Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

genital chancroid: HIV-negative

1st line – antibiotic therapy

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ACUTE
|
genital chancroid: HIV-negative
|
nonpregnant
1st line – 

antibiotic therapy

Chancroid usually responds well to appropriate antibiotic therapy.

The Centers for Disease Control and Prevention (CDC) recommend several antibiotic regimens, which are equally effective in most patients: azithromycin (single-dose regimen); ceftriaxone (single-dose regimen); ciprofloxacin (multiple-dose regimen); or erythromycin (multiple-dose regimen).[55]

Systemic fluoroquinolone antibiotics, such as ciprofloxacin, may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycemia; and central nervous system (CNS) effects including seizures, depression, psychosis, and suicidal thoughts and behavior.[74]​ Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics, that are commonly recommended for the infection, are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability). Consult your local guidelines and drug information source for more information on suitability, contraindications, and precautions.

All sexual partners within the 10 days prior to the onset of symptoms should be traced and treated, even if they are asymptomatic, to reduce the risk of reinfection.​[31][55]​​[77]​​

Primary options

azithromycin: 1 g orally as a single dose

OR

ceftriaxone: 250 mg intramuscularly as a single dose

OR

ciprofloxacin: 500 mg orally twice daily for 3 days

OR

erythromycin base: 500 mg orally three times daily for 7 days

Consider – lymph node aspiration ± incision and drainage

Back
ACUTE
|
genital chancroid: HIV-negative
|
nonpregnant
Consider – 

lymph node aspiration ± incision and drainage

Treatment recommended for SOME patients in selected patient group

Inguinal lymphadenitis usually does not resolve until at least 2 weeks after completion of treatment and may take much longer.

Repeated needle aspiration, with or without incision and drainage, may be required if fluctuant lymphadenitis does not resolve.[76]

1st line – ceftriaxone or erythromycin or azithromycin

Back
ACUTE
|
genital chancroid: HIV-negative
|
pregnant
1st line – 

ceftriaxone or erythromycin or azithromycin

Chancroid usually responds well to appropriate antibiotic therapy.

The selection of antibiotics in a pregnant patient requires care. Ceftriaxone, erythromycin, or azithromycin are acceptable choices for therapy in pregnancy; however, macrolides should be used with caution in the first trimester as population-based cohort studies have found an increased risk of cardiovascular and digestive system malformations. Fluoroquinolones (e.g., ciprofloxacin) are not recommended in women who are pregnant or breastfeeding.[31][55]

All sexual partners within the 10 days prior to the onset of symptoms should be traced and treated, even if they are asymptomatic, to reduce the risk of reinfection.[31][55][77]

Primary options

ceftriaxone: 250 mg intramuscularly as a single dose

OR

erythromycin base: 500 mg orally three times daily for 7 days

OR

azithromycin: 1 g orally as a single dose

Consider – lymph node aspiration ± incision and drainage

Back
ACUTE
|
genital chancroid: HIV-negative
|
pregnant
Consider – 

lymph node aspiration ± incision and drainage

Treatment recommended for SOME patients in selected patient group

Inguinal lymphadenitis usually does not resolve until at least 2 weeks after completion of treatment and may take much longer.

Repeated needle aspiration with or without incision and drainage may be required if fluctuant lymphadenitis does not resolve.[76]

genital chancroid: HIV-positive

1st line – antibiotic therapy

Back
ACUTE
|
genital chancroid: HIV-positive
|
nonpregnant
1st line – 

antibiotic therapy

Chancroid usually responds well to appropriate antibiotic therapy; however, patients with HIV are prone to treatment failure. Because evidence is limited with the single-dose regimens, multiple-dose regimens with ciprofloxacin or erythromycin may be preferred in patients with HIV, especially if follow-up is uncertain.[31][55]​​[72][75]

Systemic fluoroquinolone antibiotics, such as ciprofloxacin, may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycemia; and CNS effects including seizures, depression, psychosis, and suicidal thoughts and behavior.[74]​ Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics, that are commonly recommended for the infection, are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability). Consult your local guidelines and drug information source for more information on suitability, contraindications, and precautions.

All sexual partners within the 10 days prior to the onset of symptoms should be traced and treated, even if they are asymptomatic, to reduce the risk of reinfection.​[31][55]​​[77]​​

Primary options

ciprofloxacin: 500 mg orally twice daily for 3 days

OR

erythromycin base: 500 mg orally three times daily for 7 days

Secondary options

azithromycin: 1 g orally as a single dose

OR

ceftriaxone: 250 mg intramuscularly as a single dose

Consider – lymph node aspiration ± incision and drainage

Back
ACUTE
|
genital chancroid: HIV-positive
|
nonpregnant
Consider – 

lymph node aspiration ± incision and drainage

Treatment recommended for SOME patients in selected patient group

Inguinal lymphadenitis usually does not resolve until at least 2 weeks after completion of treatment and may take much longer.

Repeated needle aspiration with or without incision and drainage may be required if fluctuant lymphadenitis does not resolve.[76]

1st line – erythromycin or ceftriaxone or azithromycin

Back
ACUTE
|
genital chancroid: HIV-positive
|
pregnant
1st line – 

erythromycin or ceftriaxone or azithromycin

Chancroid usually responds well to appropriate antibiotic therapy; however, patients with HIV are prone to treatment failure. Because evidence is limited with the single-dose regimens, multiple-dose regimens may be preferred in patients with HIV, especially if follow-up is uncertain.​[31]​​[55][72][75]​

Ceftriaxone, erythromycin, or azithromycin are acceptable choices for therapy in pregnancy; however, macrolides should be used with caution in the first trimester as population-based cohort studies have found an increased risk of cardiovascular and digestive system malformations. Fluoroquinolones (e.g., ciprofloxacin) are not recommended in women who are pregnant or breastfeeding.

All sexual partners within the 10 days prior to the onset of symptoms should be traced and treated, even if they are asymptomatic, to reduce the risk of reinfection.​[31][55]​​[77]​​

Primary options

erythromycin base: 500 mg orally three times daily for 7 days

Secondary options

ceftriaxone: 250 mg intramuscularly as a single dose

OR

azithromycin: 1 g orally as a single dose

Consider – lymph node aspiration ± incision and drainage

Back
ACUTE
|
genital chancroid: HIV-positive
|
pregnant
Consider – 

lymph node aspiration ± incision and drainage

Treatment recommended for SOME patients in selected patient group

Inguinal lymphadenitis usually does not resolve until at least 2 weeks after completion of treatment and may take much longer.

Repeated needle aspiration with or without incision and drainage may be required if fluctuant lymphadenitis does not resolve.[76]

ONGOING

no response to initial treatment

1st line – reassessment of diagnosis and treatment

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ONGOING
|
no response to initial treatment
1st line – 

reassessment of diagnosis and treatment

If there is no clinical improvement 3-7 days after completion of treatment, the patient should be reassessed.[55]​ Consider: alternative diagnoses and/or coinfection with another pathogen; whether the patient may have been noncompliant with treatment; antimicrobial susceptibility testing to guide selection of an appropriate, alternative agent.[55]

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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