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Carriage of Haemophilus ducreyi has not been adequately investigated in men, and its role in urethritis is unknown. In this study 456 men with H. ducreyi-culture positive genital ulcers were investigated. Among these men, 16 (3.5%) had urethritis. H. ducreyi was isolated from the urethra of nine men (1.9%). Of 57 men who had chancroid but not urethritis, none had H. ducreyi isolated from the urethra. Of 106 patients presenting with only acute urethritis, H. ducreyi was found in one. We conclude that H. ducreyi is responsible for acute urethritis in men, but that it rarely, if ever, can be cultured from the urethra of men with chancroid who do not have symptomatic urethritis.

Chancroid is gaining importance as a sexually transmitted disease because of its association with transmission of human immunodeficiency virus type 1 (HIV-1). Effective, simply administered therapy for chancroid is necessary. Fleroxacin is effective against Haemophilus ducreyi in vitro. We performed an initial randomized clinical trial to assess the efficacy of fleroxacin for treatment of chancroid in Nairobi, Kenya. Fifty-three men with culture-positive chancroid were randomly assigned to receive either 200 mg (group 1) or 400 mg (group 2) of fleroxacin as a single oral dose. Groups 1 and 2 were similar with regard to severity of disease, bubo formation, and HIV-1 status. A satisfactory clinical response to therapy was noted in 23 of 26 patients (88%) in group 1 and 18 of 23 patients (78%) in group 2. Bacteriological failure occurred in 1 of 26 evaluable patients (4%) in group 1 and 4 of 23 evaluable patients (17%) in group 2. Two of 37 HIV-1-seronegative men (5%) and 3 of 11 HIV-1-infected men (27%) were bacteriological failures. Fleroxacin, 200 or 400 mg as a single oral dose, is efficacious therapy for microbiologically proven chancroid in patients who do not have concurrent HIV-1 infection. Among HIV-1-infected men, a single dose of 200 or 400 mg of fleroxacin is inadequate therapy for chancroid.

During an endemic appearance of chancroids (26 cases) in Berlin (West) coccobacilli were disclosed in biopsies by electron microscopy. The bacteria were aggregated predominantly in groups in the extracellular space. Their cell wall is approximately 120 A thick and trilaminar as in Gram-negative bacteria. Concerning the cell wall structure and the cytoplasmic composition, the detected coccobacilli are identical to culturally grown Haemophilus ducreyi obtained from chancroids.

The present paper records the incidence of chancroid in northern Nigeria. Out of 776 new patients registered at the Special Treatment Clinic (STC) of the Ahmadu Bello University Teaching Hospital (ABUTH) Zaria during February to August 1982, 34 cases (4.38%) were diagnosed as chancroid. Direct smear examination for Haemophilus ducreyi was positive in 33 cases and bacterial bodies devoid of cell wall (probably L-forms of H. ducreyi) were demonstrated in one. Culture for H. ducreyi was positive in only three cases. All the patients responded to co-trimoxazole and tetracyclines.

As the literature on Haemophilus ducreyi and clinical chancroid is reviewed, it becomes obvious that many significant findings have been forgotten over the years. As a result, from the time of Ducrey's original description of the organism in 1890 until about 1977, both clinical and laboratory experts in the United Kingdom believed that H. ducreyi infections were rare, generally acquired abroad, and almost impossible to confirm in the routine laboratory! In consequence it was a common view that it was not worth looking for H. ducreyi until all other possible causes of genital ulceration had been excluded. Moreover, the search for such an infection stopped as soon as any other cause for the patient's lesions had been found. A decision to ignore this 'rule' in Sheffield led to our looking for H. ducreyi in specimens from an unselected series of patients with genital ulceration including a number with herpes genitalis infections. The surprise finding of H. ducreyi in circumstances suggesting that it was a secondary invader made us re-examine the whole question of H. ducreyi infections and chancroid and wonder if the same organism can act as a primary pathogen and as a secondary invader. An account of the media and methods we used and of the characteristics of the organism is presented. In an attempt to find out more about the characteristic coherent colonies of H. ducreyi we studied them with the scanning electron microscope. It is clear that the whole subject of H. ducreyi infections has been neglected in the United Kingdom, but we believe that interest has now been aroused and progress will surely follow. Some areas for further investigation are suggested.

Of 300 men in Nairobi, Kenya, with culture-proven chancroid, 57% had acquired infection from prostitutes. The majority of infections were acquired in the city of Nairobi. All 10 female source contacts examined had genital ulcers. 13 of 29 female secondary contacts were culture-positive for Haemophilus ducreyi and 10 of these infected women had clinical chancroid. Of 122 prostitutes from the middle and lower social strata, 12 had genital ulcers, 5 of which were culture-positive for H ducreyi, and a further 5 had symptomless genital carriage of H ducreyi. Prostitutes are a major reservoir of H ducreyi in Nairobi. No evidence of transmission of H ducreyi by women without clinical chancroid was detected.

Haemophilus ducreyi is the etiologic agent of chancroid, an infection which is endemic in tropical and subtropical areas of the world and which is becoming more prevalent in Europe and North America. Recently, several strains have demonstrated resistance to several antimicrobials by plasmid acquisition and cell envelope alteration making control of the spread of this organism a challenge. Equally challenging is the growth of this organism in the clinical microbiology laboratory because of its in vitro fastidious nature. Currently, the therapy of choice for Haemophilus ducreyi infection is trimethoprim sulfamethoxazole or erythromycin. Plasmid enumeration and restriction endonuclease fingerprinting in addition to outer membrane protein profiles may provide a basis for subtyping which would be useful in epidemiologic studies.

Seven of the 96 ampicillin-resistant isolates of Haemophilus ducreyi reported in the preceding article (Bilgeri et al., Antimicrob. Agents Chemother. 22:686-688, 1982) were investigated and found to harbor plasmids of 3.95, 5.2, 5.8, and 6.4 megadaltons. All except the 5.8-megadalton plasmid have been shown to code for beta-lactamase. The 6.4- and 5.2-megadalton plasmids of three isolates were conjugally transferable to a streptomycin-resistant mutant of H. ducreyi at high frequencies, perhaps due to the presence in these strains of a high-molecular-weight plasmid.

The whole-cell proteins of 105 clinical isolates of Haemophilus ducreyi from several geographic sources (North America, Africa, Asia, and Europe) were examined by sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE). The protein profiles were reproducible and unaffected by repeated subculturing or age of culture. At least seven different subtypes were determined by proteins in the molecular weight range of 24,000-50,000. These proteins are located in the outer membrane of the cell, as determined by SDS-PAGE of the sarcosinate-insoluble membrane preparations of these strains. Thirteen isolates from a Winnipeg, Manitoba, Canada, outbreak of chancroid had identical patterns, suggesting a common origin. Although H ducreyi shares a number of proteins in common with other Haemophilus species, the protein profiles appear to be species specific. Heterogeneity in the protein composition of H ducreyi has provided a basis for subtyping, which could be of value in future epidemiologic studies.

Chancroid is a sexually transmitted disease characterized by genital ulceration. Although the pathology of chancroid lesions has been well described, we still know relatively little about the mechanism by which the causative agent, the bacterium Haemophilus ducreyi, produces disease. It is hoped that a better understanding of both the pathogenicity of H. ducreyi and the pathogenesis of chancroid will provide a rational basis for the development of improved strategies for the control of this disease.

The role of lipopolysaccharide (LPS) in the susceptibility of Haemophilus ducreyi to human serum and the mechanism of complement activation by serum-susceptible (Sers) strains were investigated. Serum treated with 2 mM Mg2+ and 20 mM ethylene glycol-bis(beta-aminoethyl ether)-N,N,N',N'-tetraacetic acid was nonbactericidal, but inulin-treated serum remained bactericidal. Absorption of serum with heat-killed whole cells of an Sers strain removed its bactericidal activity against the absorbing strain and also against other Sers strains. LPS obtained from Sers strains inhibited the bactericidal activity of serum against all Sers strains, whereas LPS from serum-resistant (Serr) strains and an Serr isogenic strain did not. However, high concentrations of LPS from the Serr strain inhibited the bactericidal activity of serum, an indication that part of the structural site involved in serum susceptibility is retained in the LPS of this strain. The LPS of Sers strains exhibited higher anticomplement activity than the LPS of Serr strains. These findings suggest that the classical pathway of complement activation is involved in the serum killing of H. ducreyi and that LPS composition may contribute to their susceptibility to complement-mediated serum bactericidal activity.

One hundred and thirty seven patients presenting with genital ulcerations from which Haemophilus ducreyi was isolated were treated with erythromycin stearate 500 mg every six hours for seven days. Of these, 91 (66%) had associated inguinal lymphadenopathy. Only two of the 100 patients who returned after one week showed no clinical improvement. Despite decrease in size H ducreyi was reisolated from the ulcers of three patients, two of whom had not complied with treatment. The patients were treated for a further week either with erythromycin or with a placebo preparation and on day 14 no discernible difference in clinical response was evident. H ducreyi was not reisolated from any lesion. In contrast, the natural course of development of associated lymphadenopathy was not modified by treatment. H ducreyi was not, however, isolated from any gland after the start of treatment. Side effects attributable to erythromycin were minimal and treatment had to be discontinued in only two patients. This study clearly indicates that treatment with erythromycin for one week results in rapid healing of lesions and the elimination of H ducreyi from both ulcers and associated lymph glands.

Some of the characteristics of 42 clinical isolates of Haemophilus ducreyi are reported. Only six of the 42 strains were able to grow on horse-blood agar. All strains gave a positive oxidase test with tetramethyl-p-phenylenediamine and a negative result with dimethyl-p-phenylenediamine. All of 15 test strains were negative in the porphyrin test. Tests for haemin requirement were inconclusive because of difficulties encountered in obtaining growth on a basal medium.

The causative organism of chancroid, Haemophilus ducreyi, is generally considered to be very fastidious and its isolation, maintenance, and detailed study very demanding. In this study a modified medium was developed, which allowed the organism to be isolated more frequently than previously would have been expected. Twenty-two cases of chancroid were confirmed by the isolation of H ducreyi in 160 patients with genital ulceration examined over a one-year period. The cases were apparently unrelated, and in only five was there a history of recent sexual contact abroad. Concurrent infection with other sexually transmitted diseases was present in 18 (81.8%) patients, and in 14 (63.6%) both H ducreyi and herpes simplex virus were isolated form the same genital ulcers. Thus, these findings indicate that chancroid is underdiagnosed in England and that H ducreyi may frequently occur as a secondary invader of damaged genital skin and mucosa.

Occasional biopsies of genital lesions due to chancroid, secondary syphilis (the condyloma latum) and granuloma inguinale are encountered in routine histopathological practice. These lesions have specific microscopical appearances enabling a confident, or at least a presumptive, diagnosis to be made in most cases, yet the value of biopsy in the diagnosis of these diseases is not generally appreciated. The ulcer of chancroid shows three zones--a narrow superficial zone of degenerate leucocytes and fibrin, a broader middle zone with characteristic vascular changes, and a deep zone in which there is a plasma cell and lymphocyte infiltrate. The condyloma latum shows hyperplasia of the epidermis which is infiltrated with polymorphonuclear leucocytes in addition to the mononuclear infiltration of the dermis. Large numbers of spirochaetes are found in the area of the polymorph exocytosis of the epidermis. The inflammatory infiltrate of granuloma inguinale consists of a neutrophil and plasma cell infiltrate with moderate numbers of large mononuclear cells in which there are one or more vacuoles containing Donovan bodies.

The rates of isolation of Haemophilus ducreyi from patients with presumed chancroid has been low, and improved cultural techniques are required. We determined the isolation rates of H. ducreyi from 38 patients with clinical chancroid and compared gonococcal agar supplemented with bovine hemoglobin to Mueller-Hinton agar supplemented with chocolated horse blood, each with and without 5% fetal calf serum. The rate of isolation and the qualitative and quantitative growth of strains was best on gonococcal agar with added fetal calf serum (GC-HgS). However, three strains were isolated only on Mueller-Hinton base (MH-base). GC-HgS was compared with MH-HB for the isolation of H. ducreyi from 201 patients with clinical chancroid. Seventy-one percent of cultures were positive on GC-HgS, and 61% were positive on MH-HB (P less than .005); however, 10% of cultures were positive only on MH-HB. The use of the two media together increased the yield of positive cultures to 81%. Thus maximal rates of isolation of H. ducreyi from clinical specimens requires the use of two media, GC-HgS and MH-HB.

We conducted a randomized double-blind trial comparing a single dose of trimethoprim-sulfametrole (640 to 3200 mg) with five-day regimens of either trimethoprim-sulfametrole (160 to 800 mg twice daily) or trimethoprim alone (200 mg twice daily) for the treatment of men with chancroid. Of 95 patients, 78 had cultures positive for Hemophilus ducreyi. Twenty-seven, 23, and 28 patients, respectively, were assigned to the single-dose trimethoprim-sulfametrole, the five-day trimethoprim-sulfametrole, and the five-day trimethoprim treatments. The rate of ulcer and bubo resolution, the mean (+/- S.D.) healing times (10.3 +/- 5.7, 11.0 +/- 7.4, and 11.9 +/- 8.2 days, respectively), the microbiologic response, the number of treatment failures, and the number of recurrent ulcers were similar in all three treatment groups. We conclude that single-dose trimethoprim-sulfametrole is a highly effective, inexpensive therapy for chancroid in men and may prove to be an important strategy for the control of H. ducreyi infection.

In October 1982, penile ulcers were identified in 248 (19%) of 1282 men at Bangrak Hospital, Bangkok, Thailand. The etiology of the ulcers was determined for 120 (48%) of these patients. Haemophilus ducreyi was isolated from 45 (38%), herpes simplex virus from 14 (12%), and Neisseria gonorrhoeae from two (2%) of 120 patients. Syphilis was detected in one patient. Two patients had both H. ducreyi and herpes simplex virus isolated from the same ulcer. Thirty-five per cent of patients had a single ulcer, 56% had two to four ulcers, and 9% had more than four. Ulcers were located on the prepuce or coronal sulcus (69%), frenulum (18%), shaft (9%), and glans (4%). Inguinal adenopathy was present in only 11% of patients. H. ducreyi infection was diagnosed by gram stain in 28 (62%) of 45 patients from whom H. ducreyi was isolated and in only one of 75 patients from whom H. ducreyi was not isolated. Of the 45 isolates of H. ducreyi, 42 (93%) were isolated with use of media containing horse blood and 34 (76%) with use of media containing rabbit blood.

Chancroid (ulcus molle) was treated in 7 male patients with enoxacin (2 X 400 mg/die). Microbiological and clinical examinations proved complete healing in all cases after 7 to 12 days. No side effects were mentioned. Enoxacin seems to be an excellent alternative treatment for this sexually transmitted disease.

Routine procedures used to isolate Haemophilus ducreyi in a busy laboratory are reported. Identification was based on colony morphology and nutritional and biochemical properties of 120 fresh isolates of H. ducreyi. These isolates grew very well on Gonococcal Agar and Mueller-Hinton Agar incubated at 34 degrees C in candle extinction jars containing moistened filter paper. Colonies varied in size, giving a polymorphic appearance. They were smooth, dome-shaped, and buff-yellow to grey in colour, and measured 2 mm in diameter. They could be pushed intact across the agar surface. By microscopic examination of gram-stained smears the isolates were gram-negative coccobacilli arranged in short chains, clumps or whorls and occasionally in typical "rail track" arrangements. Individual bacteria showed bipolar staining. Colonies autoagglutinated in saline. All strains were catalase-negative and did not produce indole or H2S. They were oxidase- and beta-lactamase positive and required X but not V factor for growth. Now that reliable techniques have been developed and characteristics established it is possible for most clinical laboratories to isolate and identify this organism from most patients with chancroid.

A useful method for isolating and recognizing Haemophilus ducreyi from chancres and buboes of male patients is presented. A total of 41 clinical isolates of H. ducreyi were recovered from 33 patients over an 8-year period, and the experience with the 15 most recent isolates is presented in detail. Chocolate agar supplemented with 1% Iso VitaleX and 5% sheep blood agar were prepared, using Trypticase soy and Mueller-Hinton Agar bases, and incubation conditions included ambient, capneic, and anaerobic environments. Mueller-Hinton agar was clearly superior over Trypticase soy agar for isolation of H. ducreyi, although there was little difference between 5% sheep blood and supplemented chocolate agar. Growth in ambient air and under anaerobiasis was poor or lacking, whereas growth in 5 to 7% CO2 was good to luxuriant. Heat-inactivated and fresh (unheated)human blood clot tubes also were used for selective isolation. Although the rates of isolation from the two types of clot tube were not significantly different, unheated clot tubes were superior to heated clot tubes because of reduced level of contaminants. Gram stain characteristics taken from blood clot tubes and solid media, cellular and colonial morphology of the bacilli, and lack of oxidase, catalase, and biochemical activity except nitrate reductase were determinant factors. The results of this study demonstrated that successful isolation of H. ducreyi can be achieved with a minimal amount of resources and expertise.

The penile ulcerations of 100 consecutive men were tested for microorganisms. A polymicrobial flora was identified in the ulcers of 97 men. The microorganisms recovered from these ulcers included combinations of anaerobic and aerobic bacteria (including Mycoplasma), herpes simplex virus, yeasts, and filamentous fungi. Fifty-three study entrants had microorganisms, identified by culture or serologic tests, that were considered primary in ulcer pathogenesis. Herpes simplex virus was the most prevalent and Treponema pallidum was the next most prevalent pathogen identified. Of our patients, 5% had two recognized pathogens confirmed by laboratory tests, and only one of these was suspected at clinical examination. In addition, the study suggests that microorganisms other than Haemophilus ducreyi can produce ulcers with a morphology mimicking chancroid.

Of 103 strains of Haemophilus ducreyi isolated in Johannesburg, 96 produced beta-lactamase and were resistant to penicillin and ampicillin. Most strains showed resistance to tetracycline, sulfisoxazole, and sulfamethoxazole. All isolates were susceptible to rifampin, erythromycin, and cefoxitin, moderately susceptible to trimethoprim-sulfamethoxazole (1:19) and minocycline, and somewhat less susceptible to doxycycline.

Using an enriched medium, H. ducreyi was isolated from 56 out of 670 patients with penile ulcers (8.3%). Their clinical, epidemiological characteristics and treatment responses to streptomycin, cotrimoxazole and other antimicrobial agents are analysed. 51% failed to respond to streptomycin.

Haemophilus influenzae was isolated from the urethra of three of 85 men attending a sexually transmitted diseases clinic. These isolates of H. influenzae were nonencapsulated; one was biotype III, and two were biotype IV. Haemophilus parainfluenzae was isolated from the urethra or coronal sulcus of five men; three isolates were biotype II, and two were biotype III. Neither H. influenzae nor H. parainfluenzae was isolated from the genital secretions of 84 women. Haemophilus ducreyi and Haemophilus equigenitalis (contagious equine metritis bacterium) were not isolated from any of the 169 patients.

The in vitro activity of the new macrolide azithromycin and erythromycin against Haemophilus ducreyi, Gardnerella vaginalis, Bacteroides spp. and Mobiluncus spp. was compared. Gardnerella vaginalis, Mobiluncus spp. and Haemophilus ducreyi were highly susceptible to both agents but azithromycin was more effective overall against all three groups of organisms. The activity of both antibiotics against Bacteroides spp. varied greatly, but azithromycin was again more active. Collectively, 62% of all Bacteroides strains were susceptible to erythromycin (MIC 1 mg/1) and 74% were susceptible to azithromycin.

We have compared the in-vitro activity of 12 quinolone antibiotics against 50 recent isolates of Haemophilus ducreyi from The Gambia. While these isolates were relatively resistant to the parent compounds, the newly synthesized quinolones exerted significant activity against H. ducreyi. Ciprofloxacin and ofloxacin were the most active compounds (MIC90 0.03 mg/l).

The emergence of Haemophilus ducreyi resistant to multiple antibiotics has limited the effectiveness of sulfonamides and tetracycline for the therapy of chancroid. A randomized, double-blind study compared 10-day courses of erythromycin base (500 mg) and rosaramicin (250 mg) each given four times daily for the treatment of men with chancroid in Nairobi, Kenya. Of 99 evaluable patients, 84 were positive for H ducreyi. H ducreyi-positive genital ulcers in men treated with either drug resolved with mean +/- SD healing times of 10.8 +/- 5.1 days for erythromycin and 10.7 +/- 5.5 for rosaramicin. There were no clinical or bacteriologic failures with either agent. Fifteen men with H ducreyi-negative genital ulcers for whom no other etiology could be determined also responded rapidly to treatment with either agent. Both erythromycin and rosaramicin are highly effective in the treatment of chancroid.

A single dose of ceftriaxone (250 mg) administered intramuscularly was compared with trimethoprim-sulfamethoxazole (TMP-SMZ; 160/800 mg) administered orally twice daily for seven days or with a single dose of TMP-SMZ (640/3,200 mg) administered orally for the treatment of chancroid in men in Thailand. Haemophilus ducreyi was isolated from 79 (48%) of 164 men with a clinical diagnosis of chancroid. For men with ulcers that were culture positive for H. ducreyi, rates of cure were 100% in 25 men treated with ceftriaxone, 87% in 23 men given TMP-SMZ for seven days, and 55% in 31 men given TMP-SMZ in a single dose. For men with ulcers that were culture negative for H. ducreyi, rates of cure were 100% in 29 men treated with ceftriaxone, 66% in 32 men given TMP-SMZ for seven days, and 63% in 24 men given TMP-SMZ in a single dose. The MIC50 of the three antibiotics for 94 isolates of H. ducreyi were as follows: 0.004 micrograms/ml for ceftriaxone, 16 micrograms/ml for trimethoprim, and greater than 512 micrograms/ml for sulfamethoxazole. Our study indicates that ceftriaxone in a single dose of 250 mg is effective, but that TMP-SMZ, even when given in a standard seven-day regimen, is not effective treatment for chancroid in Thailand.

240 patients with soft chancre who have been observed within a year dating from March 1976 at the University Dermatological Clinic of Istanbul are presented. The clinical findings encountered in our cases are presented and the therapeutic results are discussed.

In 1984 and 1985, outbreaks of genital ulcers occurred in Florida and New York. Initial investigations for syphilis, herpes simplex, Chlamydia trachomatis, and Haemophilus ducreyi did not implicate any of these organisms as etiologic agents. From the results of dot-immunobinding assays, we found that sera from the patients had higher levels of IgM (30 [47.6%] of 63 patients) and IgG (22 [34.9%] of 63 patients) reactivities with an outer-membrane preparation from H. ducreyi strain CIP542 than with outer-membrane preparations from Haemophilus influenzae ATCC 10211 or Haemophilus parainfluenzae ATCC 7901. In contrast, sera from 35 patients in the control group did not react with any of the outer-membrane preparations (P less than .01 for both IgM and and IgG reactivity), nor did sera from eight individuals with disease caused by H. influenzae (P = .051 for IgM reactivity, P = .02 for IgG reactivity). Indirect immunofluorescence assay using a monoclonal antibody reactive with outer-membrane preparations from H. ducreyi strain CIP542 stained organisms in smears of lesion material from genital ulcers from three of six patients. These results suggested that the cause of both outbreaks of genital ulcers was H. ducreyi which was subsequently isolated in both geographic areas.

Haemophilus ducreyi is a fastidious pathogen that can be routinely cultured with the appropriate media and incubation environment. Prostituted women appear to be the usual reservoir. In Africa, chancroid is emerging as the major risk factor for acquisition of HIV-1 following heterosexual intercourse. Despite the emergence of resistance to a number of antimicrobial agents, H. ducreyi remains susceptible to ceftriaxone, erythromycin, and ciprofloxacin. Control and eradication of outbreaks of chancroid have been successful on several occasions in Western societies; strategies to control epidemic genital ulcer disease are required in developing countries. Granuloma inguinale is caused by a small, gram-negative rod, which has never been well-characterized. The presence of Donovan bodies is a specific and sensitive diagnostic characteristic. Very little is known about the epidemiology of the disease. Specific treatment programs using trimethoprim-sulfamethoxazole or erythromycin seem to be quite effective. Control strategies have not been adequately investigated.