STD,HIV,ANDTBSECTION
SyphilisTreatmentProtocol
CLINICALGUIDANCEFORPRIMARYANDSECONDARYSYPHILIS
ANDLATENTSYPHILIS
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TableofContents
Description..............................................................................................................................................3
StagesandSymptoms.............................................................................................................................3
Primaryinfection:...............................................................................................................................3
Secondaryinfection:...........................................................................................................................3
Tertiarysyphilis:..................................................................................................................................3
Latentandlatelatentsyphilis:............................................................................................................4
RiskFactors.............................................................................................................................................4
DiagnosingSyphilis..................................................................................................................................5
Serology:.............................................................................................................................................5
Cerebrospinalfluid(CSF)exam:..........................................................................................................6
TreatmentofSyphilis..............................................................................................................................6
Primaryandsecondarysyphilistreatment:........................................................................................6
Latelatent(infectionofmorethanoneyear)orlatentsyphilisofunknownduration:....................7
Tertiarysyphilistreatment:................................................................................................................7
Specialpopulations:............................................................................................................................7
Neurosyphilisandocularsyphilis:.......................................................................................................7
Followup................................................................................................................................................7
ManagementofPartners........................................................................................................................8
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Description
[Link]
sexualcontact,[Link]
intothreestages;primary,[Link]
findings,[Link]
nervoussystem(CNS)canoccurduringanystageofsyphilis.
StagesandSymptoms
Primaryinfection:
Painlessulcers(s)orchancre(s)attheinfectionsite
Lesionsareusuallyfirm,roundandpainless
Appear10to90days,withanaverageof21days,afterexposuretosyphilis
Lesionsmaypersistfor36weeksthenresolve
Secondaryinfection:
Rashoftenonthepalmsofhands,bottomoffeet,onthetorsoorothersites
Mucusmembranelesionsorsoresinthemouth,vagina,oranus
Flatwartlikegrowths,condylomatalata,intheperianal/genitalareaandothermoistbodysites
Generalizedlymphadenopathy,sorethroat
Alopecia
Headaches
Weightloss
Muscleaches
Fatigue
Onsetofsymptomstypicallyoccurssixweekstosixmonthsafteronsetofthelesionorchancre(can
overlapwithprimarystage)andresolvesin210weeks.
About25percentofpeoplemayhaverelapsesofsymptomsinthefirstyear.
Tertiarysyphilis:
Tertiarysyphilisisdefinedassymptomaticlatelatentsyphilis,gummaandcardiovascularsyphilis,but
notneurosyphilis.
Damagetotheheart,bloodvessels,liver,bonesandjointscandevelop
Gummatous,softnoncancerouslesions,occur
Uveitisorotherocularmanifestations
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Latentandlatelatentsyphilis:
Latentsyphilisisdefinedasseroreactivitywithoutotherevidenceprimary,secondaryortertiary
[Link],latentandlatelatentsyphilisoverlaptheprimary,secondaryandtertiarystages
ofsyphilisbasedonlengthoftimeofinfectionandvisiblesymptoms.
[Link]
latentsyphilisincludeanegativetestinthepastyear,documentedexposuretoearlysyphilisinthe
pastyearandsymptomsofsyphilisthathaveresolvedinthepastyear.
Latentsyphilisacquiredmorethanoneyearagoorofunknowndurationisclassifiedaslatelatent
[Link].
RiskFactors
Exposuretosyphilisthroughoral,vaginalandanalsex
Transmissionfromapregnantwomantoherfetus
Lackconsistentuseofcondomswitheverysexualcontact
HistoryofpreviousofSTDdiagnosis
Multiplesexpartners
HIVinfectedpersons
Menwhohavesexwithmen
Sexualpartnersofmenwhohavesexwithmen
Personswhoexchangesexfordrugsormoneyorhavingpartnerswhodo(maleorfemale)
Sexualassaultvictims
Routine screening is recommended:
Annuallyformenwhohavesexwithmen
PersonwithHIVinfectionandatleastevery6monthsforthoseathigherrisk
Annuallyforindividualswithmultiplesexpartners,orapartnerwhohasmultiplesexpartners
Allpregnantwomenat:
theirfirstprenatalvisit
2832weeks
Delivery
Anywomanwhohasafetaldeathafter20weeksgestationshouldbetestedforsyphilis
AnypersonwithprimaryorsecondarysyphilisshouldbetestedforHIV
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DiagnosingSyphilis
[Link]
[Link]
tests:[Link]
treponemalistoconfirm,bothaspartofdiagnosticsteps.
Serology:
Nontreponemalscreening:
VenerealDiseaseResearchLaboratoryAssay(VDRL),RapidPlasmaReagin(RPR),orUnheated
SerumRegain(USR)
Nontreponemalresultsshouldbereportedquantitatively.
Nontreponemalantibodytitersmightcorrelatewithdiseaseactivityandareusedtofollow
treatmentresponse.
Afourfoldchangeintiter,equivalenttoachangeoftwodilutions(e.g.1:16to1:4or1:8to
1:32),isnecessarytodemonstrateaclinicallysignificantdifferencebetweentwo
nontreponemaltestresultsobtainedusingthesameserologictest.
Nontreponemaltesttitersusuallydeclineaftertreatmentandmightbecomenonreactivewith
time;however,insomepersons,nontreponemalantibodiescanpersistforalongperiodof
time,aresponsereferredtoastheserofastreaction
Treponemalscreening:
FluorescentTreponemalAntibodyAbsorption(FTAABS),TreponemalPallidumParticle
AgglutinationAssay(TTPA)
Personswithareactivenontreponemaltestshouldalwaysreceiveatreponemaltesttoconfirm
thediagnosisofsyphilis.
Personswithreactivetreponemaltesttestswillusuallyhaveareactivetestresultforalifetime.
Treponemaltestsaredone
Toconfirmnontreponemalreactiveresultsand
Atrecentonsetofsuspiciousnewlesion
Treponemalassaysdonotpredictresponsetotreatmentandshouldnotbeusedforthis
purpose.
Treponemaltestsby,EnzymeImmunoassay(EIA),chemiluminescenceimmunoassays(CIA)or
MicrobeadImmunoassay(MIA)areareversescreeningalgorithmforsyphilis.
Thisscreeningcanidentifypersonspreviouslytreatedforsyphilis,thosewithuntreatedor
incompletelytreatedsyphilisandpersonswithfalsepositiveresultsthatcanoccurwithalow
likelihoodofinfection.
InpersonswithHIVinfectionserologictestsareaccurateandreliablefordiagnosingsyphilisand
followingapatientsresponsetotreatment.
However,atypicalnontreponemalserologictestresults([Link],low,orfluctuating
titers)mightoccurregardlessofHIVinfectionstatus.
Whenserologictestsdonotcorrespondwithclinicalfindingssuggestiveofearlysyphilis,
presumptivetreatmentisrecommendedforpersonwithriskforsyphilis,anduseofothertests
(e.g.,biopsyandPCR)shouldbeconsidered.
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Cerebrospinalfluid(CSF)exam:
Furthertestingiswarrantedforpersonswithclinicalsignsofneurosyphilis,infectionofthenervous
[Link]
ofneurosyphilis,butnosingletestcanbeusedfordiagnosis.
Acombinationof(CSFcellcountorproteinorareactiveCSFVDRL)inthepresenceofreactive
serologictestresultsandneurologicsignsandsymptomsshouldbeusedfordiagnosis.
CSFlaboratoryabnormalitiesarecommoninpersonswithearlysyphilisandareofunknown
significanceintheabsenceofneurologicsigns.
CSFVDRLishighlyspecificbutinsensitive
PersonswhohaveHIVinfection,CSFleukocytecountusuallyiselevated(5whiteblood
[WBC]/mm).Usingahighercutoff(20WBC/mm)mightimprovethespecificityofneurosyphilis
diagnosis.
FormoredetailsontestingandinterpretingtestresultsseetheCDCMMWR;SexuallyTransmitted
DiseasesTreatmentGuidelines,2015([Link]
TreatmentofSyphilis
PenicillinGadministeredintramuscularly(IM)orintravenously(IV)isthepreferreddrugfor
[Link]([Link],aqueousprocaineoraqueous
crystalline),dosageandlengthoftreatmentdependonthestageandclinicalsignsofthedisease.
Combinationsofbenzathinepenicillin,procainepenicillinandoralpenicillinpreparationsarenot
appropriateforthetreatmentofsyphilis.
PenicillinGadministeredIMorIVistheonlytherapywithdocumentedefficacyforsyphilisduring
pregnancy.
Pregnantwomeninanystageofsyphiliswhoreportpenicillinallergyshouldbedesensitizedand
treatedwithpenicillin.
Primaryandsecondarysyphilistreatment:
AdministerbenzathinepenicillinG(BicillinLA)2.4millionunitsIntramuscularly(IM)inasingle
dose
Forpenicillinallergicpersonsadministerregimensof:
doxycycline100mgorallytwicedailyfor14daysor
tetracycline500mgfourtimesdailyfor14days.
Complianceislikelytobebetterwithdoxycyclinethantetracyclineduetothegastrointestinalside
effectsandmorefrequentdosingoftetracycline.
DenotuseAzithromycinasfirstlinetreatmentforsyphilis,itshouldbeusedwithcautiononly
[Link]
beendocumentedinmultiplegeographicareasintheUnitedStates.
OthermanagementconsiderationsincludetestingallpersonswhohavelatentsyphilisforHIVand
evaluatinganyonewithneurologicalsignsandsymptomsforneurosyphilis.
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Latelatent(infectionofmorethanoneyear)orlatentsyphilisofunknownduration:
AdministerbenzathinepenicillinG(BicillinLA)7.2millionunitstotal,administeredasthreedoses
of2.4millionunitsIMeachatoneweekintervals
Forpenicillinallergicpersonsadminister:
doxycycline100mgorallytwicedailyfor28daysor
tetracycline500mgorallyfourtimesdailyfor28days
Ifcompliancecannotbeassured,thefollowingregimenshouldbeconsidered;ProcainepenicillinG
2.4millionunitsIMoncedailyPLUSProbenecid500mgorallyfourtimesaday,bothfor1014days
Tertiarysyphilistreatment:
TertiarySyphiliswithNormalCSFExamination
AdministerbenzathinepenicillinG(BicillinLA)7.2millionunitstotal,threedosesof2.4million
unitsIMeachatoneweekintervals
AllpersonswhohavetertiarysyphilisshouldbetestedforHIVandreceiveaCSFexamination
beforetreatmentisinitiated
Specialpopulations:
Pregnancy,CongenitalSyphilis,Infants/Children
SeeSampleClinicalGuidelinesforPregnancy,CongenitalSyphilisandInfants/Children
([Link]
HIVInfectedPersons
PersonswithHIVinfectionwithlatentsyphilisshouldbetreatedaspersonswhodonothaveHIV
infection.
Neurosyphilisandocularsyphilis:
AdministeraqueouscrystallinepenicillinG1824millionunitsperday,34millionunitsIVevery
fourhoursorcontinuousinfusion,for1014days.
FormoredetailsontreatmentofsyphilisseetheCDCMMWR;SexuallyTransmittedDiseases
TreatmentGuidelines,2015([Link]
Followup
Personswithprimaryandsecondarysyphilisshouldhavebothclinicalandserologicevaluationat6
and12monthsaftertreatment.
PersonswithHIVinfectionshouldhavebothclinicalandserologicalevaluationfortreatmentfailure
at3,6,9,12,and24months.
Personswithlatentsyphilisshouldhavequantitativenontreponemalserologictestsrepeatedat6,
12,[Link]
treatment.
FormoredetailsonFollowup,seetheCDCMMWR;SexuallyTransmittedDiseasesTreatment
Guidelines,2015([Link]
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ManagementofPartners
Allpersonswhohavehadsexualcontactwithpersonswithprimary,secondaryorlatentsyphilisshould
beexaminedclinicallyandserologically,andreceivetreatmentbasedon:
Personswhohavehadsexualcontactwithapersonwhoreceivesadiagnosisofprimary,secondaryor
earlylatentsyphiliswithin90daysprecedingthediagnosisshouldbetreatedpresumptivelyforearly
syphilis,eveniftheserologictestresultsarenegative.
Personswhohavehadsexualcontactwithapersonwhoreceivesadiagnosisofprimary,secondary,or
earlylatentsyphilis90daysbeforethediagnosisshouldbetreatedpresump velyforearlysyphilisof
[Link]
serologictestsarenegative,[Link],treatmentshould
bebasedonclinicalandserologicevaluationandstageofsyphilis.
UnderMinnesotastatelaw,physicians,healthcarefacilities,andmedicallaboratoriesarerequiredto
reportalllaboratoryconfirmedcasesofsyphilistotheMinnesotaDepartmentofHealth(MDH)
[MinnesotaRules,part4605.70307040].MDHwillmakeeveryattempttocontactthepatientandto
obtainpartnerinformationforfollowup.
Longtermsexpartnersofpersonswhohavelatelatentsyphilisshouldbeevaluatedclinicallyand
serologicallyforsyphilisandtreatedonthebasisoftheevaluationsfindings.
MinnesotaDepartmentofHealth
STD,HIV,andTBSection
6512015414
[Link]/std
Toobtainthisinformation
inadifferentformat,call:
6512015414
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