active
5. Last sexual contact; new partner
6. If partner complained of sores
7. LMP
8. Method of birth control; other medications (antibiotics may mask symptoms)
9. Any associated vaginal discharge; duration of ulcers
10. Any associated pain
11. Travel to Asia (Thailand especially), Africa, South America, or the Philippines in past month
IV. PHYSICAL EXAMINATION
A. Vital signs
1. Temperature
2. Blood pressure
3. Pulse
B. Inguinal nodes
1. Size
2. Tenderness
3. Nodes matted together forming a fluctuant abscess (buboes) in groin; usually unilateral inguinal lymphadenopathy
C. External examination
1. Observe labia, fourchette, clitoris, vagina, anal area for macules, papules
2. Observe for shallow, nonindurated, painful ulcers with ragged, undetermined edges, varying in size and often coalesced; base of ulcers may be gray/bluish gray; surrounding red halo
3. Observe for sinuses that may have formed when skin over abscesses has broken down
4. Look for new lesions that may be forming as a result of autoinoculation
D. Vaginal examination (speculum); observe for lesions in vagina, on cervix
E. Bimanual examination
V. LABORATORY EXAMINATION
A. Usually based on clinical findings and history
B. Cultures to laboratory; use media containing fresh defibrinated rabbit’s blood or patient’s own serum
C. Dark-field exam for Treponema pallidum or serologic test for syphilis performed at least 7 days after onset of lesions and repeated in 3 months
D. Gonococcus (GC) culture, Chlamydia test
E. Herpes antibodies
F. HIV testing should be done at the time of this diagnosis and again in 3 months if initial results are negative
G. Further laboratory work as indicated
H. Polymerase chain reaction (PCR) testing for H. ducreyi is available in clinical laboratories that have conducted the Clinical Laboratory Improvement Amendments (CLIA) verification studies.
VI. DIFFERENTIAL DIAGNOSIS
A. Herpes simplex
B. Syphilis
VII. TREATMENT
A. Medications
1. Azithromycin 1 g orally in a single dose or
2. Ceftriaxone 250 mg im in a single dose or
3. Ciprofloxacin 500 mg orally twice a day for 3 days (safety in children younger than 18 years of age or in pregnancy or lactation has not been established) or
4. Erythromycin base 500 mg orally three times a day for 7 days
B. Medications in pregnancy
1. Azithromycin 1 g orally in a single dose or
2. Ceftriaxone 250 mg im in a single dose or
3. Erythromycin base 500 mg orally four times a day for 7 days
C. General measures
1. Buboes should be aspirated through adjacent intact skin, not incised
2. No sexual contact until the course of medication is finished
3. Stress the importance of completing the course of medication
4. Comfort measures
a. Take tepid water sitz baths; dry carefully with cool-air hair dryer, making sure to hold it away from body
b. Avoid tight, restricting clothing
c. Expose perineum to airflow as much as possible (wear a skirt without underpants when at home)
d. Recommend peri-irrigation set for comfort
5. Patient education
a. Explain disease process and route of transmission
b. Stress that sexual partner(s) needs to be checked regularly (see Chancroid, Follow-up, X.C)
VIII. COMPLICATIONS
A. Phimosis in the male
B. Urethral stricture
C. Urethral fistula
D. Severe tissue destruction
E. Ulcers may take years to heal
F. Perineal fistulas
IX. CONSULTATION/REFERRAL
A. If infection is suspected
B. If no response after 7 days of treatment, treatment as outlined previously
C. Secondary infections
D. All HIV-positive persons diagnosed with chancroid
X. FOLLOW-UP
A. Patient should be reexamined 3 to 7 days after initiation of therapy. If treatment is successful, there should be symptomatic improvement within 3 days of starting therapy. Clinical improvement should be evident within 7 days. If no improvement, consultation as described previously.
B. It should be noted that it may take more than 2 weeks for complete healing of ulcers. The amount of time is related to the size of the ulcer.
C. All sexual partners who have had sexual contact within 10 days preceding symptoms with a person diagnosed with chancroid should be evaluated and treated even in the absence of symptoms.
See Bibliographies.
Website: www.cdc.gov/mmwr/pdf/rr/rr5912.pdf