Treatment of syphilis is determined by disease stage and by CNS involvement. Treponemapallidum is exquisitely sensitive to penicillin, which remains the treatment of choice for all stages. In pregnant women, penicillin is the only treatment option. Acceptable alternatives to penicillin include erythromycin, azithromycin, chloramphenicol, tetracycline, doxycycline, and the cephalosporins.
Treatment of ocular syphilis and neurosyphilis is either aqueous crystalline penicillin G IV or procaine penicillin IM with probenecid for 10–14 days. Per the CDC, cases of ocular syphilis should be reported to the local or state health department.
Lumbar puncture should be performed to determine cerebrospinal fluid involvement in several circumstances, namely in cases of latent syphilis of more than 1 year’s duration, suspected neurosyphilis, treatment failure, HIV coinfection, high RPR titers (>1:32), and evidence of other late manifestations (cardiac involvement, gummata). Either penicillin G or a single oral dose of azithromycin has been recommended for treatment of patients who were recently exposed to a sexual partner with infectious syphilis.
Many reports have described an accelerated clinical course of syphilis in HIV-infected patients; furthermore, such patients may experience an incomplete response to standard therapy. A patient coinfected with HIV and syphilis often requires a longer and more intensive treatment regimen, ongoing follow-up to assess for recurrence, and a complete neurologic workup with an aggressive cerebrospinal fluid investigation for evidence of neurosyphilis. Ceftriaxone compares favorably with intravenous penicillin for the treatment of neurosyphilis in HIV-coinfected patients. Patients with any stage of clinical syphilis should be tested for HIV serostatus.
Cantor AG, Pappas M, Daeges M, Nelson HD. Screening for syphilis: updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2016;315(21):2328–2337.
Centers for Disease Control and Prevention. Sexually transmitted disease surveillance 2017. Atlanta: US Department of Health and Human Services; 2018. www.cdc.gov/std/stats17/default.htm. Accessed February 22, 2019.
Ghanem KG, Workowski KA. Management of adult syphilis. Clin Infect Dis. 2011;53(Suppl 3):S110–128.
Excerpted from BCSC 2020-2021 series: Section 1 - Update on General Medicine. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.