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This document is being maintained for historical purposes, but is now out of date.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

Latent Syphilis
     
     Latent syphilis is defined as those periods after infection
with T. pallidum when patients are seroreactive, but show no other
evidence of disease. Patients who have latent syphilis and who have
acquired syphilis within the preceding year are classified as
having early latent syphilis. Patients can be demonstrated to have
acquired syphilis within the preceding year on the basis of
documented seroconversion, a fourfold or greater increase in titer
of a nontreponemal serologic test, history of symptoms of primary
or secondary syphilis, or if they had a sex partner with primary,
secondary, or latent syphilis (documented independently as duration
less than 1 year). Nearly all others have latent syphilis of
unknown duration and should be managed as if they had late latent
syphilis.

Treatment
     Treatment of latent syphilis is intended to prevent occurrence
or progression of late complications. Although clinical experience
supports belief in the effectiveness of penicillin in achieving
those goals, limited evidence is available for guidance in choosing
specific regimens. There is very little evidence to support the use
of nonpenicillin regimens.

Recommended Regimens for Adults -
     These regimens are for nonallergic patients with normal CSF
examination (if performed).

     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 3 doses of 2.4 million units IM each, at 1-week intervals.

Recommended Regimens for Children -
     After the newborn period, children diagnosed with syphilis
should have a CSF examination to exclude neurosyphilis, and birth
and maternal medical records should be reviewed to assess whether
the child has congenital or acquired syphilis (see Congenital
Syphilis). Older children with acquired latent syphilis should be
evaluated as described for adults and treated using the following
pediatric regimens (see Sexual Assault or Abuse of Children). These
regimens are for nonallergic children who have acquired syphilis
and who have had a normal CSF examination.

     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, for three total doses (total 150,000
        units/kg up to adult total dose of 7.2 million units).


Other Management Considerations
     All patients with latent syphilis should be evaluated
clinically for evidence of tertiary disease (e.g., aortitis,
neurosyphilis, gumma, and iritis). Recommended therapy for patients
with latent syphilis may not be optimal therapy for the persons
with asymptomatic neurosyphilis. However, the yield from CSF
examination, in terms of newly diagnosed cases of neurosyphilis, is
low.

     Patients with any one of the criteria listed below should have
a CSF examination before treatment:

--   Neurologic or ophthalmic signs or symptoms;

--   Other evidence of active syphilis (e.g., aortitis, gumma,
     iritis);

--   Treatment failure;

--   HIV infection;

--   Serum nontreponemal titer greater than or equal to 1:32,
     unless duration of infection is known to be less than 1 year; or

--   Nonpenicillin therapy planned, unless duration of infection is
     known to be less than 1 year.

     If dictated by circumstances and patient preferences, CSF
examination may be performed for persons who do not meet the
criteria listed above. If a CSF examination is performed and the
results show abnormalities consistent with CNS syphilis, the
patient should be treated for neurosyphilis (see Neurosyphilis).

--   All syphilis patients should be tested for HIV.

Follow-Up
     Quantitative nontreponemal serologic tests should be repeated
at 6 months and again at 12 months. Limited data are available to
guide evaluation of the response to therapy for a patient with
latent syphilis. If titers increase fourfold, or if an initially
high titer ( greater than or equal to 1:32) fails to decline at
least fourfold (two dilutions) within 12-24 months, or if the
patient develops signs or symptoms attributable to syphilis, the
patient should be evaluated for neurosyphilis and re-treated
appropriately.

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

Special Considerations

Penicillin Allergy -
     For patients who have latent syphilis and who are allergic to
penicillin, nonpenicillin therapy should be used only after CSF
examination has excluded neurosyphilis. Nonpregnant,
penicillin-allergic patients should be treated with the following
regimens.
     Doxycycline 100 mg orally 2 times a day
                    or
     Tetracycline 500 mg orally 4 times a day.

     Both drugs are administered for 2 weeks if duration of
infection is known to have been less than 1 year; otherwise, for 4
weeks.

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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