Syphilis Treatment in Singapore: Syphilis treatment clinic, Singapore. Private and confidential service. Definitions, references, and latest news.
Syphilis Treatment is usually with
Syphilis is a treatable and curable infection. Penicillin given by injection is the drug of choice; it effectively cures a person with syphilis in the early stage and prevents further organ damage in the late stages. Thereafter routine monitoring of blood every six months for up to two years is needed to ensure adequate treatment.
Parenteral penicillin G (aqueous crystalline, aqueous procaine, or benzathine) is the drug of choice for treating all stages of syphilis. If the patient is allergic to penicillin, tetracycline, doxycycline, azithromycin and erythromycin are the alternatives. However, they do not have the established and well-evaluated high rate of success of penicillin.
Latent syphilis of less than 1 year’s duration
For HIV-infected individuals, we recommend the same treatment regimens as those who are HIV negative (see section on infection in HIV infected individuals) [IV, C]
Late Syphilis (excluding neurosyphilis)
Latent syphilis of more than 1 year’s duration, or of unknown duration
Late benign syphilis
Penicillin-allergic patients (close follow-up required)
Neurosyphilis, ocular and otologic syphilis
A high sustained blood level of penicillin is required for adequate penetration of the blood- brain barrier in the treatment of neurosyphilis.
Patients with syphilis and the following should have CSF examination:
Some experts recommend CSF examination in HIV infection with late syphilis or syphilis of unknown duration (some experts would treat all HIV positive syphilis with neurosyphilis regimens) but newer evidence suggests that treatment outcomes are not significantly altered.
The CSF findings in neurosyphilis are:
RAST tests, skin testing and desensitisation should be performed in consultation with an expert.
Penicillin is the drug of choice unless really contraindicated.
Doxycycline is the preferred oral alternative in view of its more favourable dosing intervals.
Oral corticosteroid cover
This is to minimize the effects of the Jarisch-Herxheimer reaction that may occur 4 to 12 hours after the first dose of antibiotic therapy and is indicated in the following situations where the reaction may result in morbidity or even mortality:
Prednisolone orally 20 mg tid (60mg/day) for 24 hours before treatment and continued for 2 days after starting therapy [IV, C].
Quantitative nontreponemal tests should be repeated for a total period of two years (at 3 months; 6 months; 12 months; 18 months; 24 months).
Following treatment of early syphilis, VDRL/RPR should demonstrate a 4 x (2 dilutions) decrease in titre within 6 months. Failure to do so probably means treatment failure, and is an indication for retreatment with 3 injections of Benzathine penicillin. Some experts recommend CSF examination.
Clinical signs that persist or recur, or a rising VDRL/RPR titre of 4 x or more suggests either reinfection or relapse. In these situations CSF examination is recommended before retreatment. Seroreversion in primary syphilis often occurs within 12 months; it may take a longer time for secondary and early latent syphilis, but usually occurs within 24 months. Following treatment of late syphilis, seroreversion occurs rarely; a stable, low titre, serological scar, is the result in most patients.
All patients treated for neurosyphilis should be followed up for life at 6-month intervals. If CSF pleocytosis was present initially, CSF examinations should be repeated every 6 to 12 months until the cell count returns to normal. Serologic tests for HIV should be performed 3 months after the last risky exposure.
MANAGEMENT OF SEXUAL CONTACTS
At risk partners are those who have been exposed within the following periods – 3 months plus duration of symptoms for primary syphilis, 6 months plus duration of symptoms for secondary syphilis, and 1 year for early latent syphilis.
Epidemiologic treatment should be given to sexual contacts who were exposed 3 months prior to the diagnosis of primary, secondary or early latent syphilis, if follow-up is uncertain. Sexual partners of late syphilis should be screened and evaluated for syphilis, and treated on the basis of these findings.
Epidemiologic treatment can be given as follows
Syphilis in pregnancy
All pregnant women should have serological tests for syphilis at the first antenatal visit. This should be repeated in women who have high-risk behaviour or have spouses who have high-risk behaviour.
Penicillin should be used in dosage schedules appropriate for the stage of syphilis as recommended for the treatment of non-pregnant patients. A Jarisch-Herxheimer reaction may precipitate premature labour or foetal distress; women should be advised to seek obstetric care if abnormal contractions and decreased foetal movements occur.
For penicillin-allergic patients, give erythromycin in dosage schedules appropriate for the stage of syphilis as recommended for the treatment of non-pregnant patients. However, as erythromycin exhibits poor penetration across the placental barrier, the infant should be routinely treated with penicillin at birth. For these patients, retreatment with doxycycline can be considered after delivery when breastfeeding has been stopped.
Ceftriaxone 500 mg i/m od x 10 days and Azithromycin 500 mg orally od x 10 days (limited data only) have been tried.
Tetracyclines are contraindicated in pregnancy. Pregnant woman treated for early syphilis should have monthly RPR/VDRL for the remainder of the current pregnancy.
Children with acquired syphilis
Birth and maternal records should be reviewed to exclude congenital syphilis.
Primary, Secondary and Early Latent Syphilis
Benzathine penicillin G 50,000 units/kg i/m, up to adult dose of 2.4 mega units in single dose.
Late latent syphilis, latent syphilis of unknown duration, late syphilis (not neurosyphilis)
Benzathine penicillin G 50,000 units/kg i/m, up to adult dose of 2.4 mega units, administered as three doses at 1 week intervals (total 150,000 units/kg up to adult dose of 7.2 million units).
Aq. Crystalline Penicillin G 50,000 unit/kg i/v every 4-6 hours (total 200,000 – 300,000 unit/ kg/day) for 10 days.
Diagnosis and treatment decisions must be based on
Who should be evaluated?
Infants should be evaluated if they have been born to seropositive mothers who –
Evaluation is not required if both these criteria are met –
Some experts would treat the infant with a single dose of Benzathine Penicillin 50,000 units/ kg i/m; others would not but instead provide close serologic follow-up. If the infant’s RPR/ VDRL is non-reactive, no treatment is needed.
What to evaluate in the infant?
When to treat infants?
Seroreactive infants and infants whose mothers were reactive at delivery should be followed up every 2-3 months until the test becomes nonreactive or the titre falls fourfold; the RPR/ VDRL should fall by 3 months of age and be nonreactive by 6 months of age if the infant was not infected (passive transfer) or if treatment was adequate. Treatment after the neonatal period may result in a slower decline of titres.
Passively transferred treponemal antibodies may be present in the infant for 15 months, the presence of a reactive treponemal test after 18 months indicates congenital syphilis, and the infant should be (re)evaluated.
Congenital syphilis in older infants and children
Treatment of syphilis in a HIV infected person
Serological tests for syphilis are generally reliable in HIV co-infection. Some authorities recommend routine CSF examination and/or treatment for neurosyphilis for all patients, regardless of the stage of syphilis. However, most HIV-infected persons respond appropriately to standard benzathine penicillin for primary and secondary syphilis. CSF abnormalities (e.g. mononuclear pleocytosis and elevated protein levels) are common in HIV-infected persons, even in those without neurologic symptoms, although the clinical and prognostic significance of such CSF abnormalities with primary and secondary syphilis is unknown. Several studies have demonstrated that among persons infected with both HIV and syphilis, clinical and CSF abnormalities consistent with neurosyphilis are associated with a CD4 count of ≤350 cells/ mL and/or an RPR titer of ≥1:32; however, unless neurologic symptoms are present, CSF examination in this setting has not been associated with improved clinical outcomes.
A lumbar puncture is recommended for HIV patients with syphilis if there are any neurological abnormalities, or if titres do not decline after penicillin therapy. All HIV patients should be treated wherever possible with penicillin.
Some experts recommend treatment in the same doses as for HIV-negative patients, while others would treat all HIV-infected patients with the neurosyphilis regimen [IV, C].
We recommend that all HIV-infected patients without evidence of neurosyphilis be given doses of benzathine penicillin that are appropriate for the stage of syphilis as in non HIV patients.
However, it is more important to monitor for treatment failures in these patients.
Such patients should be followed-up clinically and with nontreponemal tests at 3, 6, 9, 12 and 24 months after treatment.
Best to refer to a specialist.