Warning:

This document is being maintained for historical purposes, but is now out of date. To view current guidelines please visit:

• STD Treatment Guidelines   at http://www.cdc.gov/STD/treatment

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1993 Sexually Transmitted Diseases Treatment Guidelines

09/24/1993

SUGGESTED CITATION
Centers for Disease Control and Prevention. 1993 Sexually
transmitted diseases treatment guidelines. MMWR 1993;42(No. RR-14):
{inclusive page numbers}.

CIO Responsible for this publication:
National Center for Prevention Services,
Division of Sexually Transmitted Diseases and HIV Prevention

General Principles

Background -
     
     Syphilis is a systemic disease caused by T. pallidum. Patients
with syphilis may seek treatment for signs or symptoms of primary
infection (ulcer or chancre at site of infection), secondary
infection (manifestations that include rash, mucocutaneous lesions,
and adenopathy), or tertiary infection (cardiac, neurologic,
ophthalmic, auditory, or gummatous lesions). Infections also may be
detected during the latent stage by serologic testing. Patients
with latent syphilis who are known to have been infected within the
preceding year are considered to have early latent syphilis; others
have late latent syphilis or syphilis of unknown duration.
Theoretically, treatment for late latent syphilis (as well as
tertiary syphilis) requires therapy of longer duration because
organisms are dividing more slowly; however, the validity of this
division and its timing are unproven.

Diagnostic Considerations and Use of Serologic Tests -
     
     Darkfield examinations and direct fluorescent antibody tests
of lesion exudate or tissue are the definitive methods for
diagnosing early syphilis. Presumptive diagnosis is possible with
the use of two types of serologic tests for syphilis: a)
nontreponemal (e.g., Venereal Disease Research Laboratory {VDRL}
and RPR, and b) treponemal (e.g., fluorescent treponemal antibody
absorbed {FTA-ABS} and microhemagglutination assay for antibody to
T. pallidum {MHA-TP}). The use of one type of test alone is not
sufficient for diagnosis. Nontreponemal test antibody titers
usually correlate with disease activity, and results should be
reported quantitatively. A fourfold change in titer, equivalent to
a change of two dilutions (e.g., from 1:16 to 1:4, or from 1:8 to
1:32), is necessary to demonstrate a substantial difference between
two nontreponemal test results that were obtained using the same
serologic test. A patient who has a reactive treponemal test
usually will have a reactive test for a lifetime, regardless of
treatment or disease activity (15%-25% of patients treated during
the primary stage may revert to being serologically nonreactive
after 2-3 years). Treponemal test antibody titers correlate poorly
with disease activity and should not be used to assess response to
treatment.

     Sequential serologic tests should be performed using the same
testing method (e.g., VDRL or RPR) by the same laboratory. The VDRL
and RPR are equally valid, but quantitative results from the two
tests cannot be directly compared because RPR titers are often
slightly higher than VDRL titers.

     Abnormal results of serologic testing (unusually high,
unusually low, and fluctuating titers) have been observed among
HIV-infected patients. For such patients, use of other tests (e.g.,
biopsy and direct microscopy) should be considered. However,
serologic tests appear to be accurate and reliable for the
diagnosis of syphilis and for evaluation of treatment response for
the vast majority of HIV-infected patients.

     No single test can be used to diagnose neurosyphilis among all
patients. The diagnosis of neurosyphilis can be made based on
various combinations of reactive serologic test results,
abnormalities of cerebrospinal fluid (CSF) cell count or protein,
or a reactive VDRL-CSF (RPR is not performed on CSF) with or
without clinical manifestations. The CSF leukocyte count is usually
elevated ( greater than 5 WBC/mm3) when active neurosyphilis is
present, and it is also a sensitive measure of the effectiveness of
therapy. The VDRL-CSF is the standard serologic test for CSF; when
reactive in the absence of substantial contamination of the CSF
with blood, it is considered diagnostic of neurosyphilis. However,
the VDRL-CSF may be nonreactive when neurosyphilis is present. Some
experts recommend performing an FTA-ABS test on CSF. The CSF
FTA-ABS is less specific (i.e., yields more false positives) for
neurosyphilis than the VDRL-CSF; however, the test is believed to
be highly sensitive.

Treatment -
     
     Parenteral penicillin G is the preferred drug for treatment of
all stages of syphilis. The preparation(s) used (i.e., benzathine,
aqueous procaine, or aqueous crystalline), the dosage, and the
length of treatment depend on the stage and clinical manifestations
of disease.

     The efficacy of penicillin for the treatment of syphilis was
well established through clinical experience before the value of
randomized controlled clinical trials was recognized. Therefore,
nearly all the recommendations for the treatment of syphilis are
based on expert opinion reinforced by case series, open clinical
trials, and 50 years of clinical experience.

     Parenteral penicillin G is the only therapy with documented
efficacy for neurosyphilis or for syphilis during pregnancy.
Patients with neurosyphilis and pregnant women with syphilis in any
stage who report penicillin allergy should almost always be treated
with penicillin, after desensitization, if necessary. Skin testing
for penicillin allergy may be useful for some patients and in some
settings (see Management of the Patient With a History of
Penicillin Allergy). However, minor determinants needed for
penicillin skin testing are not available commercially.

     The Jarisch-Herxheimer reaction is an acute febrile reaction -- 
accompanied by headache, myalgia, and other symptoms -- that may occur 
within the first 24 hours after any therapy for syphilis; patients should 
be advised of this possible adverse reaction. The Jarisch-Herxheimer 
reaction is common among patients with early syphilis. Antipyretics may 
be recommended, but there are no proven methods for preventing this 
reaction. The Jarisch-Herxheimer reaction may induce early labor or 
cause fetal distress among pregnant women. This concern should not 
prevent or delay therapy (see Syphilis During Pregnancy).

Management of Sex Partners -
     
     Sexual transmission of T. pallidum occurs only when
mucocutaneous syphilitic lesions are present; such manifestations
are uncommon after the first year of infection. However, persons
sexually exposed to a patient with syphilis in any stage should be
evaluated clinically and serologically according to the following
recommendations:

--   Persons who were exposed to a patient with primary, secondary,
     or latent (duration less than 1 year) syphilis within the preceding
     90 days might be infected even if seronegative, and therefore
     should be treated presumptively.

--   Persons who were sexually exposed to a patient with primary,
     secondary, or latent (duration less than 1 year) syphilis greater
     than 90 days before examination should be treated presumptively if
     serologic test results are not available immediately, and the
     opportunity for follow-up is uncertain.

--   For purposes of partner notification and presumptive treatment
     of exposed sex partners, patients who have syphilis of unknown
     duration and who have high nontreponemal serologic test titers (
     greater than or equal to 1:32) may be considered to be infected
     with early syphilis.

--   Long-term sex partners of patients with late syphilis should
     be evaluated clinically and serologically for syphilis.


     The time periods before treatment used for identifying at-risk
sex partners are 3 months plus duration of symptoms for primary
syphilis, 6 months plus duration of symptoms for secondary
syphilis, and 1 year for early latent syphilis.

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