Genital ulcers in a primary health clinic in Rwanda: impact of HIV infection on diagnosis and ulcer healing (1986-1992).

During 1986-88 and 1990-92, 1025 (97%) out of 1057 genital ulcer patients in Kigali, Rwanda, were tested for HIV antibodies and for infection with Treponema pallidum, Haemophilus ducreyi and herpes simplex virus. Overall, 57% of men and 80% of women had antibodies to HIV-1. The most frequent laboratory diagnoses were chancroid (27%), syphilis (19%) and genital herpes (19%) among men and syphilis (35%), genital herpes (23%) and chancroid (20%) among women. HIV-1 seroprevalence increased sharply over time among men but not among women. The clinical presentation of ulcers as well as laboratory diagnoses were similar in the HIV-1 seropositive and seronegative groups. The relative frequency of all laboratory diagnoses remained unchanged over time. HIV-1 seropositivity had no impact on ulcer healing. Advanced immunodeficiency was diagnosed among 12% of the HIV-1 seropositive patients and was significantly associated with increasing age and genital herpes.

PIP: A study conducted at the Centre Medico-Social de Bilyogo, a primary health clinic located in an area of Nyamirambo, Kigali (Rwanda), where prostitution is widespread, assessed the frequencies of the causes of genital ulcer disease. Out of 1057 consecutive genital ulcer patients tested in 1986-88, 57% of men and 80% of women were infected with HIV-1. The most frequent laboratory diagnoses were chancroid (27%), syphilis (19%), and genital herpes (19%) among men and syphilis (35%), genital herpes (23%), and chancroid (20%) among women. During follow-up in 1990-92, HIV-1 seroprevalence increased sharply among men of all ages and women under 30 years of age. HIV-1 seropositivity had no effect on the clinical presentation of ulcers or on the time required for ulcer healing. Advanced immunodeficiency, diagnosed among 12% of HIV-positive patients, was significantly associated with increasing age and genital herpes.

Failure of treatment for chancroid in Rwanda is not related to human immunodeficiency virus infection: in vitro resistance of Haemophilus ducreyi to trimethoprim-sulfamethoxazole.

A comparative open study was performed to evaluate the efficacy of single doses of ciprofloxacin (500 mg) and trimethoprim-sulfamethoxazole (TMP-SMZ; 640 mg/3,200 mg) for the treatment of culture-proven chancroid. Clinical cure or improvement was observed 7 days after treatment in 32 (76.2%) of the 42 patients who received ciprofloxacin and 21 (52.5%) of the 40 patients who received TMP-SMZ (P = .04). Cultures for one (4.5%) of 22 patients not cured with ciprofloxacin and 16 (59.3%) of 27 patients not cured with TMP-SMZ were still positive for Haemophilus ducreyi 7 days after treatment (P < .001). Although 77 (71.3%) of the 108 patients tested were seropositive for HIV-1 antibody, HIV infection and the degree of CD4+ lymphocyte depletion had no effect on clinical and bacteriologic outcome. All isolates of H. ducreyi were highly susceptible to ciprofloxacin (MIC, 0.004-0.06 mg/L). In contrast, resistance to TMP-SMZ (MIC, > or = 4/76 micrograms/mL) was observed in 48.9% of isolates (22 of 45) and was significantly associated with treatment failure. Therefore, the administration of TMP-SMZ, in single or multiple doses, is no longer indicated for the treatment of chancroid in Rwanda.

Simple algorithms for the management of genital ulcers: evaluation in a primary health care centre in Kigali, Rwanda.

A cross-sectional study was conducted among 395 patients presenting with genital ulcers at a primary health care centre in Kigali, Rwanda. Using clinical data and the results of a rapid plasma reagin (RPR) test, we simulated the diagnostic outcome of two simple WHO flowcharts for the management of genital ulcers. These outcomes and a clinical diagnosis were then compared with the laboratory diagnosis based on culture for genital herpes and Haemophilus ducreyi and serology for syphilis. The prevalence of HIV infection was high (73%) but there was no difference between HIV-positive and HIV-negative patients in the clinical presentation and etiology of genital ulcer disease. The proportion of correctly managed chancroid and/or syphilis cases was 99% using a syndromic approach, 82.1% using a hierarchical algorithm including an RPR test, and 38.3% with a clinical diagnosis. In situations where no laboratory support is available, a simple syndromic approach is preferable to the clinical approach for the management of genital ulcer. If an RPR test can be included in the diagnostic strategy, patients with a reactive RPR test should be treated for both syphilis and chancroid infection.

PIP: A cross-sectional study was conducted among 395 patients presenting with genital ulcers at a primary health care center in Kigali, Rwanda. Using clinical data and the results of a rapid plasma reagin (RPR) test, the authors simulated the diagnostic outcome of two simple WHO flowcharts for the management of genital ulcers. These outcomes and a clinical diagnosis were then compared with the laboratory diagnosis based on culture for genital herpes and Haemophilus ducreyi and serology for syphilis. The prevalence of HIV infection was high (73%) but there was no difference between HIV-positive and HIV-negative patients in the clinical presentation and etiology of genital ulcer disease. The proportion of correctly managed chancroid and/or syphilis cases was 99% using a syndromic approach, 82.1% using a hierarchical algorithm including an RPR test, and 38.3% with a clinical diagnosis. In situations where no laboratory support is available, a simply syndromic approach is preferable to the clinical approach for the management of genital ulcer. If an RPR test can be included in the diagnostic strategy, patients with a reactive RPR test should be treated for both syphilis and chancroid infection. (author's)

Emergence of Haemophilus ducreyi resistance to trimethoprim-sulfamethoxazole in Rwanda.

The in vitro susceptibilities of 112 clinical isolates of Haemophilus ducreyi to six antimicrobial agents were determined. These isolates were obtained in Kigali, Rwanda, during three studies on genital ulcer disease performed in 1986 (18 isolates), 1988 (23 isolates), and 1991 (71 isolates). All H. ducreyi isolates were susceptible to azithromycin, ceftriaxone, ciprofloxacin, and erythromycin; all isolates obtained in 1986 were also susceptible to trimethoprim and to the combination trimethoprim-sulfamethoxazole. In contrast, 39 and 9% of the isolates obtained in 1988 and 59 and 48% of the isolates obtained in 1991 were resistant to trimethoprim (MIC, > or = 4.0 mg/liter) and trimethoprim-sulfamethoxazole (MIC, < or = 4.0/76 mg/liter), respectively. These data indicate that trimethoprim-sulfamethoxazole can no longer be recommended for use in the treatment of chancroid in Rwanda, and possibly elsewhere in Africa.

Effectiveness of norfloxacin and ofloxacin for treatment of gonorrhoea and decrease of in vitro susceptibility to quinolones over time in Rwanda.

OBJECTIVE: To study the effectiveness of single-dose norfloxacin and ofloxacin in the treatment of gonococcal urethritis in men, and to monitor in vitro antimicrobial susceptibility to these antibiotics over time. SETTING: Centre Médico-Social de Bilyogo, Kigali, Rwanda. The only clinic in Rwanda using quinolones for the treatment of gonorrhoea. METHODS: As part of a monitoring programme, men with gonococcal urethritis were evaluated after treatment with norfloxacin (800 mg) in 1986 and 1987, and after treatment with ofloxacin (400 mg) in 1989. RESULTS: Neisseria gonorrhoeae was eradicated from the urethra from 96.0% (189/197) and from 97.1% (166/171) men treated with norfloxacin and ofloxacin, respectively. Overall 38.2% of the pretreatment isolates produced penicillinase (PPNG isolates) and 20.4% (44/216) of the tested non-PPNG isolates were chromosomally resistant to penicillin (MIC > or = 2.0 mg/l). Resistance to tetracycline and thiamphenicol was common in both PPNG and non-PPNG and increased considerably in 1989. All isolates were susceptible to kanamycin, spectinomycin, ceftiaxone, norfloxacin, ofloxacin and ciprofloxacin. However, a higher number of isolates recovered in 1989 showed decreased susceptibility to the quinolones. Treatment failure occurred more often in subjects with isolates having MIC values > or = 0.06 mg/L of norfloxacin (p = 0.006). Seven out of 13 patients who did not respond to therapy had no signs nor symptoms of urethritis. CONCLUSION: Quinolone antibiotics are now indicated as a first line treatment of gonorrhoea in countries with a problem of antimicrobial multiresistance. However, antimicrobial susceptibility to the quinolones may decrease rapidly, and close monitoring of the in vitro susceptibility of N gonorrhoeae and the clinical effectiveness of the antibiotics is imperative.