Do not use quinolones for pregnant women. Due to a theoretical risk of adverse joint and tendon reactions in immature joints, CDC guidelines recommend against quinolone use in adolescents who weigh less than 45kg (100lbs); other clinicians prefer an age cutoff such as not less than 16 years old.
Do not use doxycycline for pregnant women or for adolescents under 8 years old.
Test of cure is generally not needed with non-erythromycin regimens (even for pregnant women) unless symptoms present before treatment fail to resolve. Erythromycin is less effective than other regimens, so patients treated with erythromycin should be tested for cure 3-4 weeks after treatment.
Concomitant treatment for gonorrhea should be very strongly considered, unless gonorrhea has been ruled out by laboratory testing, because of high rates of co-infection.
Treatment for HIV is beyond the scope of this document. Please consult with a physician experienced in HIV management.
Treatment of syphilis can be very complex. Contact an infectious disease specialist or your local health department for support and advice. In Milwaukee, physicians and other health professionals are invited to call the Milwaukee Health Department Sexually Transmitted Disease program at 414-286-5526.
If neurologic symptoms exist or neurosyphilis is suspected, CSF testing should be done prior to treatment. Neurosyphilis requires intensive, parenteral antibiotic treatment, often in an inpatient setting.
Uncomplicated syphilis under 1 year duration
Benzathine penicillin G (Bicillin LA) 2.4 million units IM in a single dose.
Uncomplicated syphilis of unknown duration or of greater than 1 year duration:
Benzathine penicillin G (Bicillin LA) 7.2 million units total, administered as three doses of 2.4 million units IM each at 1-week intervals.
No less than 5 days nor more than 10 days may elapse between the three doses. If so, the 3-shot series must be started from scratch.
Never use Bicillin CR as a substitute for Bicillin LA. Bicillin CR contains only half the dose of benzathine penicillin G recommended for syphilis.
Children. Dosing of penicillin for children is done by weight. Consult a pediatric infectious disease specialist or your local health department.
Penicillin-allergic patients. Although a doxycycline alternative exists, it is less effective, and the best approach is inpatient penicillin desensitization. Consult an infectious disease specialist or your local health department.
HIV positive patients should have CSF testing to rule out neurosyphilis. Some experts recommend three weeks of Bicillin regardless of duration of syphilis in HIV-positive patients. Close monitoring of frequent non-treponemal titers 3, 6, 9, 12, and 24 months after therapy is essential to assure that treatment was effective.
Pregnant women are treated with penicillin in the same dose as if they were not pregnant. However, their newborn(s) must be evaluated extensively at birth to rule out congenital syphilis. Consult with a neonatologist or your local health department.
HIV-positive (see above)
HIV-negative syphilis under 1 year duration: obtain VDRL or RPR test at 6 and 12 months after therapy. A four-fold drop in titer is required to assure that treatment was effective.
HIV-negative syphilis of unknown duration or over 1 year duration: obtain VDRL or RPR test at 6, 12, and 24 months after therapy. A four-fold drop in titer is required to assure that treatment was effective.
Authorship: Geoffrey R. Swain, MD, MPH; Paul P. Hartlaub, MD, MSPH; Michael Lynch, MD; Seth L. Foldy, MD Acknowledgements: Additional valuable input provided by colleagues from CCHQ’s member organizations
STD SCREENING, TESTING AND TREATMENT GUIDELINES FOR HIGH PREVALENCE AREAS Approved 11/4/03 by the MSMC Community Collaboration on Healthcare Quality & the City of Milwaukee Health Department
Treatment for Gonorrhea Updated 1/21/08
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