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This document is being maintained for historical purposes, but is now out of date.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

Congenital Syphilis

Diagnostic Considerations

Who Should Be Evaluated -
     Infants should be evaluated for congenital syphilis if they
were born to seropositive (nontreponemal test confirmed by
treponemal test) women who meet the following criteria:

--   Have untreated syphilis;* or

--   Were treated for syphilis during pregnancy with erythromycin; or

--   Were treated for syphilis less than 1 month before delivery; or

--   Were treated for syphilis during pregnancy with the
     appropriate penicillin regimen, but nontreponemal antibody titers
     did not decrease sufficiently after therapy to indicate an adequate
     response ( greater than or equal to fourfold decrease); or

--   Do not have a well-documented history of treatment for
     syphilis; or

--   Were treated appropriately before pregnancy but had
     insufficient serologic follow-up to assure that they had responded
     appropriately to treatment and are not currently infected ( greater
     than or equal to fourfold decrease for patients treated for early
     syphilis; stable or declining titers less than or equal to 1:4 for
     other patients).

     No infant should leave the hospital without the serologic
status of the infant's mother having been documented at least once
during pregnancy. Serologic testing also should be performed at
delivery in communities and populations at risk for congenital
syphilis. Serologic tests can be nonreactive among infants infected
late during their mother's pregnancy.

* A woman treated with a regimen other than those recommended for
treatment of syphilis (for pregnant women or otherwise) in these
guidelines should be considered untreated.

Evaluation of the Infant -
     The clinical and laboratory evaluation of infants born to
women described above should include the following:

--   A thorough physical examination for evidence of congenital
     syphilis;

--   A quantitative nontreponemal serologic test for syphilis
     performed on the infant's sera (not on cord blood);

--   CSF analysis for cells, protein, and VDRL;

--   Long bone x-rays;

--   Other tests as clinically indicated (e.g., chest x-ray,
     complete blood count, differential and platelet count, liver
     function tests);

--   For infants who have no evidence of congenital syphilis on the
     above evaluation, determination of presence of specific
     antitreponemal IgM antibody by a testing method recognized by CDC
     as having either provisional or standard status;

--   Pathologic examination of the placenta or amniotic cord using
     specific fluorescent antitreponemal antibody staining.

Treatment

Therapy Decisions -
     Infants should be treated for presumed congenital syphilis if
they were born to mothers who, at delivery, had untreated syphilis
or who had evidence of relapse or reinfection after treatment (see
Congenital Syphilis, Diagnostic Considerations). Additional
criteria for presumptively treating infants with congenital
syphilis are as follows:

--   Physical evidence of active disease;

--   X-ray evidence of active disease;

--   A reactive VDRL-CSF or, for infants born to seroreactive
     mothers, an abnormal ** CSF white blood cell count or protein,
     regardless of CSF serology;

--   A serum quantitative nontreponemal serologic titer that is at
     least fourfold greater than the mother's titer ***;

--   Specific antitreponemal IgM antibody detected by a testing
     method that has been given provisional or standard status by CDC;

--   If they meet the previously cited criteria for "Who Should Be
     Evaluated," but have not been fully evaluated (see Congenital
     Syphilis, Diagnostic Considerations).

NOTE: Infants with clinically evident congenital syphilis
should have an ophthalmologic examination.

** In the immediate newborn period, interpretation of CSF test
results may be difficult; normal values vary with gestational age
and are higher in preterm infants.  Other causes of elevated values
also should be considered when an infant is being evaluated for
congenital syphilis.  Though values as high as 25 white blood
cells(WBC)/mm3 and 150 mg protein/dL occur among normal neonates,
some experts recommend that lower values (5 WBC/mm3 and 40 mg/dL)
be considered the upper limits of normal.  The infant should be
treated if test results cannot exclude infection.

*** The absence of a fourfold greater titer for an infant cannot be
used as evidence against congenital syphilis.


Recommended Regimens -
     Aqueous crystalline penicillin G, 100,000-150,000 units/kg/day
     (administered as 50,000 units/kg IV every 12 hours during the first
     7 days of life and every 8 hours thereafter) for 10-14 days,
                                or
     Procaine penicillin G, 50,000 units/kg IM daily in a single
     dose for 10-14 days.

     If more than 1 day of therapy is missed, the entire course
should be restarted. An infant whose complete evaluation was normal
and whose mother was a) treated for syphilis during pregnancy with
erythromycin, or b) treated for syphilis less than 1 month before
delivery, or c) treated with an appropriate regimen before or
during pregnancy but did not yet have an adequate serologic
response should be treated with benzathine penicillin G, 50,000
units/kg IM in a single dose. In some cases, infants with a normal
complete evaluation for whom follow-up can be assured can be
followed closely without treatment.

Treatment of Older Infants and Children with Congenital Syphilis
     After the newborn period, children diagnosed with syphilis
should have a CSF examination to exclude neurosyphilis and records
should be reviewed to assess whether the child has congenital or
acquired syphilis (see Primary and Secondary Syphilis and Latent
Syphilis). Any child who is thought to have congenital syphilis (or
who has neurologic involvement) should be treated with aqueous
crystalline penicillin G, 200,000-300,000 units/kg/day IV or IM
(administered as 50,000 units/kg every 4-6 hours) for 10-14 days.

Follow-Up
     A seroreactive infant (or an infant whose mother was
seroreactive at delivery) who is not treated for congenital
syphilis during the perinatal period should receive careful
follow-up examinations at 1 month and at 2, 3, 6, and 12 months
after therapy. Nontreponemal antibody titers should decline by 3
months of age and should be nonreactive by 6 months of age if the
infant was not infected and the titers were the result of passive
transfer of antibody from the mother. If these titers are found to
be stable or increasing, the child should be re-evaluated,
including CSF examination, and fully treated. Passively transferred
treponemal antibodies may be present for as long as 1 year. If they
are present greater than 1 year, the infant should be re-evaluated
and treated for congenital syphilis.

     Treated infants also should be followed every 2-3 months to
assure that nontreponemal antibody titers decline; these infants
should have become nonreactive by 6 months of age (response may be
slower for infants treated after the neonatal period). Treponemal
tests should not be used to evaluate response to treatment because
test results can remain positive despite effective therapy if the
child was infected. Infants with CSF pleocytosis should undergo CSF
examination every 6 months, or until the cell count is normal. If
the cell count is still abnormal after 2 years, or if a downward
trend is not present at each examination, the child should be
re-treated. The VDRL-CSF also should be checked at 6 months; if
still reactive, the infant should be re-treated.

     Follow-up of children treated for congenital syphilis after
the newborn period should be the same as that prescribed for
congenital syphilis among neonates.

Special Considerations

Penicillin Allergy -
     Children who require treatment for syphilis after the newborn
period, but who have a history of penicillin allergy, should be
treated with penicillin after desensitization, if necessary. Skin
testing may be helpful in some patients and settings (see
Management of the Patient With a History of Penicillin Allergy).

HIV Infection -
     Mothers of infants with congenital syphilis should be tested
for HIV. Infants born to mothers who have HIV infection should be
referred for evaluation and appropriate follow-up.

     No data exist to suggest that infants with congenital syphilis
whose mothers are coinfected with HIV require different evaluation,
therapy, or follow-up for syphilis than is recommended for all
infants.

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