Background: Data concerning the spectrum and antimicrobial susceptibility of STDs in Madagascar are scarce.
Objectives: Improvement of STD patient management in Madagascar.
Goal of the study: Assessment of the spectrum of STDs and improvement of therapy.
Study design: Etiologic study of 400 patients (169 men, 231 women) under consultation at the major STD service in Antananarivo for one or more of the STD syndromes, urethral discharge, cervicovaginal discharge, genital ulcers, or condylomata according to a fixed diagnostic schedule.
Results: Of genital ulcers, syphilis accounted for 46%, lymphogranuloma venereum for 24%, chancroid for 16%, and herpes for 1%. Of the syphilis cases, 51% presented as condyloma lata. Discharge was found in 124 men and 210 women. Counting concomitant infections separately, gonorrhea occurred in 69% of the men and 20% of the women with discharges, chlamydia infection in 42% and 52%, trichomoniasis in 9% and 31%, candidiasis in 12% and 30%. Bacterial vaginosis was found in 37% of the women with discharges. In 32% of male and 71% of female gonorrhea cases, there was concurrent chlamydia infection. Infection with HIV 1 or 2 was not detected. Determination of the antibiotic susceptibility of Neisseria gonorrhoea revealed high efficacy of ampicillin, ciprofloxacin, and spectinomycin; but frequent resistance to tetracycline and cotrimoxazole.
Conclusions: High priority should be given to the management of infections with chlamydia and with Treponema pallidum as well as to educational measures to increase awareness of genital ulcer disease.
PIP: Between November 1992 and April 1993, interviews were conducted with 400 patients (169 men, 231 women) aged 14-52 years at the sexually transmitted disease (STD) clinic of the Institut d'Hygiene Sociale in Antananarivo, Madagascar, to determine the pattern of STDs and to improve treatment of the leading STDs. The 400 patients presented with 434 syndromes. 124 men had urethral discharge. 210 women had cervicovaginal discharge. 43 men and 18 women had genital ulcers. Clinicians could not establish a diagnosis in 33 patients. 171 patients had more than one infection. Chlamydia infection was the most common infection associated with another STD (gonorrhea in 22% of men and 11% of women with discharge, trichomoniasis in 2.4% of men and 13% of women, candidiasis in 1.6% of men and 9% of women, and bacterial vaginosis in 15% of women with discharge). Gonorrhea was the most common etiology for male discharge (69%) while chlamydia infection was for female discharge (52%). Women with discharge were more likely than men with discharge to have chlamydia infection (52% vs. 42%), trichomoniasis (30% vs. 9%; p 0.00001), and candidiasis (32% vs. 12%; p 0.00001). 37% of women with discharge had bacterial vaginosis. Chlamydia infection was the most common STD in this population (45%). 32% of male and 71% of female gonorrhea cases also had chlamydia infection. 70 patients had syphilis. 36 of them had secondary stage syphilis. No one had HIV-1 or HIV-2 infection. The most efficacious antibiotics for gonorrhea were ampicillin, ciprofloxacin, and spectinomycin (100% susceptibility). 31% and 26% of isolates were susceptible to tetracycline and cotrimoxazole, respectively. Public facilities in Madagascar do not have the capabilities to diagnosis chlamydia, resulting in many untreated chlamydia cases. These findings stress the need to improve combined treatment of gonorrhea and chlamydia infection and for educational efforts to increase awareness of genital ulcer disease.