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Chapter 146: Granuloma Inguinale

John R. Edminister; Stephne S. Rasiah; Rita O. Pichardo

GRANULOMA INGUINALE

Therapeutic Approach

Granuloma inguinale, also known as donovanosis, is an uncommon sexually transmitted infection (STI) of the skin that manifests as painless but slowly expanding “beefy” red genital ulcers without inguinal lymphadenopathy.1 The causative organism is the bacterium Klebsiella granulomatis, an intracellular gram-negative rod. Administration of systemic antibiotics, typically by oral route, is the mainstay of treatment. Guidelines from the Centers for Disease Control and Prevention (CDC) recommend a minimum treatment duration of 3 weeks and until all lesions are healed. It is prudent to screen patients for other STIs, including syphilis and HIV. Contact tracing of known sexual partners and reporting of cases to local and national health agencies should be considered, if applicable. See Table 146-1.

Table 146-1Granuloma Inguinale Treatment Table
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Table 146-1 Granuloma Inguinale Treatment Table
MEDICATION NAME INDICATION MECHANISM OF ACTION DOSING ADVERSE EFFECTS SUGGESTED MONITORING LEVEL OF EVIDENCE (REFERENCE)
Systemic Therapy      
Azithromycina Pregnancy and lactation Antimicrobial 1 g PO QW or 500 mg QD Contraindicated in cholestatic jaundice; liver injury, C. difficile infection, QT prolongation, GI upset Baseline ECG, consider LFTs with prolonged duration IIB2
Doxycyclineb   Antimicrobial 100 mg PO BID Contraindicated in pregnancy, <8 yo; photosensitivity, GI upset, esophagitis, headache None IV3
Erythromycinb Pregnancy and lactation Antimicrobial 500 mg PO QID Avoid in neonates (may cause pyloric stenosis); liver injury, altered cardiac conduction Baseline ECG, consider LFTs with prolonged duration IV4
Trimethoprim-sulfamethoxazole (TMP-SMX)b   Antimicrobial 160 mg/800 mg PO BID Contraindicated in pregnancy, breastfeeding, neonates <2 mo; C. difficile infection, liver injury, blood dyscrasias, electrolyte abnormalities, hypoglycemia, hypersensitivity reactions (immediate and delayed), renal dosing Baseline renal function and electrolytes; consider repeat monitoring in adults receiving >5 mg/kg/d of TMP5 IV6
Ciprofloxacin   Antimicrobial 500 mg PO BID Avoid in pregnant or breastfeeding patients if alternative agents are available, avoid in myasthenia gravis; aortic aneurysm/dissection, CNS effects, C. difficile infection, liver injury, dysglycemia, hypersensitivity reactions (immediate and delayed), QT prolongation, tendinitis/tendon rupture, renal dosing CBC, renal function, LFTs with prolonged duration IV7
Gentamycin Consider addition of aminoglycoside if lack of clinical improvement is observed within several days of initiating a preferred agent Antimicrobial 1 mg/kg IV Q8h Avoid in pregnancy; nephrotoxicity, ototoxicity, neuromuscular blockade, hypersensitivity reactions (immediate and delayed) Baseline and after 3rd dose: urinalysis, urine output, renal function, plasma drug concentration. Obtain baseline hearing test and repeat during and after treatment IV8

a2021 CDC recommended regimen9.

b2021 CDC alternative regimen9.

Levels of evidence are based on the Journal of the American Academy of Dermatology guidelines: level IA evidence includes evidence from meta-analysis of randomized controlled trials; level IB evidence includes evidence from ≥1 randomized controlled trial; level IIA evidence includes evidence from ≥1 controlled study without randomization; level IIB evidence includes ...

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