Treatment of primary or secondary syphilis

A. Primary or secondary syphilis. Benzathine penicillin G, 2.4 million units IM in a single dose.

B. Patients who have syphilis and who also have symptoms or signs suggesting neurologic disease (meningitis) or ophthalmic disease (uveitis) should be fully evaluated for neurosyphilis and syphilitic eye disease (CSF analysis and ocular slit-lamp examination).

C. Penicillin allergic patients. Doxycycline 100 mg PO 2 times a day for 2


D. Follow-up and retreatment

1. Early syphilis--repeat VDRL at 3, 6, and 12 months to ensure that titers are declining.

2. Syphilis >1 year--also repeat VDRL at 24 months.

3. Neurosyphilis-- also repeat VDRL for 3 years.

4. Indications for retreatment a. Clinical signs or symptoms persist or recur.

b. 4-fold increase in the titer of a nontreponemal test (VDRL).

c. Failure of an initially high titer nontreponemal test (VDRL) to show a 4-fold decrease within a year.

5. Sex partners should be evaluated and treated.

IV. Treatment of latent syphilis

A. Patients who have latent syphilis who have acquired syphilis within the preceding year are classified as having early latent syphilis. Latent syphilis of unknown duration should be managed as late latent syphilis.

B. Treatment of early latent syphilis. Benzathine penicillin G, 2.4 million units IM in a single dose.

C. Treatment of late latent syphilis or latent syphilis of unknown duration Benzathine penicillin G 2.4 million units IM each week x 3 weeks.

D. All patients should be evaluated clinically for evidence of late syphilis (aortitis, neurosyphilis, gumma, iritis).

E. Indications for CSF examination before treatment

1. Neurologic or ophthalmic signs or symptoms

2. Other evidence of active syphilis (aortitis, gumma, iritis)

3. Treatment failure

4. HIV infection

5. Serum nontreponemal titer >1:32, unless duration of infection is known to be <1 year

6. Nonpenicillin therapy planned, unless duration of infection is known to be <1 year.

F. CSF examination includes cell count, protein, and CSF-VDRL. If a CSF examination is performed and the results are abnormal, the patient should be treated for neurosyphilis.

V. Treatment of late syphilis

A. Benzathine penicillin G 2.4 million units IM weekly x 3 weeks. Penicillin allergic patients are treated with doxycycline 100 mg PO bid x 4 weeks.

B. Patients with late syphilis should undergo CSF examination before therapy.

VI. Treatment of neurosyphilis

A. Central nervous system disease can occur during any stage of syphilis. Clinical evidence of neurologic involvement (eg, ophthalmic or auditory symptoms, cranial nerve palsies) warrants a CSF examination. Patients with CSF abnormalities should have follow-up CSF examinations to assess response to treatment.

B. Treatment of neurosyphilis. Penicillin G 2-4 million units IV q4h for 10-14 days. Alternatively, penicillin G procaine 2.4 million units IM daily plus probenecid 500 mg PO qid, both for 10-14 days can be used.

C. Follow-up. If CSF pleocytosis was present initially, CSF examination should be repeated every 6 months until the cell count is normal. Follow-up CSF examinations also may be used to evaluate changes in the VDRL-CSF or CSF protein in response to therapy.

References: See page 195.

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