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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.

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.