Antimicrobial susceptibility and serotype distribution of Streptococcus agalactiae rectovaginal colonising isolates from pregnant women at a tertiary hospital in Pretoria, South Africa: An observational descriptive study.

BACKGROUND: Streptococcus agalactiae or group B streptococcus (GBS) is a significant cause of neonatal sepsis. Intrapartum antibiotic prophylaxis is recommended for pregnant women identified to be rectovaginally colonised between 34 and 37 weeks' gestational age to decrease the risk of invasive disease in their newborns. An effective multivalent GBS vaccine may prevent a broader scope of GBS-associated diseases, such as GBS early-onset disease, GBS late-onset disease, spontaneous abortion, stillbirth and maternal bacteraemia. Serotype distribution of GBS isolates is essential to determine the efficacy of such a vaccine. OBJECTIVES: To investigate serotype distribution and antimicrobial susceptibility patterns of GBS isolates cultured from rectovaginal specimens during pregnancy. METHODS: Sixty-nine archived maternal colonising isolates were tested against penicillin, erythromycin, clindamycin, vancomycin and levofloxacin. Minimum inhibitory concentration testing was performed using the ETEST method. Serotyping was performed by the latex agglutination method. RESULTS: The most common serotypes detected were Ia (54%), III (20%), V (16%), II (6%), IV (2%) and Ib (1%). All isolates were fully susceptible to penicillin, vancomycin and levofloxacin. Eight (11%) and 50 (56%) isolates showed intermediate resistance to erythromycin and clindamycin, respectively, and 1 isolate was resistant to erythromycin. The macrolide-lincosamide-streptogramin B (MLSB) phenomenon was noted in 3 (4%) of the isolates. CONCLUSIONS: GBS-colonising isolates remain susceptible to penicillin, which remains the drug of choice for intrapartum antibiotic prophylaxis and treatment of invasive disease in newborns. Macrolides should only be used if clinically indicated due to the high prevalence of intermediate resistance. A pentavalent GBS vaccine currently in phase I trials should provide coverage for 97% of the isolates identified in this study.

Comparison of Xpert GBS v. culture for rapid detection of group B streptococcus in pregnant women: Sensitivity, specificity and predictive values.

BACKGROUND: Group B streptococcus (GBS) is a leading cause of invasive disease, particularly in newborns. Seventy-five percent of neonates will be colonised by mothers carrying the organism. Confirmation of maternal colonisation with GBS is essential for prompt treatment and prevention of neonatal sepsis. The current gold standard of culture for isolation of GBS has a disadvantage of long turnaround time (24 - 72 hours). Rapid assays are required to determine maternal carriage of GBS. OBJECTIVES: To determine the usefulness of the Xpert GBS technology v. culture methods to detect GBS carriage in pregnant women. METHODS: This was a prospective observational study of 284 pregnant women between 26 and 37 weeks' gestation. Two vaginorectal swabs were collected from each participant. One swab was processed using the gold-standard culture method, while the second swab was processed using the Xpert GBS assay. The performance of the Xpert GBS assay was then compared with that of the culture method. RESULTS: Two swabs were processed from each of 284 pregnant women between 26 and 37 weeks' gestation. Culture detected 70 GBS isolates from a total of 279 specimens (25.1%), whereas the Xpert GBS detected 66 positive specimens (23.7%). The Xpert GBS assay had a sensitivity of 87% and specificity of 98%, with a positive predictive value of 92% and a negative predictive value of 96%. CONCLUSIONS: The Xpert GBS assay is a rapid and sensitive tool for prenatal detection of GBS. The assay should ideally be available in every labour ward, where women can be screened for GBS on arrival.

Meningococcal infections in hospitalised patients in Pretoria.

We report on 13 patients diagnosed with meningococcal infections in patients attending state-owned hospitals serving an indigent population in Pretoria in 2009. The case fatality rate was 27%. Ceftriaxone was the main antibiotic (9 out of 13 patients) for therapy. Five isolates (39%) were serogroup B and 4 (31%) serogroup W135. Most isolates (12/13) were fully susceptible to penicillin (MIC range 0.016 - 0.047 µg/ml). A single isolate was intermediately resistant to penicillin (MIC, 0.125 µg/ml) while all isolates were uniformly susceptible to ceftriaxone, ciprofloxacin and rifampicin. This pattern reveals a shift in serogroups with an increase of serogroup B disease in the Pretoria region, and the need for ongoing monitoring of antimicrobial susceptibility profiles and the value of ceftriaxone for favourable therapeutic outcome.

Antimicrobial Susceptibility Patterns of Gonococcal Isolates in Pretoria; South Africa; over a 20-Year Period (1984-2004)

This paper reviews the susceptibility profiles of Neisseria gonorrhoeae over a 20-year period in the Pretoria region. Endourethral specimens were collected from adult men with symptoms of urethritis attending primary health care clinics and private medical practitioners. These swabs were plated on enriched media for isolation of N. gonorrhoeae. Antimicrobial susceptibility of the organisms was performed using the disc diffusion and agar dilution methods. Plasmid analyses were performed on beta-lactamase-producing isolates. Penicillase-producing N. gonorrhoeae strains increased from 4to 16; whilst chromosomally mediated penicillin-resistant strains increased dramatically from 0to 16from 1984 to 2004. There was an equal distribution of the 3.2 MDa African and 4.4 MDa Asian plasmids. High-level tetracycline-resistant strains (36) were detected for the first time in 2004. Ciprofloxacin resistance emerged at 7in the same year. Gonococcal isolates remained susceptible to cefoxitin; ceftriaxone; cefpodoxime; and spectinomycin. However; the minimum inhibitory concentration values for spectinomycin were very close to the breakpoint. We have shown a continuing increase in resistance to penicillin (plasmid and chromosomal); the emergence of high-level tetracycline resistance and an emergence of resistance to ciprofloxacin. Susceptibility testing is essential for successful therapeutic outcomes and needs to be performed in an ongoing basis

Antimicrobial Susceptibility Patterns of Gonococcal Isolates in Pretoria; South Africa; Over a 20-Year Period (1984-2004)

Abstract:This paper reviews the susceptibility profiles of Neisseria gonorrhoeae over a 20-year period in the Pretoria region. Endourethral specimens were collected from adult men with symptoms of urethritis attending primary health care clinics and private medical practitioners. These swabs were plated on enriched media for isolation of N. gonorrhoeae. Antimicrobial susceptibility of the organisms was performed using the disc diffusion and agar dilution methods. Plasmid analyses were performed on beta-lactamase-producing isolates. Penicillase-producing N. gonorrhoeae strains increased from 4 to 16; whilst chromosomally mediated penicillin-resistant strains increased dramatically from 0 to 16 from 1984 to 2004. There was an equal distribution of the 3.2 MDa African and 4.4 MDa Asian plasmids. High-level tetracycline-resistant strains (36) were detected for the first time in 2004. Ciprofloxacin resistance emerged at 7 in the same year. Gonococcal isolates remained susceptible to cefoxitin; ceftriaxone; cefpodoxime; and spectinomycin. However; the minimum inhibitory concentration values for spectinomycin were very close to the breakpoint. We have shown a continuing increase in resistance to penicillin (plasmid and chromosomal); the emergence of high-level tetracycline resistance and an emergence of resistance to ciprofloxacin. Susceptibility testing is essential for successful therapeutic outcomes and needs to be performed in an ongoing basis

Neisseria gonorrhoeae multi-antigen sequence typing (NG-MAST) of ciprofloxacin resistant isolates of Pretoria, South Africa.

Gonococcal isolates resistant to ciprofloxacin collected from 2004 to 2005, in the Pretoria region, were characterised using Neisseria gonorrhoeae multi-antigen sequence typing (NG-MAST). The isolates were obtained from men presenting with urethritis to primary healthcare clinics and general practitioners. All isolates were tested for susceptibility to ciprofloxacin by Etest, disc diffusion and agar dilution methods. Sequence-based typing, directed at the por and tbpB genes, and compared with international isolates using the NG-MAST database on the internet, was done for 18 isolates (10 ciprofloxacin-resistant isolates and 8 susceptible controls). There was one cluster (four isolates) of known sequence type (ST) similar to the pattern seen among strains from Scotland, England, and Durban, South Africa. Two other known STs were identified, while the remaining STs were unique.

Human immunodeficiency virus infection and genital ulcer disease in South Africa: the herpetic connection.

BACKGROUND AND OBJECTIVES: While genital ulcers are a risk factor in HIV infection, the association of specific agents of genital ulcer disease (GUD) with HIV infection may vary. GOAL: To determine the etiology of GUD in HIV-infected and HIV-uninfected men attending sexually transmitted disease (STD) clinics in Durban, Johannesburg, and Cape Town, South Africa, and the association of previous and current sexually transmitted infections with HIV infection in men with ulcerative and nonulcerative STDs. STUDY DESIGN: A cross-sectional study of 558 men with genital ulcers and 602 men with urethritis. RESULTS: Patients with GUD were more likely to be infected with HIV than patients with urethritis (39.4% versus 21.4%, P< or =0.001). Herpes simplex virus 2 (HSV-2) was the most common agent identified in ulcer specimens (35.9%), and was detected in a significantly higher proportion of ulcer specimens from HIV-infected patients than in specimens from HIV-uninfected patients (47.4% versus 28.2%, P< or =0.001). Patients infected with HIV-1 were significantly more likely to have HSV-2 infection, as measured by the presence of the antibody to glycoprotein G-2, than patients not infected with HIV (63.1% versus 38.5%, P< or =0.001). Patients infected with HIV-1 were also significantly more likely to have initial HSV-2 infection than HIV-uninfected patients with GUD (50.0% versus 31.6%, P = 0.007). Haemophilus ducreyi was detected in 31.7% of ulcer specimens; prevalence did not vary by HIV-infection status. Treponema pallidum DNA was detected significantly less frequently in ulcer specimens from patients infected with HIV than in specimens from patients not infected with HIV (10.2% versus 26%, P< or =0.001); no association was found between HIV-infection status and fluorescent treponemal antibody absorption test seroreactivity, even when men with M-PCR-positive syphilis lesions were excluded from the analyses. CONCLUSION: The authors found that HSV-2 is a more common etiology of GUD than has been suggested by previous studies conducted in South Africa; serologic evidence of HSV-2 infection and current cases of genital herpes are strongly associated with HIV infection among men who present to STD clinics with GUD or urethritis.

Comparison of clinically directed, disease specific, and syndromic protocols for the management of genital ulcer disease in Lesotho.

OBJECTIVE: To evaluate two protocols for the syndromic management of genital ulcer disease (GUD) in Lesotho, southern Africa and to compare the performance of these protocols with that of a conventional disease specific approach. METHODS: A cross sectional study was conducted among consecutive patients with GUD attending an STD clinic in Maseru, Lesotho. The clinical diagnoses were made by using predefined criteria at the initial visit before the performance of laboratory tests. Attempts were made to detect the specific aetiology of the genital ulcers using PCR assays and syphilis serology. The results of PCR assays and syphilis serology were used as the gold standard against which the performance of the management approaches were applied. RESULTS: Of 100 patients initially recruited into the study, Haemophilus ducreyi infection was detected in 56%, herpes simplex virus in 26%, Treponema pallidum in 23%, and lymphogranuloma venereum in 7%. No pathogens were detected in 6% of patients. 17% of patients had mixed infections. Sensitivity, specificity, positive and negative predictive values of the three management protocols for GUD were compared after applying each to the study population. Theoretically, the lowest correct treatment rate would have been obtained by using the disease specific protocol (62%) compared with more than 90% in both syndromic management protocols. Considerable overtreatment for primary syphilis would occur following application of both syndromic protocols. This would be the result of the overdiagnosis of chancroid, in particular the misdiagnosis of genital herpes as chancroid, which would receive treatment for syphilis unnecessarily. The HIV seroprevalence among these patients was 36%. A significantly higher rate of HIV seropositivity was detected among the patients with herpes simplex virus infection when compared with those patients having other causes of genital ulcer disease (58% v 27%; odds ratio 3.73; 95% CI 1.26-11.26; p = 0.01). CONCLUSIONS: Poor sensitivity, specificity, and predictive values were recorded when the disease specific protocol was applied to the study population. In contrast, the syndromic management protocols provided adequate treatment for more than 90% of patients with GUD. Protocol C, which identified a minority of cases of genital herpes, was found to have an advantage when compared with protocol B (all patients with genital ulcer disease treated for both syphilis and chancroid) in that 29% of genital herpes cases would receive appropriate counselling.

Screening for sexually transmitted diseases in rural South African women.

OBJECTIVE: This paper reports on a study undertaken in a rural area of South Africa, to develop a non-laboratory tool to screen for sexually transmitted diseases (STDs) among family planning clients. METHODS: A cross sectional study was performed of 249 consecutive women attending a family planning service between November and December 1994. A questionnaire was administered, and a clinical examination and laboratory tests conducted. Sociodemographic, clinical, and other non-laboratory variables that were significantly associated with laboratory evidence of infection were combined to produce non-hierarchical scoring systems for three "syndromes": gonococcal and/or chlamydial cervical infection, trichomoniasis, and cervical infection and/or trichomoniasis combined. The sensitivity, specificity, and predictive values of the scoring systems as a screening tool were assessed against the gold standard of laboratory tests. RESULTS: The prevalence of reproductive tract infections among the study participants was as follows: Chlamydia trachomatis 12%, Neisseria gonorrhoeae 3%, Trichomonas vaginalis 18%, and bacterial vaginosis 29%. Although vaginal discharge and other symptoms were frequently reported, symptoms bore no relation to the presence of infection. The following independent associations with gonococcal/chlamydial cervical infection were found: age less than 25 years and cervical mucopus and/or friability. Abnormal discharge on examination, visible inflammatory changes of the cervix (increased redness), no recent travel, and unemployment were associated with trichomoniasis. The combination of trichomonas and/or cervical infection ("STD syndrome") was associated with cervical mucopus/friability, unemployment, lack of financial support, and increased redness of the cervix. Of the three scoring systems developed on the basis of these associations, that of the "STD syndrome" achieved the best performance characteristics as a screening tool, with a sensitivity of 62%, specificity of 74%, and positive predictive value of 48%. CONCLUSION: STDs are common in a population of rural, sexually active women attending a family planning service. In resource poor settings, non-laboratory screening tools could play some role in identifying and treating infections in these women, especially since the majority would not otherwise have been reached. However, such screening tools cannot be viewed as the only way to identify STDs and should be considered as part of an overall strategy of STD control that includes, for example, good management of symptomatic individuals and their partners.

Comparison of clinical diagnosis and standard laboratory and molecular methods for the diagnosis of genital ulcer disease in Lesotho: association with human immunodeficiency virus infection.

A multiplex polymerase chain reaction (M-PCR) assay for Haemophilus ducreyi, Treponema pallidum, and herpes simplex virus (HSV) was compared with clinical and standard laboratory methods for the diagnosis of genital ulcer disease (GUD) in 105 patients; 36% were human immunodeficiency virus (HIV)-seropositive. Chancroid (80%), syphilis (8%), and genital herpes (8%) were the most frequent diagnoses. H. ducreyi and HSV were isolated from ulcers of 43% and 18% of patients, respectively; in 35%, all cultures were negative and the laboratory diagnosis indeterminate. M-PCR detected H. ducreyi, T. pallidum, and HSV in 56%, 23%, and 26% of patients, respectively; (no definitive diagnosis, 6%). The proportion of patients with more than one agent was 4% by culture and 17% by M-PCR (P = .002). Resolved sensitivities of M-PCR for H. ducreyi and HSV cultures were 95% and 93%, respectively. The sensitivities of H. ducreyi and HSV cultures were 75% and 60%, respectively. HSV, detected in 47% of specimens from HIV-infected versus 16% from HIV-uninfected patients (P < .001), may be emerging as a more frequent cause of GUD.

An evaluation of the capillus HIV-1/HIV-2 latex agglutination test using serum and whole blood.

The capillus HIV-1/HIV-2 latex agglutination (LA) test was evaluated for its potential as an initial screening test in primary health care. For the serum study, panels totalling 289 HIV-positive sera and 323 known HIV-negative sera plus 50 individual seroconversion samples were tested by capillus. Paired blood specimens were also collected in heparinized and plain tubes from 501 consecutive patients with newly diagnosed sexually transmitted diseases (STDs) attending an STD clinic at a Transvaal hospital. Overall, an initial sensitivity of 99.3% and an initial specificity of 99.7% were obtained by visual reading of the capillus HIV-1/ HIV-2 LA tests on serum samples. Capillus also detected 40 (80%) of the 50 seroconversion samples. Of the 501 paired plain and heparinized blood specimens, serum testing by enzyme immunoassay (EIA) and indirect immunofluorescence/ Western blot (IFA/WB) showed 147 (29%) to be HIV Ab positive. Capillus testing of the paired specimens correctly identified all 147 known positive patients and 345 of the 346 negative patients, thus showing an initial sensitivity of 100% and an initial specificity of 99.7% for the testing of heparinized whole blood by a relatively unskilled health worker. It was concluded that the capillus HIV-1/HIV-2 LA test would be suitable for use as a primary screening test in small outlying laboratories or primary health care clinics.

Cefaclor, an alternative to third generation cephalosporins for the treatment of gonococcal urethritis in the developing world?

OBJECTIVE: To reassess the in vivo and in vitro efficacy of cefaclor for the treatment of uncomplicated gonococcal infection. DESIGN: Open clinical trail conducted in South Africa among consecutive male patients with symptoms and signs of uncomplicated urethritis and laboratory evidence of gonorrhoea. METHODS: Patients were treated with 3 g of cefaclor plus 1 g probenecid as a single dose. Urethral specimens were cultured for Neisseria gonorrhoeae at the initial visit and at follow up. Patients were considered cured if follow up cultures were negative. Treatment was considered to have failed in the patients infected with identical gonococcal strains at the initial and at the control visit. Those with evidence of infection at the follow up visit were administered 400 mg of ofloxacin and doxycycline 100 mg twice daily for 7 days. Minimal inhibitory concentrations (MICs) of cefaclor were determined by an agar dilution technique on the gonococcal isolates from the study subjects. The results were compared with those of isolates from three other African countries. RESULTS: Of 155 patients evaluated, 151 were cured (97%). Thirty per cent of the patients complained of adverse effects, mainly gastrointestinal. Even though MICs for the isolates from the three other African countries were significantly higher than those for the isolates from the study, none was considered resistant to cefaclor in vitro. MICs were markedly influenced by the type of test medium used. CONCLUSION: The trial demonstrated the efficacy of a single oral dose of cefaclor with probenecid for the treatment of uncomplicated gonococcal urethritis in South Africa. Its potential as an alternative therapy to third generation cephalosporins deserves to be further investigated.

Treatment of chancroid with azithromycin.

A randomized, comparative study undertaken in Nairobi, Kenya and a non-comparative evaluation undertaken in Carletonville, South Africa have both shown that a single oral dose of azithromycin 1 g is effective in the treatment of the genital ulcer disease (GUD), chancroid, with cure rates of 89% and 92% recorded respectively. While treatment failure was associated with human immunodeficiency virus seropositivity and lack of circumcision in Kenya, no such association could be found in the South African study. In both series, azithromycin treatment resulted in cure of both Haemophilus ducreyi culture-positive and culture-negative cases of GUD, including two cases subsequently diagnosed as lymphogranuloma venereum. A combination of single-dose azithromycin with single-dose benzathine penicillin may provide effective 'single-visit' syndromic treatment for GUD in many developing countries.

Antimicrobial susceptibilities and serotyping of Neisseria gonorrhoeae in southern Africa: influence of geographical source of infection.

One hundred and ninety-two strains of Neisseria gonorrhoeae isolated from migrant mine-workers were tested for their susceptibility to antibiotics, auxotyped and serotyped. Of the total, 93 (48%) were acquired locally and 64 (33%) from different geographical locations. Plasmid-mediated resistance to penicillin was found in 28 (14.6%) strains and was associated predominantly with the presence of 5.0 kb penicillinase encoding plasmid (18/28, 64%). Chromosomal resistance to penicillin (MIC > or = 1 mg/l) was detected in 14 (7.3%) strains. Resistance to tetracycline was chromosomally and not plasmid-mediated. Antibiotic resistance was encountered most commonly among strains acquired in Natal. The overall gonococcal population was sensitive to ceftriaxone, ciprofloxacin, spectinomycin and azithromycin. Nine auxotype/serovar (A/S) classes were encountered among penicillinase-producing N. gonorrhoeae (PPNG) compared to 24 A/S classes among non-PPNG strains. The most common A/S class was NR/IA-6 which accounted for 38% of PPNG and 15% of non-PPNG.

Transport media for Haemophilus ducreyi.

Stuart's, Amies' and four thioglycollate/hemin-based media containing, respectively, selenium dioxide and albumin (SA); selenium dioxide, L-glutamine and albumin (SGA); selenium dioxide and L-glutamine (SG); and L-glutamine and albumin (GA); were evaluated as transport media for Haemophilus ducreyi in a simulated, laboratory-based study. No transport medium was able to maintain the viability of H. ducreyi for more than 24 hours at room temperature. Amies' transport medium, however, maintained viability of H. ducreyi for up to 3 days and all the newly formulated transport media maintained viability of H. ducreyi for more than 4 days at 4 degrees C. Subsequently, swabs were taken from cases of genital ulcerations with a diagnosis of chancroid, plated directly onto selective media, and held at 4 degrees C in the two most efficient transport media (SGA and GA) for various periods of time. On direct plating, H. ducreyi was recovered from the genital ulcerations of 110 of 156 (71%) patients. The rates of recovery of H. ducreyi from transport media stored at 4 degrees C decreased with time. Although recovery was enhanced at day 4 (117/110 [106%]) using both SGA and GA, a recovery rate of 37/41 (90%) was obtained after storage in GA for 1 week.

A simple medium for the primary isolation of Haemophilus ducreyi.

Two simple, inexpensive media containing gonococcal agar-base, supplemented with 5% Fildes' extract and either chocolated or unchocolated horse blood (GC-FHBC or GC-FHB) were compared with the standard gonococcal agar-based (GC-HgS) and Mueller-Hinton agar-based media (MH-HB) normally used for primary isolation of Haemophilus ducreyi from presumptive chancroid lesions. Overall, Haemophilus ducreyi was recovered from 162 of 178 (91%) samples from primary chancroid lesions. As a single isolation medium GC-HgS proved the most sensitive with an isolation rate of 80% followed by GC-FHB (75%), MH-HB and GC-FHC (both 71%). Use of a combination of GC-HgS and MH-HB resulted in isolation of Haemophilus ducreyi in 160 of 178 cases (90%). Since GC-FHB is approximately one-quarter the cost of the combination and half the cost of GC-HgS or MH-HB alone, this medium could prove suitable for diagnostic purposes in developing countries where chancroid is endemic.

A serological test for granuloma inguinale.

OBJECTIVES: An indirect immunofluorescence technique applied to paraffin embedded tissue sections of lesions containing Donovan bodies was evaluated as a serological test for the diagnosis of granuloma inguinale. METHODS: Sera from patients with proven granuloma inguinale, other sexually acquired genital ulcerations and blood donors from areas where granuloma inguinale is rarely encountered as well as from disease-endemic regions were tested. Sera were tested either unabsorbed or following absorption with whole Klebsiella pneumoniae bacteria. RESULTS: Using unabsorbed sera at a dilution of 1:160 the test was found to have a sensitivity of 100%, specificity of 98%, positive predictive value (PPV) of 89% and negative predictive value (NPV) of 100%. There proved to be no advantage in preabsorbing sera with K. pneumoniae antigen. CONCLUSIONS: In the absence of culture methods for Calymmatobacterium granulomatis, an indirect immunofluorescence technique may prove valuable for the diagnosis of individual cases of granuloma inguinale and as an epidemiological tool in studies of the disease.

Syphilis serology in patients with primary syphilis and non-treponemal sexually transmitted diseases in southern Africa.

The reactivity of a non-specific reagin (RPR) test and a specific treponemal (FTA-ABS) test were determined in 21 patients with primary syphilis, 430 patients with proven non-treponemal genital ulcerations and 719 patients with acute urethritis presenting at a clinic for sexually transmitted diseases in southern Africa. Excluding those 21 cases of primary syphilis, 358 of 1149 tests performed (31%) were found to be reactive by at least one test. The rate of false positive RPR tests was very low (0.02%). Significantly higher rates of seropositivity were detected in patients with genital ulcerations than in patients with acute urethritis. The highest rates were detected among patients with proven lymphogranuloma venereum (34% RPR positive, FTA-ABS positive; 19% RPR negative, FTA-ABS positive). The geometric mean titres (GMT) of positive RPR tests in non-treponemal infections were found to be lower than in darkfield positive cases of genital ulcer disease.

Accuracy of clinical diagnosis of genital ulcer disease.

In Africa, establishment of an accurate clinical diagnosis in cases of genital ulcer disease is difficult owing to atypical presentation of ulcerations and mixed infections. This is compounded by the frequent lack of suitable laboratory facilities. In 240 cases of genital ulcer disease among mineworkers in Carletonville, South Africa, this study endeavored to correlate the clinical diagnosis with laboratory findings. Clinical accuracy and positive and negative predictive values were determined for each type of genital ulcer disease encountered. Overall, the accuracy of clinical diagnosis was 68% for single infections, 80% for chancroid, 55% for primary syphilis, 27% for lymphogranuloma venereum (LGV), and 22% for genital herpes. Adequate laboratory facilities are indispensible for the establishment of an accurate etiologic diagnosis of genital ulcer disease and thus the institution of appropriate antimicrobial therapy.

A comparative study of spectinomycin and erythromycin in the treatment of chancroid.

In a randomized, controlled study, 55 patients with genital ulcerations, culture-positive for Haemophilus ducreyi, were treated with a single intramuscular injection of 2 g spectinomycin. A further 61 patients were treated with a five-day oral course of erythromycin base (500 mg, three times daily). Treatment failure occurred in seven patients who received spectinomycin (13%), whilst no treatment failures were recorded among patients who received erythromycin. This difference in efficacy was statistically significant. In contrast, spectinomycin proved significantly more effective than erythromycin in the treatment of the lymphadenopathy associated with primary chancroid lesions.