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__NOTOC__
__NOTOC__
{{CMG}}
{{CMG}}{{AE}}{{AA}}; {{NRM}}
{{Syphilis}}
{{Syphilis}}
==Overview==
==Overview==
[[Penicillin#Benzylpenicillin (penicillin G)|Penicillin G]], administered parenterally, is the preferred drug for treating all stages of syphilis. If allergic, then [[tetracycline]] or [[doxycycline]] may also be used. During pregnancy, [[Penicillin#Benzylpenicillin (penicillin G)|parenteral penicillin G]] is the only therapy with documented efficacy for syphilis.  
[[Penicillin#Benzylpenicillin (penicillin G)|Penicillin G]], administered [[parenterally]], is the preferred drug for treating all stages of syphilis. If the patient is allergic, then [[Tetracycline]] or [[doxycycline]] may also be used. During pregnancy, [[Penicillin#Benzylpenicillin (penicillin G)|parenteral penicillin G]] is the only therapy with documented efficacy for syphilis.  The [[Jarisch-Herxheimer reaction]] is an acute adverse febrile reaction that may occur after initiation of therapy for syphilis.


==Medical Therapy==
==Medical Therapy==
*[[Penicillin#Benzylpenicillin (penicillin G)|Penicillin G]], administered parenterally, is the preferred drug for treating all stages of syphilis.  
*[[Penicillin#Benzylpenicillin (penicillin G)|Penicillin G]], administered [[parenterally]], is the preferred drug for treating all stage of syphilis.<ref name=cdcsyphilis>http://www.cdc.gov/std/tg2015/syphilis.htm Accessed on September 26, 2016</ref>


:*The preparation used (i.e., benzathine, aqueous procaine, or aqueous crystalline), the dosage, and the length of treatment depend on the stage and clinical manifestations of the disease.  
:*The preparation used (i.e., [[Benzathine penicillin G|benzathine]], aqueous [[Procaine penicillin G|procaine]], or [[Penicillin G potassium|aqueous crystalline]]), the dosage, and the length of treatment depend on the stage and clinical manifestations of the disease.  


:*Selection of the appropriate [[Penicillin#Benzylpenicillin (penicillin G)|penicillin preparation]] is important, because T. pallidum can reside in sequestered sites (e.g., the CNS and aqueous humor) that are poorly accessed by some forms of penicillin.  
:*Treatment for longer duration is required in patients with late latent, latent with unknown duration and tertiary syphilis.


:*Combinations of benzathine penicillin, procaine penicillin, and oral penicillin preparations are not considered appropriate for the treatment of syphilis.  
:*Selection of the appropriate [[Penicillin#Benzylpenicillin (penicillin G)|penicillin preparation]] is important, because ''T. pallidum'' can reside in sequestered sites (e.g., the [[CNS]] and [[aqueous humor]]) that are poorly accessed by some forms of penicillin.


*During pregnancy, [[Penicillin#Benzylpenicillin (penicillin G)|parenteral penicillin G]] is the only therapy with documented efficacy for syphilis. Pregnant women with syphilis in any stage who report penicillin allergy should be desensitized and treated with penicillin
:*Combinations of benzathine penicillin, procaine penicillin, and oral penicillin preparations are not considered appropriate for the treatment of syphilis.<ref name=BCR>http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5409a1.htm</ref> 
 
*The [[Herxheimer reaction|Jarisch-Herxheimer reaction]] is an acute febrile reaction
 
:*Frequently accompanied by [[headache]], [[myalgia]], [[fever]], and other symptoms that usually occur within the first 24 hours after the initiation of any therapy for syphilis.  
 
:*Patients should be informed about this possible adverse reaction.  
 
:*The Jarisch-Herxheimer reaction occurs most frequently among patients who have early syphilis, presumably because bacterial burdens are higher during these stages.  
 
:*[[Antipyretics]] can be used to manage symptoms, but they have not been proven to prevent this reaction.
 
:*The Jarisch-Herxheimer reaction might induce early labor or cause [[fetal distress]] in pregnant women, but this should not prevent or delay therapy.


===Pharmacotherapy===
===Pharmacotherapy===
:* 1. '''Syphilis Among non-HIV-Infected Persons''' <ref name="pmid26042815">{{cite journal |vauthors=Workowski KA, Bolan GA |title=Sexually transmitted diseases treatment guidelines, 2015 |journal=[[MMWR. Recommendations and Reports : Morbidity and Mortality Weekly Report. Recommendations and Reports / Centers for Disease Control]] |volume=64 |issue=RR-03 |pages=1–137 |year=2015 |pmid=26042815 |doi= |url=http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6403a1.htm |issn=}}</ref>
:'''Syphilis Among non-HIV-Infected Persons'''<ref name="pmid26042815">{{cite journal |vauthors=Workowski KA, Bolan GA |title=Sexually transmitted diseases treatment guidelines, 2015 |journal=[[MMWR. Recommendations and Reports : Morbidity and Mortality Weekly Report. Recommendations and Reports / Centers for Disease Control]] |volume=64 |issue=RR-03 |pages=1–137 |year=2015 |pmid=26042815 |doi= |url=http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6403a1.htm |issn=}}</ref>
::* 1.1 '''Primary and Secondary Syphilis'''
::'''Primary and Secondary Syphilis'''
:::* Preferred regimen: [[Benzathine penicillin G]] 2.4 MU IM single dose
::*Preferred regimen: [[Benzathine penicillin G]] 2.4 MU IM single dose
:::* Pediatric regimen: [[Benzathine penicillin G]] 50,000 U/kg (Maximum, 2.4 MU) IM single dose  
::*Pediatric regimen: [[Benzathine penicillin G]] 50,000 U/kg (Maximum, 2.4 MU) IM single dose
::* 1.2 '''Latent Syphilis'''
::'''Latent Syphilis'''
:::* 1.2.1 '''Early Latent Syphilis'''
:::Early Latent Syphilis:
::::* Preferred regimen: [[Benzathine penicillin G]] 2.4 MU IM in a single dose
:::*Preferred regimen: [[Benzathine penicillin G]] 2.4 MU IM in a single dose
::::* Pediatric regimen: [[Benzathine penicillin G]] 50,000 U/kg (Maximum, 2.4 MU) IM single dose  
:::*Pediatric regimen: [[Benzathine penicillin G]] 50,000 U/kg (Maximum, 2.4 MU) IM single dose
:::* 1.2.2 '''Late Latent Syphilis or Latent Syphilis of Unknown Duration'''
:::Late Latent Syphilis or Latent Syphilis of Unknown Duration:
::::* Preferred regimen: [[Benzathine penicillin G]] 7.2 MU total, administered as 3 doses of 2.4 MU IM each at 1 week intervals
:::*Preferred regimen: [[Benzathine penicillin G]] 7.2 MU total, administered as 3 doses of 2.4 MU IM each at 1 week intervals
::::* Pediatric regimen: [[Benzathine penicillin G]] 50,000 U/kg IM (Maximum, 2.4 MU), administered as 3 doses at 1 week intervals (total 150,000 U/kg up to the adult total dose of 7.2 MU)
:::*Pediatric regimen: [[Benzathine penicillin G]] 50,000 U/kg IM (Maximum, 2.4 MU), administered as 3 doses at 1 week intervals (total 150,000 U/kg up to the adult total dose of 7.2 MU)
::* 1.3 '''Tertiary Syphilis'''
::'''Tertiary Syphilis'''
:::* Preferred regimen: [[Benzathine penicillin G]] 7.2 MU total, administered as 3 doses of 2.4 MU IM each at 1 week intervals
::*Preferred regimen: [[Benzathine penicillin G]] 7.2 MU total, administered as 3 doses of 2.4 MU IM each at 1 week intervals
::* 1.4 '''Neurosyphilis and ocular syphilis'''
::'''Ocular syphilis'''
:::* Preferred regimen: [[Aqueous crystalline penicillin G]] 18-24 MU per day, administered as 3-4 MU IV q4h or continuous infusion, for 10-14 days
:::Pathogen-directed antimicrobial therapy:<ref>{{cite book | last = Bennett | first = John | title = Mandell, Douglas, and Bennett's principles and practice of infectious diseases | publisher = Elsevier/Saunders | location = Philadelphia, PA | year = 2015 | isbn = 978-1455748013 }}</ref>
:::* Alternative regimen: [[Procaine penicillin]] 2.4 MU IM q24h {{and}} [[Probenecid]] 500 mg PO qid for 10-14 days
:::*Preferred regimen (1): [[Penicillin]] 4 MU IV q4h for 10-14 days {{and}} [[Benzathine penicillin G]] 2.4 MU IM once weekly for 3 weeks
 
:::*Note (1): [[Corticosteroids]] (Prednisone 60-80 mg PO qd) are co-administered to decrease intraocular inflammation and prevent rebound inflammation from [[Jarisch-Herxheimer reaction]].
:* 2. '''Syphilis Among HIV-Infected Persons'''
:::*Note (2): All patients with presumed ocular syphilis should be tested for [[Human Immunodeficiency Virus (HIV)|HIV]], and all should have a [[lumbar puncture]] before starting therapy to exclude concurrent [[neurosyphilis]].
::* 2.1 '''Primary and Secondary Syphilis Among HIV-Infected Persons'''
:'''Syphilis Among HIV-Infected Persons'''
:::* Preferred regimen: [[Benzathine penicillin G]] 2.4 MU IM single dose
::'''Primary and Secondary Syphilis Among HIV-Infected Persons'''
::* 2.2 '''Latent Syphilis Among HIV-Infected Persons'''
::*Preferred regimen: [[Benzathine penicillin G]] 2.4 MU IM single dose<ref name="pmid9235493">{{cite journal| author=Rolfs RT, Joesoef MR, Hendershot EF, Rompalo AM, Augenbraun MH, Chiu M et al.| title=A randomized trial of enhanced therapy for early syphilis in patients with and without human immunodeficiency virus infection. The Syphilis and HIV Study Group. | journal=N Engl J Med | year= 1997 | volume= 337 | issue= 5 | pages= 307-14 | pmid=9235493 | doi=10.1056/NEJM199707313370504 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9235493  }} </ref>
:::* 2.2.1 '''early latent'''
::'''Latent Syphilis Among HIV-Infected Persons'''
::::* Preferred regimen: [[Benzathine penicillin G]] 2.4 MU IM single dose
:::Early latent:
:::* 2.2.2 '''late latent'''
:::*Preferred regimen: [[Benzathine penicillin G]] 2.4 MU IM single dose<ref name="pmid25286091">{{cite journal| author=Yang CJ, Lee NY, Chen TC, Lin YH, Liang SH, Lu PL et al.| title=One dose versus three weekly doses of benzathine penicillin G for patients co-infected with HIV and early syphilis: a multicenter, prospective observational study. | journal=PLoS One | year= 2014 | volume= 9 | issue= 10 | pages= e109667 | pmid=25286091 | doi=10.1371/journal.pone.0109667 | pmc=4186862 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25286091  }} </ref>
::::* Preferred regimen: [[Benzathine penicillin G]] 2.4 MU once a week for 3 weeks
:::Late latent:
::* 2.3 '''Neurosyphilis Among HIV-Infected Persons'''
:::*Preferred regimen: [[Benzathine penicillin G]] 2.4 MU once a week for 3 weeks
:::* Preferred regimen: [[Aqueous crystalline penicillin G]] 18-24 MU per day, administered as 3-4 MU IV q4h or continuous infusion, for 10-14 days
::'''Neurosyphilis Among HIV-Infected Persons'''
:::* Alternative regimen: [[Procaine penicillin]] 2.4 MU IM q24h {{and}} [[Probenecid]] 500 mg PO qid  for 10-14 days
::*Preferred regimen: [[Aqueous crystalline penicillin G]] 18-24 MU per day, administered as 3-4 MU IV q4h or continuous infusion, for 10-14 days
 
::*Alternative regimen: [[Procaine penicillin]] 2.4 MU IM q24h {{and}} [[Probenecid]] 500 mg PO qid  for 10-14 days
:* 3. '''Syphilis During Pregnancy'''
:'''Syphilis During Pregnancy'''
::* Pregnant women should be treated with the [[penicillin]] regimen appropriate for their stage of infection
:*Pregnant women should be treated with the [[penicillin]] regimen appropriate for their stage of infection.
 
:*[[Penicillin#Benzylpenicillin (penicillin G)|Parenteral penicillin G]] is the only therapy with documented efficacy for syphilis. Pregnant women with syphilis in any stage who report penicillin allergy should be desensitized and treated with penicillin  
:* 4. '''Congenital Syphilis in neonates'''
:*The [[Herxheimer reaction|Jarisch-Herxheimer reaction]] is an acute febrile reaction.  
::* 4.1 '''condition1''': Infants with proven or highly probable disease and (1) an abnormal physical examination that is consistent with congenital syphilis;（2）a serum quantitative nontreponemal serologic titer that is fourfold higher than the mother's titer; or（3）a positive darkfield test of body fluid(s).
::*Frequently accompanied by [[headache]], [[myalgia]], [[fever]], and other symptoms that usually occur within the first 24 hours after the initiation of any therapy for syphilis.  
:::* Preferred regimen (1): [[Aqueous crystalline penicillin G]] 100,000-150,000 U/kg/day, administered as 50,000 U/kg/dose IV q12h during the first 7 days of life and q8h thereafter for a total of 10 days
::*Patients should be informed about this possible adverse reaction.  
 
::*The Jarisch-Herxheimer reaction occurs most frequently among patients who have early syphilis, presumably because bacterial burdens are higher during these stages.
:::* Preferred regimen (2): [[Procaine penicillin G]] 50,000 U/kg/dose IM q24h for 10 days
::*[[Antipyretics]] can be used to manage symptoms, but they have not been proven to prevent this reaction.
:::* Note: If more than 1 day of therapy is missed, the entire course should be restarted. Data are insufficient regarding the use of other antimicrobial agents (e.g., ampicillin). When possible, a full 10-day course of penicillin is preferred, even if ampicillin was initially provided for possible sepsis. The use of agents other than penicillin requires close serologic follow-up to assess adequacy of therapy. In all other situations, the maternal history of infection with T. pallidum and treatment for syphilis must be considered when evaluating and treating the infant.
::*The Jarisch-Herxheimer reaction might induce early labor or cause [[fetal distress]] in pregnant women, but this should not prevent or delay therapy.
 
:'''Congenital Syphilis in Neonates'''
::* 4.2 '''condition2''': Infants who have a normal physical examination and a serum quantitive nontreponemal serologic titer the same or less than fourfold the maternal titer and the (1) mother was not treated, inadequately treated, or has no documentation of having received treatment; (2) mother was treated with erythromycin or another nonpenicillin regimen; or (3) mother received treatment <4 weeks before delivery.
::'''Condition 1''': Infants with proven or highly probable disease and (1) an abnormal physical examination that is consistent with congenital syphilis;（2）a serum quantitative nontreponemal serologic titer that is fourfold higher than the mother's titer; or （3）a positive darkfield test of body fluid(s).
:::* Preferred regimen (1): [[Aqueous crystalline penicillin G]] 100,000-150,000 U/kg/day, administered as 50,000 U/kg/dose IV q12h during the first 7 days of life and q8h thereafter for a total of 10 days 
::*Preferred regimen (1): [[Aqueous crystalline penicillin G]] 100,000-150,000 U/kg/day, administered as 50,000 U/kg/dose IV q12h during the first 7 days of life and q8h thereafter for a total of 10 days
 
::*Preferred regimen (2): [[Procaine penicillin G]] 50,000 U/kg/dose IM q24h for 10 days
:::* Preferred regimen (2): [[Procaine penicillin G]] 50,000 U/kg/dose IM q24h for 10 days 
::*Note: If more than 1 day of therapy is missed, the entire course should be restarted. Data are insufficient regarding the use of other antimicrobial agents (e.g., [[ampicillin]]). When possible, a full 10-day course of penicillin is preferred, even if ampicillin was initially provided for possible sepsis. The use of agents other than penicillin requires close serologic follow-up to assess adequacy of therapy. In all other situations, the maternal history of infection with ''T. pallidum'' and treatment for syphilis must be considered when evaluating and treating the infant.
 
::'''Condition 2''': Infants who have a normal physical examination and a serum quantitative nontreponemal serologic titer the same or less than fourfold the maternal titer and the (1) mother was not treated, inadequately treated, or has no documentation of having received treatment; (2) mother was treated with [[erythromycin]] or another non-penicillin regimen; or (3) mother received treatment <4 weeks before delivery.
:::* Preferred regimen (3): [[Benzathine penicillin G]] 50,000 U/kg/dose IM single dose
::*Preferred regimen (1): [[Aqueous crystalline penicillin G]] 100,000-150,000 U/kg/day, administered as 50,000 U/kg/dose IV q12h during the first 7 days of life and q8h thereafter for a total of 10 days
:::* Note: If the mother has untreated early syphilis at delivery, 10 days of parenteral therapy can be considered
::*Preferred regimen (2): [[Procaine penicillin G]] 50,000 U/kg/dose IM q24h for 10 days
 
::*Preferred regimen (3): [[Benzathine penicillin G]] 50,000 U/kg/dose IM single dose
::* 4.3 '''condition3''': Infants who have a normal physical examination and a serum quantitative nontreponemal serologic titer the same or less than fourfold the maternal titer and the (1) mother was treated during pregnancy, treatment was appropriate for the stage of infection, and treatment was administered >4 weeks before delivery and (2) mother has no evidence of reinfection or relapse.
::*Note: If the mother has untreated early syphilis at delivery, 10 days of parenteral therapy can be considered
:::* Preferred regimen: [[Benzathine penicillin G]] 50,000 U/kg/dose IM single dose
::'''Condition 3''': Infants who have a normal physical examination and a serum quantitative nontreponemal serologic titer the same or less than fourfold the maternal titer and the (1) mother was treated during pregnancy, treatment was appropriate for the stage of infection, and treatment was administered >4 weeks before delivery; and (2) mother has no evidence of reinfection or relapse.
::*Preferred regimen: [[Benzathine penicillin G]] 50,000 U/kg/dose IM single dose
::'''Condition 4''': Infants who have a normal physical examination and a serum quantitative nontreponemal serologic titer the same or less than fourfold the maternal titer and the (1) mother's treatment was adequate before pregnancy; and (2) mother's nontreponemal serologic titer remained low and stable before and during pregnancy and at delivery (VDRL <1:2; RPR <1:4).
::*No treatment is required
::*[[Benzathine penicillin G]] 50,000 U/kg IM single dose might be considered, particularly if follow-up is uncertain.
:'''Congenital Syphilis in infants and children'''
:*Preferred regimen: [[Aqueous crystalline penicillin G]] 50,000 U/kg q4–6h for 10 days


::* 4.4 '''condition4''': Infants who have a normal physical examination and a serum quantitative nontreponemal serologic titer the same or less than fourfold the maternal titer and the (1) mother's treatment was adequate before pregnancy; and (2) mother's nontreponemal serologic titer remained low and stable before and during pregnancy and at delivery (VDRL <1:2; RPR <1:4).
==Approach to Diagnosis and Management of Syphilis==
:::* No treatment is required
:::* [[Benzathine penicillin G]] 50,000 U/kg IM single dose might be considered, particularly if follow-up is uncertain.


:* 5. '''Congenital Syphilis in infants and children'''
{{Family tree/start}}
:::* Preferred regimen: [[Aqueous crystalline penicillin G]] 50,000 U/kg q4–6h for 10 days
{{Family tree | | | | | | | | | | | | | | A01 | | | | | | | | | | | | |A01=Positive syphilis screening test}}
{{Family tree | | | | | | | | | | | | | | |!| | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | B01 | | | | | | | | | | | | |B01=Perform treponemal-specific test}}
{{Family tree | | | | | | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|.| | | | | | | }}
{{Family tree | | | | | | | C01 | | | | | | | | | | | | C02 | | | | | |C01=Positive treponemal-specific test|C02=Negative treponemal-specific test}}
{{Family tree | | | | | | | |!| | | | | | | | | | | |,|-|^|-|.| | | | |}}
{{Family tree | | | | | | | D01 | | | | | | | | | | D02 | | D03 | | | |D01=Establish stage of infection; obtain quantitative nontreponemal test titres|D02=Primary syphilis suspected|D03=False-positive test result suspected}}
{{Family tree | | |,|-|-|-|-|+|-|-|-|-|-|.| | | | | |!| | | |!| | | | |}}
{{Family tree | | E01 | | | E02 | | | | E03 | | | | E04 | | E05 | | | |E01=Signs or symptoms of primary or secondary syphilis|E02=No clinical signs or symptoms (latent syphilis)|E03=Signs or symptoms of tertiary (late) syphilis, or patient is HIC positive or otherwise immunocompromised|E04=Obtain quantitative nontreponemal test titres|E05=Consider other causes}}
{{Family tree | | |!| | |,|-|^|-|.| | | | | | | | | |!| | | | | | | | |}}
{{Family tree | | |!| | F01 | | F02 | | F03 | | | | F04 | | | | | | | |F01=Early latent syphilis|F02=Late latent syphilis|F03=Lumbar puncture|F04=Penicillin G benzazthine, 2.4 million units IM (single dose)<sup>*</sup>}}
{{Family tree | | |!| |!| | | | |!| | | |!| | | | | |!| | | | | | | | |}}
{{Family tree | | | G01 | | | | G02 | | |!| | | | | G03 | | | | | | |G01=Penicillin G benzazthine, 2.4 million units IM (single dose)*|G02=Penicillin G benzazthine, 2.4 million units IM once a week for 3 weeks (three doses)<sup>**</sup>|G03=Signs, symptoms, or CSF findings consistent with neurosyphilis}}
{{Family tree | | | | | | | | | | | | | |!| | | | | | | | | | | | | | }}
{{Family tree | | | | | | | | | |,|-|-|-|^|-|-|-|.| | | | | | | | | |}}
{{Family tree | | | | | | | | | H01 | | | | | | H02 | | | | | | | | |H01=Yes|H02=No}}
{{Family tree | | | | | | | |,|-|^|-|.| | | | | |!| | | | | | | | |}}
{{Family tree | | | | | | | I01 | | I02 | | | | I03 | | | | | | | |I01=No penicillin allergy|I02=Penicillin allergy|I03=Unvolve appropriate subspecialists. Penicillin G benzazthine, 2.4 million units IM once a week for 3 weeks (three doses)<sup>**</sup>}}
{{Family tree | | | | | | | | |!| | |!| | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | |!| | J01 | | | | | | | | | | | | | |J01=Desensitization}}
{{Family tree | | | | | | | | |!| |!| | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | K01 | | | | | | | | | | | | | | | |K01=Aqueous crystalline penicillin G, 3 to 4 million units IV every 4 hours for 10 to 14 days; or penicillin G procaine, 2.4 million units once daily, plus 500 mg of probenecid orally four times daily for 10 to 14 days}}
{{Family tree/end}}


==References==
==References==
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Latest revision as of 00:23, 30 July 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Aysha Anwar, M.B.B.S[2]; Nate Michalak, B.A.

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Overview

Penicillin G, administered parenterally, is the preferred drug for treating all stages of syphilis. If the patient is allergic, then Tetracycline or doxycycline may also be used. During pregnancy, parenteral penicillin G is the only therapy with documented efficacy for syphilis. The Jarisch-Herxheimer reaction is an acute adverse febrile reaction that may occur after initiation of therapy for syphilis.

Medical Therapy

  • The preparation used (i.e., benzathine, aqueous procaine, or aqueous crystalline), the dosage, and the length of treatment depend on the stage and clinical manifestations of the disease.
  • Treatment for longer duration is required in patients with late latent, latent with unknown duration and tertiary syphilis.
  • Selection of the appropriate penicillin preparation is important, because T. pallidum can reside in sequestered sites (e.g., the CNS and aqueous humor) that are poorly accessed by some forms of penicillin.
  • Combinations of benzathine penicillin, procaine penicillin, and oral penicillin preparations are not considered appropriate for the treatment of syphilis.[2]

Pharmacotherapy

Syphilis Among non-HIV-Infected Persons[3]
Primary and Secondary Syphilis
Latent Syphilis
Early Latent Syphilis:
Late Latent Syphilis or Latent Syphilis of Unknown Duration:
  • Preferred regimen: Benzathine penicillin G 7.2 MU total, administered as 3 doses of 2.4 MU IM each at 1 week intervals
  • Pediatric regimen: Benzathine penicillin G 50,000 U/kg IM (Maximum, 2.4 MU), administered as 3 doses at 1 week intervals (total 150,000 U/kg up to the adult total dose of 7.2 MU)
Tertiary Syphilis
  • Preferred regimen: Benzathine penicillin G 7.2 MU total, administered as 3 doses of 2.4 MU IM each at 1 week intervals
Ocular syphilis
Pathogen-directed antimicrobial therapy:[4]
Syphilis Among HIV-Infected Persons
Primary and Secondary Syphilis Among HIV-Infected Persons
Latent Syphilis Among HIV-Infected Persons
Early latent:
Late latent:
Neurosyphilis Among HIV-Infected Persons
Syphilis During Pregnancy
  • Pregnant women should be treated with the penicillin regimen appropriate for their stage of infection.
  • Parenteral penicillin G is the only therapy with documented efficacy for syphilis. Pregnant women with syphilis in any stage who report penicillin allergy should be desensitized and treated with penicillin
  • The Jarisch-Herxheimer reaction is an acute febrile reaction.
  • Frequently accompanied by headache, myalgia, fever, and other symptoms that usually occur within the first 24 hours after the initiation of any therapy for syphilis.
  • Patients should be informed about this possible adverse reaction.
  • The Jarisch-Herxheimer reaction occurs most frequently among patients who have early syphilis, presumably because bacterial burdens are higher during these stages.
  • Antipyretics can be used to manage symptoms, but they have not been proven to prevent this reaction.
  • The Jarisch-Herxheimer reaction might induce early labor or cause fetal distress in pregnant women, but this should not prevent or delay therapy.
Congenital Syphilis in Neonates
Condition 1: Infants with proven or highly probable disease and (1) an abnormal physical examination that is consistent with congenital syphilis;（2）a serum quantitative nontreponemal serologic titer that is fourfold higher than the mother's titer; or （3）a positive darkfield test of body fluid(s).
  • Preferred regimen (1): Aqueous crystalline penicillin G 100,000-150,000 U/kg/day, administered as 50,000 U/kg/dose IV q12h during the first 7 days of life and q8h thereafter for a total of 10 days
  • Preferred regimen (2): Procaine penicillin G 50,000 U/kg/dose IM q24h for 10 days
  • Note: If more than 1 day of therapy is missed, the entire course should be restarted. Data are insufficient regarding the use of other antimicrobial agents (e.g., ampicillin). When possible, a full 10-day course of penicillin is preferred, even if ampicillin was initially provided for possible sepsis. The use of agents other than penicillin requires close serologic follow-up to assess adequacy of therapy. In all other situations, the maternal history of infection with T. pallidum and treatment for syphilis must be considered when evaluating and treating the infant.
Condition 2: Infants who have a normal physical examination and a serum quantitative nontreponemal serologic titer the same or less than fourfold the maternal titer and the (1) mother was not treated, inadequately treated, or has no documentation of having received treatment; (2) mother was treated with erythromycin or another non-penicillin regimen; or (3) mother received treatment <4 weeks before delivery.
  • Preferred regimen (1): Aqueous crystalline penicillin G 100,000-150,000 U/kg/day, administered as 50,000 U/kg/dose IV q12h during the first 7 days of life and q8h thereafter for a total of 10 days
  • Preferred regimen (2): Procaine penicillin G 50,000 U/kg/dose IM q24h for 10 days
  • Preferred regimen (3): Benzathine penicillin G 50,000 U/kg/dose IM single dose
  • Note: If the mother has untreated early syphilis at delivery, 10 days of parenteral therapy can be considered
Condition 3: Infants who have a normal physical examination and a serum quantitative nontreponemal serologic titer the same or less than fourfold the maternal titer and the (1) mother was treated during pregnancy, treatment was appropriate for the stage of infection, and treatment was administered >4 weeks before delivery; and (2) mother has no evidence of reinfection or relapse.
Condition 4: Infants who have a normal physical examination and a serum quantitative nontreponemal serologic titer the same or less than fourfold the maternal titer and the (1) mother's treatment was adequate before pregnancy; and (2) mother's nontreponemal serologic titer remained low and stable before and during pregnancy and at delivery (VDRL <1:2; RPR <1:4).
  • No treatment is required
  • Benzathine penicillin G 50,000 U/kg IM single dose might be considered, particularly if follow-up is uncertain.
Congenital Syphilis in infants and children

Approach to Diagnosis and Management of Syphilis

 
 
 
 
 
 
 
 
 
 
 
 
 
Positive syphilis screening test
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Perform treponemal-specific test
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Positive treponemal-specific test
 
 
 
 
 
 
 
 
 
 
 
Negative treponemal-specific test
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Establish stage of infection; obtain quantitative nontreponemal test titres
 
 
 
 
 
 
 
 
 
Primary syphilis suspected
 
False-positive test result suspected
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Signs or symptoms of primary or secondary syphilis
 
 
No clinical signs or symptoms (latent syphilis)
 
 
 
Signs or symptoms of tertiary (late) syphilis, or patient is HIC positive or otherwise immunocompromised
 
 
 
Obtain quantitative nontreponemal test titres
 
Consider other causes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Early latent syphilis
 
Late latent syphilis
 
Lumbar puncture
 
 
 
Penicillin G benzazthine, 2.4 million units IM (single dose)*
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Penicillin G benzazthine, 2.4 million units IM (single dose)*
 
 
 
Penicillin G benzazthine, 2.4 million units IM once a week for 3 weeks (three doses)**
 
 
 
 
 
 
 
 
Signs, symptoms, or CSF findings consistent with neurosyphilis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No penicillin allergy
 
Penicillin allergy
 
 
 
Unvolve appropriate subspecialists. Penicillin G benzazthine, 2.4 million units IM once a week for 3 weeks (three doses)**
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Desensitization
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Aqueous crystalline penicillin G, 3 to 4 million units IV every 4 hours for 10 to 14 days; or penicillin G procaine, 2.4 million units once daily, plus 500 mg of probenecid orally four times daily for 10 to 14 days
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

References

  1. ↑ http://www.cdc.gov/std/tg2015/syphilis.htm Accessed on September 26, 2016
  2. ↑ http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5409a1.htm
  3. ↑ Workowski KA, Bolan GA (2015). "Sexually transmitted diseases treatment guidelines, 2015". MMWR. Recommendations and Reports : Morbidity and Mortality Weekly Report. Recommendations and Reports / Centers for Disease Control. 64 (RR-03): 1–137. PMID 26042815.
  4. ↑ Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
  5. ↑ Rolfs RT, Joesoef MR, Hendershot EF, Rompalo AM, Augenbraun MH, Chiu M; et al. (1997). "A randomized trial of enhanced therapy for early syphilis in patients with and without human immunodeficiency virus infection. The Syphilis and HIV Study Group". N Engl J Med. 337 (5): 307–14. doi:10.1056/NEJM199707313370504. PMID 9235493.
  6. ↑ Yang CJ, Lee NY, Chen TC, Lin YH, Liang SH, Lu PL; et al. (2014). "One dose versus three weekly doses of benzathine penicillin G for patients co-infected with HIV and early syphilis: a multicenter, prospective observational study". PLoS One. 9 (10): e109667. doi:10.1371/journal.pone.0109667. PMC 4186862. PMID 25286091.


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