Syphilis Organism-Specific Therapy 

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Syphilis is a disease that is caused by Treponema pallidum. The treatment recommendations for syphilis are categorized by stage, such as primary (ulcer or chancre), secondary (skin rash, mucocutaneous lesions, and lymphadenopathy), tertiary (cardiac or gummatous lesions), or neurologic (cranial nerve dysfunction, meningitis, stroke, acute or chronic altered mental status, loss of vibration sense, auditory or ophthalmic abnormalities). ^{[1, 2]}

Latent syphilis (ie, without symptoms) is detected by serological testing and is divided into early latent syphilis (acquired within the preceding year) and late latent syphilis or latent syphilis of unknown origin. ^[1]

Penicillin is the treatment of choice for all stages of syphilis, with the type of penicillin and dosing based on clinical staging of the disease. ^[1] However, it is important to be sure to order the appropriate formulation of penicillin. Alternatives to penicillin may be used, but should be used with caution. ^[1]

Benzathine penicillin G 2.4 million units IM for 1 dose ^[1]

Retreatment: benzathine penicillin G 2.4 million units IM once weekly for 3 weeks

Pediatric dosing: Benzathine penicillin G 50,000 units/kg IM, up to the adult dose of 2.4 million units for 1 dose ^[1]

Benzathine penicillin G 2.4 million units IM for 1 dose ^[1]

Pediatric dosing: Benzathine penicillin G 50,000 units/kg IM, up to the adult dose of 2.4 million units for 1 dose ^[1]

Benzathine penicillin G 2.4 million units IM once weekly for 3 weeks ^[1]

Pediatric dosing: Benzathine penicillin G 50,000 units/kg IM, up to the adult dose of 2.4 million units, once weekly for 3 weeks ^[1]

Benzathine penicillin G 2.4 million units IM once weekly for 3 weeks ^[1]

First-line therapy ^[1]

Aqueous crystalline penicillin G 18-24 million units divided into 3-4 million units IV q4h or continuous infusion for 10-14 days

Second-line therapy

Procaine penicillin 2.4 million units IM daily plus probenecid 500 mg PO QID for 10-14 days

Primary, secondary, or early latent syphilis ^[1]

Doxycycline 100 mg PO q12h for 14d or

Tetracycline 500 mg PO QID for 14d or

Azithromycin 2000 mg PO single dose (see below) or

Ceftriaxone 250 mg IM/IV qd for 10-14 days

Late latent syphilis

Doxycycline 100 mg PO q12h for 28d or

Tetracycline 500 mg PO QID for 28d

Pregnancy, tertiary syphilis, or neurosyphilis

Desensitize and treat with appropriate penicillin regimen

Persons who were exposed within the 90 days preced­ing the diagnosis of primary, secondary, or early latent syphilis in a sex partner might be infected even if seronegative; therefore, such persons should be treated presumptively. ^[1]

Persons who were exposed > 90 days before the diagnosis of primary, secondary, or early latent syphilis in a sex partner should be treated presumptively if serologic test results are not available immediately and the opportunity for follow-up is uncertain.

Patients with syphilis of unknown duration who have high nontreponemal serologic test titers (i.e. > 1:32) can be assumed to have early syphilis.

Long-term sex partners of patients who have latent syphilis should be evaluated clinically and serologically for syphilis and treated on the basis of the evaluation findings.

Sex partners of infected patients should be considered at risk and provided treatment if they have had sexual contact with the patient within 3 months plus the duration of symp­toms for patients diagnosed with primary syphilis, within 6 months plus the duration of symptoms for patients with secondary syphilis, and within 1 year for patients with early latent syphilis.

All patients diagnosed with syphilis should be screened for the human immunodeficiency virus (HIV).

Pregnant women and HIV-infected patients should be treated with the penicillin regimen appropriate for their stage of infection.

Pregnant women who have a history of penicillin allergy should be desensitized and treated with penicillin.

Patients should have follow-up testing at 6 and 12 months for early syphilis (primary, secondary, and early latent). Patients should have follow-up testing at 6, 12, and 24 months for late latent or latent syphilis of unknown duration. ^[1]

Patients with neurosyphilis should have repeat CSF testing every 6 months until cell count is normal. ^[1]

HIV-positive patients should be treated the same as HIV-negative patients in all stages of syphilis. ^[1]

All patients with syphilis should be tested for HIV infection if their HIV status is unknown. If the geographic area has a high prevalence for HIV, the patient should be retested for acute HIV infection if the initial HIV test was negative.

Doxycycline is the preferred second-line agent if penicillin cannot be given. Ceftriaxone may also be given, but it has not been studied as thoroughly. ^[1]

Azithromycin has been shown to be as effective as penicillin in early syphilis. ^[3] However, resistance to azithromycin has been reported, and it should only be used when penicillin or doxycycline are not feasible. ^{[1, 4]} Azithromycin should not be used in men who have sex with men. ^[1]

Jarisch-Herxheimer reaction may occur within the first 24 hours after the initiation of any therapy for syphilis. It is an acute febrile reaction frequently accompanied by headache, myalgia, fever, and other symptoms. This can be treated symptomatically with antipyretics. ^[1]

[Guideline] Workowski KA, Berman S. Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep. 2010 Dec 17. 59:1-110. [Medline].

Euerle B, Chandrasekar PH, Diaz MM, et al. Syphillis. Medscape Reference. Available at http://emedicine.medscape.com/article/229461-overview. Accessed: July 1, 2013.

Bai ZG, Wang B, Yang K, Tian JH, Ma B, Liu Y, et al. Azithromycin versus penicillin G benzathine for early syphilis. Cochrane Database Syst Rev. 2012 Jun 13. 6:CD007270. [Medline].

Azithromycin treatment failures in syphilis infections–San Francisco, California, 2002-2003. MMWR Morb Mortal Wkly Rep. 2004 Mar 12. 53(9):197-8. [Medline].

Bruce M Lo, MD, MBA, CPE, RDMS, FACEP, FAAEM, FACHE Medical Director, Department of Emergency Medicine, Sentara Norfolk General Hospital; Professor and Assistant Program Director, Core Academic Faculty, Department of Emergency Medicine, Eastern Virginia Medical School

Bruce M Lo, MD, MBA, CPE, RDMS, FACEP, FAAEM, FACHE is a member of the following medical societies: American Academy of Emergency Medicine, American Association for Physician Leadership, American College of Emergency Physicians, American College of Healthcare Executives, American Institute of Ultrasound in Medicine, Emergency Nurses Association, Medical Society of Virginia, Norfolk Academy of Medicine, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Jasmeet Anand, PharmD, RPh Adjunct Instructor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Thomas E Herchline, MD Professor of Medicine, Wright State University, Boonshoft School of Medicine; Medical Consultant, Public Health, Dayton and Montgomery County (Ohio) Tuberculosis Clinic

Thomas E Herchline, MD is a member of the following medical societies: Alpha Omega Alpha, Infectious Diseases Society of America, Infectious Diseases Society of Ohio

Disclosure: Nothing to disclose.

Kelley Struble, DO Fellow, Department of Infectious Diseases, University of Oklahoma College of Medicine

Kelley Struble, DO is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Syphilis Organism-Specific Therapy 

Research & References of Syphilis Organism-Specific Therapy |A&C Accounting And Tax Services
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