Granuloma Inguinale,

Lymphogranuloma Venereum,

Gonorrhea

082012100062

Nur Hanisah Zainoren

Objective

To understand the underlying causes of the

diseases

To understand the clinical findings of the

diseases

To know and memorize the drug used for the

treatment of the diseases

Pathology of the Diseases

Granuloma Inguinale

Chronic, relapsing granulomatous anogenital

infection

Due to: Calymmatobacterium granulomatis

Lesion occur on the skin or mucous membranes of

the genitalia or perineal area

Painless infiltrated nodules that soon slough.

A shallow, sharply demarcated ulcer forms, with a

beefy-red friable base of granulation tissue.

Lymphogranuloma Venereum

LGV is an acute and chronic sexually transmitted

disease caused by Chlamydia trachomatis types

L1-L3

Disease is acquired during intercourse or through

contact with contaminated exudate from active

lesions.

After the genital lesions disappears, the infection

spreads to lymph channels and lymph nodes of

genital and rectal areas.

Gonorrhea

Caused by: Neisseria Gonorrrhoeae

Transmitted during sexual activity and has greater

incidence in the 15-29-year-old age group.

Characterized by thick discharge from the penis

and vagina.

In addition to male reproductive organs & female

genital tract, gonorrhea may infect the rectum,

throat, eyes, blood, skin & joints.

Pharmacotherapy of the

Diseases

Granuloma Inguinale

Long duration of therapy

The following recommended regimens should be

given for 3 weeks or until all lesions have healed:

Drug Dose Route

Azithromycin 1g

once weekly

O

Ciprofloxacin 700mg

twice daily

O

Doxycycline 100mg

twice daily

O

Erythromycin 500mg

4 times daily

O

TREATMENT OF

Lymphogranuloma Venereum

Patient with a clinical presentation suggestive of

LGV should be treated empirically.

Drug Dose Route

Azithromycin 1g

once weekly

For 3 weeks

O

Doxycycline

*C/I in

pregnancy

100mg

twice daily

for 21 days

O

Erythromycin 500mg

4 times daily

For 21 days

O

TREATMENT OF

Gonorrhea

The choice of which regimen to use should be based on the national prevalences of antibiotic resistant organisms.

Nationwide, strains of gonococci that are resistant to penicillin, tetracycline, or ciprofloxacin have been increasingly observed.

Hence no longer be considered as 1st line therapy

Treatment of: 1. Uncomplicated Gonorrhea

2. Disseminated gonococcal infection

3. Endocarditis

4. Postgonococcal urethritis and cervicitis

5. Pelvic inflammatory disease

TREATMENT OF

Gonorrhea

1. Uncomplicated Gonorrhea

Higher dose of IM Ceftriaxone in combination with

second drug (Azithromycin or Doxycyline)

regardless of concern for possible secondary infection

with chlamydia.

For uncomplicated gonococcal infection of the cervix,

urethra, and rectum and pharyngeal gonorrhea

Ceftriaxone (250mg IM) + Azithromycin (1000mg orally as

SD) / Doxycycline (100mg BD for 7 days)

TREATMENT OF

*In case where an oral cephalosporin is the only option,

Cefixime (400mg, O, SD) can be combined with

Azithromycin/Doxycycline as above

but a “test of cure” is recommended 1 week after treatment

Gonorrhea

2. Disseminated gonococcal infection should be

treated with:

1st option

Ceftriaxone (1g daily, IV, until 48 hours after improvement

begins)

Cefixime (400mg daily, O, to complete at least one week of

antimicrobial therapy)

2nd option

Oral fluoroquinolone :

Ciprofloxacin (500mg, BD)

OR

Levofloxacin (500mg, OD)

Switched to

for 7 days

TREATMENT OF

Gonorrhea

3. Endocarditis should be treated with: Ceftriaxone ( 2g every 24 hours, IV, for at least 3 weeks)

4. Postgonococcal urethritis and cervicitis are treated with a regimen of erythromycin, doxycycline or azithromycin

5. Pelvic inflammatory disease:

1st option Cefoxitin (2g parenterally every 6 hours) OR

Cefotetan (2g IV every 12 hours)

Doxycycline (100mg every 12 hours)

TREATMENT OF

Gonorrhea

Pelvic inflammatory disease:

2nd option

Clindamycin (900mg, IV every 8 hours)

Gentamicin ( IV as a 2mg/kg loading dose followed by

1.5 mg/kg every 8 hours)

3rd option

Ceftriaxone (250mg IM, SD) OR

[Cefoxitin (2g IM, SD) + Probenecid (1g orally as a

SD)]

Doxycycline (100mg BD for 14 days)

With or without Metronidazole (500mg, BD for 14 days)

TREATMENT OF

Conclusion

1. Granuloma inguinale

Caused by: Calymmatobacterium granulomatis

Treatment:

Drug Dose Route

Azithromycin 1g

once weekly

O

Ciprofloxacin 700mg

twice daily

O

Doxycycline 100mg

twice daily

O

Erythromycin 500mg

4 times daily

O

2. Lymphogranuloma Venereum:

Caused by: Chlamydia trachomatis types L1-L3

Treatment:

Drug Dose Route

Azithromycin 1g

once weekly

For 3 weeks

O

Doxycycline

*C/I in pregnancy

100mg

twice daily

for 21 days

O

Erythromycin 500mg

4 times daily

For 21 days

O

3. Gonorrhea

Caused by: Neisseria Gonorrrhoeae

Treatment:

1.Uncomplicated Gonorrhea-Ceftriaxone/Cefixime+Azithromycin/Doxycycline

2.Disseminated gonococcal infection-CeftriaxoneCefixime or

-Oral fluoroquinolones (Ciprofloxacin/Levofloxacin)

3.Endocarditis

-Ceftriaxone

4.Postgonococcal urethritis and cervicitis

-Erythromycin, Doxycycline or Azithromycin

5.Pelvic inflammatory disease-Cefoxitin/Cefotetan+Doxycycline

-Clindamycin+Gentamicin

- Ceftriaxone OR [Cefoxitin + Probenecid] + Doxycycline

With or without Metronidazole

Reference

Stephen J.McPhee, Macine A.Papakadis, Current

Medical Diagnosis and Treatment, McGrawHill.

Thank you