Global eradication of donovanosis: an opportunity for limiting the spread of HIV-1 infection

Donovanosis in Australia: going, going

In the 1990s donovanosis (or granuloma inguinale) had disappeared from most parts of the developed world. However, any practitioner working in the Northern Territory, far north Queensland, or the northern part of Western Australia would have been aware of the spectrum of morbidity associated with the condition in the Aboriginal and Torres Strait Islander population--ranging from mild genital ulceration to severe, disfiguring disease and disseminated, life threatening infection.

Donovanosis

Donovanosis, a chronic cause of genital ulceration, has recently been the subject of renewed interest after a long period of relative obscurity. The causative organism, Calymmatobacterium granulomatis, has been cultured for the first time in many years and a polymerase chain reaction diagnostic using a colorimetric detection system has been developed. Phylogenetic analysis confirms close similarities with the genus Klebsiella and a proposal made that C granulomatis be reclassified as Klebsiella granulomatis comb nov. Azithromycin has emerged as the drug of choice and should be used if the diagnosis is confirmed or suspected. In donovanosis endemic areas, syndromic management protocols for genital ulceration may need to be adapted locally. A significant donovanosis epidemic was reported in Durban from 1988-97 but the current status of this epidemic is unclear. The donovanosis elimination programme among Aboriginals in Australia appears successful and is a model that could be adopted in other donovanosis endemic areas. Overall, the incidence of donovanosis seems to be decreasing. Increased attention would undoubtedly be paid to donovanosis if policy makers recognised more readily the importance of genital ulcers in fuelling the HIV epidemic.

Pilot study of azithromycin in the treatment of genital donovanosis

OBJECTIVES

To determine the effectiveness of azithromycin, an azalide antibiotic with long tissue half-life, in a pilot study of patients with genital donovanosis in the Northern Territory, Australia.

DESIGN

Patients with histologically confirmed donovanosis were randomised to receive one of two open-label azithromycin dosage regimens: Regimen A--1.0 g once weekly for 4 weeks; or Regimen B--500 mg daily for 7 days. Patients were assessed at 6 weeks and classified as either "cured", "improved" or "failed".

RESULTS

Seven patients received regimen A and 4 received regimen B. Six weeks after commencing treatment the genital ulcers of four patients receiving regimen A and one patient receiving regimen B had healed; the lesions of the other six patients (3 in each regimen) were "improved". No patient failed to respond and no significant adverse reaction was recognised. The eleven patients were reviewed after completing the six-week trial; all lesions had re-epithelialised without further antibiotic treatment, no relapses had occurred, the longest follow-up period being seven months. A further 17 patients with donovanosis who were unable to meet the entry criteria were also treated successfully with azithromycin during the study period.

CONCLUSIONS

This is the first time that azithromycin has been shown to have clinical activity against donovanosis. Poor compliance with prolonged courses of antibiotics is one of the major barriers to control of the disease. Intermittent or short-course therapy, made possible by the long tissue half-life of the drug, could facilitate control of donovanosis in endemic populations if the high cost of medication can be addressed.