Parenteral penicillin G is the only therapy with documented efficacy for syphilis during pregnancy. Pregnant women with syphilis in any stage who report penicillin allergy should be desensitized and treated with penicillin. Skin testing for penicillin allergy may be useful in pregnant women; such testing also is useful in other patients
Primary and Secondary Syphilis
Treatment
- Parenteral penicillin G has been used effectively for more than 50 years to achieve clinical resolution (i.e., healing of lesions and prevention of sexual transmission) and to prevent late sequelae.
Recommended Regimen for Adults
Benzathine penicillin G 2.4 million units IM in a single dose
Recommended Regimen for Children
Children with acquired primary or secondary syphilis should be evaluated (e.g., through consultation with child-protection services) and treated by using the following pediatric regimen.
Benzathine penicillin G 50,000 units/kg IM, up to the adult dose of 2.4 million units in a single dose.
Follow-Up
- Patients should be reexamined clinically and serologically 6 months and 12 months following treatment; more frequent evaluation may be prudent if follow-up is uncertain
- Patients who have signs or symptoms that persist or recur or who have a sustained fourfold increase in nontreponemal test titer probably failed treatment or were reinfected. These patients should be re-treated and reevaluated for HIV infection
- Because treatment failure usually cannot be reliably distinguished from reinfection with T. pallidum, a CSF analysis also should be performed
- Failure of nontreponemal test titers to decline fourfold within 6 months after therapy for primary or secondary syphilis is indicative of probable treatment failure. Persons for whom titers remain serofast should be reevaluated for HIV infection. Optimal management of such patients is unclear. At a minimum, these patients should have additional clinical and serologic follow-up. HIV-infected patients should be evaluated more frequently. If additional follow-up cannot be ensured, re-treatment is recommended. Because treatment failure may be the result of unrecognized CNS infection, some specialists recommend CSF examination in such situations.
- When patients are re-treated, most STD specialists recommend administering weekly injections of benzathine penicillin G 2.4 million units IM for 3 weeks, unless CSF examination indicates that neurosyphilis is present. In rare instances, serologic titers do not decline despite a negative CSF examination and a repeated course of therapy. Additional therapy or repeated CSF examinations are not warranted in these circumstances.
Latent Syphilis
- Patients can be diagnosed as having early latent syphilis if, within the year preceding the evaluation, they had:
- Documented seroconversion
- Unequivocal symptoms of primary or secondary syphilis
- A sex partner documented to have primary, secondary, or early latent syphilis
- Patients who have latent syphilis of unknown duration should be managed as if they have late latent syphilis
- Nontreponemal serologic titers usually are higher during early latent syphilis than late latent syphilis. However, early latent syphilis cannot be reliably distinguished from late latent syphilis solely on the basis of nontreponemal titers
- All patients with latent syphilis should have careful examination of all accessible mucosal surfaces to evaluate for internal mucosal lesions
Treatment
Recommended Regimens for Adults
Early Latent Syphilis
Benzathine penicillin G 2.4 million units IM in a single dose.
Late Latent Syphilis or Latent Syphilis of Unknown Duration
Benzathine penicillin G 7.2 million units total, administered as three doses of 2.4 million units IM each at 1-week intervals.
Recommended Regimens for Children
Early Latent Syphilis
Benzathine penicillin G 50,000 units/kg IM, up to the adult dose of 2.4 million units in a single dose.
Late Latent Syphilis or Latent Syphilis of Unknown Duration
Benzathine penicillin G 50,000 units/kg IM, up to the adult dose of 2.4 million units, administered as three doses at 1-week intervals (total 150,000 units/kg up to the adult total dose of 7.2 million units).
Tertiary Syphilis
Recommended Regimen
Benzathine penicillin G 7.2 million units total, administered as three doses of 2.4 million units IM each at 1-week intervals.
Syphilis During Pregnancy
Diagnostic Considerations
Seropositive pregnant women should be considered infected unless an adequate treatment history is documented in the medical records and sequential serologic antibody titers have declined.
Treatment
Penicillin is effective for preventing maternal transmission to the fetus and for treating fetal infection. Evidence is insufficient to determine whether the specific, recommended penicillin regimens are optimal.
Recommended Regimen
Treatment during pregnancy should consist of the penicillin regimen appropriate for the stage of syphilis.
