Dr Kieran Mutimer
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Clinical
Aboriginal Health
Sexual HealthSyphilis Treatment Options
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Procaine penicillin
The gold standard for treatment of syphilis is consecutive daily intramuscular injections with procaine penicillin. The dosage and duration of treatment are determined by the clinical presentation. e.g. chancre, secondary mucocutaneous manifestations, neurosyphilis, etc. If no clinical staging is possible (as is usually the case), serological staging (e.g. RPR or VDRL titres) determines the treatment regime. There are a number of treatment options for patients who are allergic to penicillin, who are needle-phobic or who may not comply with a course of daily injections. These treatment options have not been as well studied as the procaine penicillin regimes but are totally acceptable alternatives.Benzathine penicillin
The role of benzathine penicillin in the treatment of syphilis warrants special mention. Benzathine penicillin (marketed in Australia by Wyeth as bicillin L-A 1.8gm/4ml syringe) for I.M. injection as a single injection will adequately treat primary and secondary syphilis, or sero positive syphilis with a VDRL or RPR titre of 1:16 or higher. This regime is much more user friendly than a 10 day use of I.M. procaine penicillin and compliance is not an issue. This same dose can be given to sexual contacts of the above groups as epidemiological treatment. As benzathine penicillin DOES NOT cross the blood brain barrier it is only suitable for use in treating latent syphilis (VDRL or RPR titre< 8) if the C.S.F. is normal. Benzathine penicillin DOES cross the placenta and is therefore suitable for treating pregnant women with early syphilis.
Syphilis and the pregnant patient
All pregnant women should be screened at least once for syphilis during early pregnancy. If the non-specific screening test is positive exposure to syphilis should be confirmed with a positive TPHA or FTA-ABS. There is a high incidence of syphilis among Aboriginal women and a number of babies with congenital syphilis have been born at Lismore Base Hospital in recent years. These patients should be re-screened in the third trimester to exclude recent infection.
If there has been no antenatal screening mother and baby should be screened at the time of birth and followed up in the postnatal period.
Maternally acquired antibodies will be detectable in on-infected infants for some months after delivery. Advice from the pathologist, paediatrician, obstetrician or sexual health service can be obtained if there is doubt about interpreting neonatal syphilis serology.
Penicillin is the drug of choice for treatment of the pregnant woman with the aforementioned treatment regimes being appropriate. Pregnant patients who are allergic to penicillin should be desensitized in hospital prior to treatment.
Alternative treatment regimes
Non pregnant patients allergic to penicillin may be treated with doxycycline 300mg daily for 21 days. This regime is considered adequate for treatment of early and late disease, whether symptomatic or latent.
This regime would also be appropriate for needle-phobic patients, as would oral amoxycillin 3gm twice daily with 1 gm of probenecid for 2 weeks.
Patients with coincident HIV infection
These patients are best referred for a specialist opinion. Higher antibiotic
doses of longer duration are required.
Summary
Early syphilis - primary, secondary and early latent (<2 years duration)
Latent syphilis (> 2 years duration)
Neurosyphilis (or where CSF examination not performed)
Congenital syphilis
Many syphilis treatment regimes vary slightly from one reference to the
next. If in doubt please consult your local sexual health service for further information.
Dr Kieran Mutimer
SHAIDS
Lismore NSW
Phone 6620 2980
Email: shaids@nor.com.au
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