(A report back on Jose Blanco's session - Effective Treatment of Lymphogranuloma proctitis with extended azithromycin regimen)

Jose Blanco presented an alternative and effective treatment to LGV proctitis utilising azithromycin 1 gm po weekly x 3 weeks. This was based on their study-analysis of 125 HIV-infected MSM who were randomised to either the standard treatment of doxycycline 100mg BD x 21 days or to the extended azithromycin regimen. Both arms produced equally effective cures in both symptomatic (12 weeks) and microbial (defined as a negative rectal PCR in 4-6 weeks) end points.

Lymphogranuloma venereum (LGV) caused by Chlamydia trachomatis serovars L1-3, generally presents as a painless ulcer and painful lymphadenopathy. However, it may present as proctocolitis mimicking inflammatory bowel disease, which if not treated, can lead to fistula-formation and strictures.

Patients intolerant to doxycycline may be treated with erythromycin 500 mg QID x 21 days, which is (I feel) brutal to the gastrointestinal system in a number of patients. Hence the extended azithromycin regimen given weekly may be a better choice as an alternative.

There were 3 main points to ponder before jumping to the extended azithromycin regimen though:

1. It was pointed out that studies have shown azithromycin is inferior to doxycycline in rectal infections.

2. In the global rise of gonorrhoea rates in the era of PrEP (in a number of presentations in CROI 2019), there is concern about the use of azithromycin leading to resistance, in areas of high gonorrhoea prevalence.

3. we have also noticed an increase in Mycoplasma genitalium cases in Central Queensland, and a few failures to azithromycin. Definitely the presence of M. genitalium and its treatment should be a consideration when discovering LGV proctocolitis and deciding on the extended azithromycin regimen.

And as they always say: more research is needed!

Author bio: Board certified in Infectious Diseases by the American Board of Internal Medicine, Rudyard has worked in Infectious Diseases (including HIV) in New York, New Zealand and Australia. Rudyard is currently a Senior Lecturer University of Queensland Rural Clinical School, and an Infectious Disease Physician at Central Queensland Hospital and Health Services.