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This document is being maintained for historical purposes, but is now out of date.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

Primary and Secondary Syphilis

Treatment
     Four decades of experience indicate that parenteral penicillin
G is effective in achieving local cure (healing of lesions and
prevention of sexual transmission) and in preventing late sequelae.
However, no adequately conducted comparative trials have been
performed to guide the selection of an optimal penicillin regimen
(i.e., dose, duration, and preparation). Substantially fewer data
on nonpenicillin regimens are available.

Recommended Regimen for Adults -
     Nonallergic patients with primary or secondary syphilis should
be treated with the following regimen:

     Benzathine penicillin G, 2.4 million units IM in a single
     dose.

NOTE: Recommendations for treating pregnant women and
HIV-infected persons for syphilis are discussed in separate
sections.

Recommended Regimen for Children -
     After the newborn period, children diagnosed with syphilis
should have a CSF examination to exclude a diagnosis of
neurosyphilis, and birth and maternal medical records should be
reviewed to assess whether the child has congenital or acquired
syphilis (see Congenital Syphilis). Children with acquired primary
or secondary syphilis should be evaluated (including consultation
with child-protection services) and treated using the following
pediatric regimen (see Sexual Assault or Abuse of Children).

     Benzathine penicillin G, 50,000 units/kg IM, up to the adult
     dose of 2.4 million units in a single dose.

Other Management Considerations
     All patients with syphilis should be tested for HIV. In areas
with high HIV prevalence, patients with primary syphilis should be
retested for HIV after 3 months.

     Patients who have syphilis and who also have symptoms or signs
suggesting neurologic disease (e.g., meningitis) or ophthalmic
disease (e.g., uveitis) should be fully evaluated for neurosyphilis
and syphilitic eye disease (including CSF analysis and ocular
slit-lamp examination). Such patients should be treated
appropriately according to the results of this evaluation.

     Invasion of CSF by T. pallidum with accompanying CSF
abnormalities is common among adults who have primary or secondary
syphilis. However, few patients develop neurosyphilis after
treatment with the regimens described in this report. Therefore,
unless clinical signs or symptoms of neurologic involvement are
present (e.g., auditory, cranial nerve, meningeal, or ophthalmic
manifestations), lumbar puncture is not recommended for routine
evaluation of patients with primary or secondary syphilis.

Follow-Up
     Treatment failures can occur with any regimen. However,
assessing response to treatment is often difficult, and no
definitive criteria for cure or failure exist. Serologic test
titers may decline more slowly among patients with a prior syphilis
infection. Patients should be re-examined clinically and
serologically at 3 months and again at 6 months.

     Patients with signs or symptoms that persist or recur or who
have a sustained fourfold increase in nontreponemal test titer
compared with either the baseline titer or to a subsequent result,
can be considered to have failed treatment or to be reinfected.
These patients should be re-treated after evaluation for HIV
infection. Unless reinfection is likely, lumbar puncture also
should be performed.

     Failure of nontreponemal test titers to decline fourfold by 3
months after therapy for primary or secondary syphilis identifies
persons at risk for treatment failure. Those persons should be
evaluated for HIV infection. Optimal management of such patients is
unclear if they are HIV negative. At a minimum, these patients
should have additional clinical and serologic follow-up. If further
follow-up cannot be assured, re-treatment is recommended. Some
experts recommend CSF examination in such situations.

     When patients are re-treated, most experts recommend
re-treatment with three weekly injections of benzathine penicillin
G 2.4 million units IM, unless CSF examination indicates that
neurosyphilis is present.

Management of Sex Partners
     Refer to General Principles, Management of Sex Partners.

Special Considerations

Penicillin Allergy -
     Nonpregnant penicillin-allergic patients who have primary or
secondary syphilis should be treated with the following regimen.

     Doxycycline 100 mg orally 2 times a day for 2 weeks
                           or
     Tetracycline 500 mg orally 4 times a day for 2 weeks.

     There is less clinical experience with doxycycline than with
tetracycline, but compliance is likely to be better with
doxycycline. Therapy for a patient who cannot tolerate either
doxycycline or tetracycline should be based upon whether the
patient's compliance with the therapy regimen and with follow-up
examinations can be assured.

     For nonpregnant patients whose compliance with therapy and
follow-up can be assured, an alternative regimen is erythromycin
500 mg orally 4 times a day for 2 weeks. Various ceftriaxone
regimens also may be considered.

     Patients whose compliance with therapy or follow-up cannot be
assured should be desensitized, if necessary, and treated with
penicillin. Skin testing for penicillin allergy may be useful in
some situations (see Management of the Patient With a History of
Penicillin Allergy).

     Erythromycin is less effective than other recommended
regimens. Data on ceftriaxone are limited, and experience has been
too brief to permit identification of late failures. Optimal dose
and duration have not been established for ceftriaxone, but
regimens that provide 8-10 days of treponemicidal levels in the
blood should be used. Single dose ceftriaxone therapy is not
effective for treating syphilis.

Pregnancy -
     Pregnant patients who are allergic to penicillin should be
treated with penicillin, after desensitization, if necessary (see
Management of the Patient With a History of Penicillin Allergy and
Syphilis During Pregnancy).

HIV Infection -
     Refer to Syphilis Among HIV-Infected Patients.

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