Syphilis Guidelines

Updated: Jul 11, 2017
  • Author: Pranatharthi Haran Chandrasekar, MBBS, MD; Chief Editor: Michael Stuart Bronze, MD  more...
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Guidelines

WHO Guidelines on the Treatment of Syphilis by the World Health Organization

Guidelines on the treatment of Treponema pallidum infection (syphilis) by the World Health Organization (WHO) are summarized below. [40]

Early Syphilis in Adults and Adolescents

WHO recommendations on the treatment of early syphilis in adults and adolescents are as follows:

  • Benzathine penicillin G 2.4 million units once intramuscularly is recommended over no treatment.
  • Benzathine penicillin G 2.4 million units once intramuscularly is recommended over procaine penicillin G 1.2 million units 10-14 days intramuscularly.
  • When benzathine or procaine penicillin cannot be used (eg, owing to penicillin allergy) or is not available (eg, owing to stock-outs), the guidelines suggest using doxycycline 100 mg twice daily orally for 14 days or ceftriaxone 1 g intramuscularly once daily for 10-14 days or, in special circumstances, azithromycin 2 g once orally.
  • Doxycycline is preferred over ceftriaxone owing to its lower cost and oral administration.
  • Doxycycline should not be used in pregnant women.
  • Azithromycin is an option in special circumstances only when local susceptibility to azithromycin is likely. If the stage of syphilis is unknown, recommendations for people with late syphilis (see below) should be followed.

Early Syphilis in Pregnant Women

WHO recommendations on the treatment of early syphilis in pregnancy are as follows:

  • Benzathine penicillin G 2.4 million units once intramuscularly is preferred over no treatment.
  • Benzathine penicillin G 2.4 million units once intramuscularly is preferred over procaine penicillin G 1.2 million units intramuscularly once daily for 10 days.
  • When benzathine or procaine penicillin cannot be used (eg, owing to penicillin allergy when penicillin desensitization is not possible) or is not available (eg, owing to stock-outs), the guidelines suggest using, with caution, erythromycin 500 mg orally 4 times daily for 14 days or ceftriaxone 1 g intramuscularly once daily for 10-14 days or azithromycin 2 g once orally.
  • Erythromycin and azithromycin do not cross the placental barrier completely, so the fetus does not receive treatment. It is therefore necessary to treat the newborn soon after delivery.
  • Doxycycline should not be used in pregnant women.

Late Syphilis in Adults and Adolescents

WHO recommendations on the treatment of late syphilis in adults and adolescents are as follows:

  • Benzathine penicillin G 2.4 million units intramuscularly once weekly for 3 consecutive weeks is preferred over no treatment.
  • The interval between consecutive doses of benzathine penicillin should not exceed 14 days.
  • Benzathine penicillin G 2.4 million units intramuscularly once weekly for 3 consecutive weeks is preferred over procaine penicillin 1.2 million units once daily for 20 days.
  • When benzathine or procaine penicillin cannot be used (eg, owing to penicillin allergy where penicillin desensitization is not possible) or is not available (eg, owing to stock-outs), the guidelines suggest using doxycycline 100 mg twice daily orally for 30 days.

Late Syphilis in Pregnant Women

WHO recommendations on the treatment of late syphilis in pregnancy are as follows:

  • Benzathine penicillin G 2.4 million units intramuscularly once weekly for 3 consecutive weeks is recommended over no treatment.
  • Benzathine penicillin G 2.4 million units intramuscularly once weekly for 3 consecutive weeks is recommended over procaine penicillin 1.2 million units intramuscularly once daily for 20 days.
  • When benzathine or procaine penicillin cannot be used (eg, owing to penicillin allergy where penicillin desensitization is not possible) or is not available (eg, owing to stock-outs), the guidelines suggest using, with caution, erythromycin 500 mg orally 4 times daily for 30 days.
  • Although erythromycin treats the pregnant woman, it does not cross the placental barrier completely, so the fetus does not receive treatment. It is therefore necessary to treat the newborn soon after delivery.
  • Doxycycline should not be used in pregnant women.

Syphilis in Infants

WHO recommendations on the treatment of syphilis in infants are as follows:

  • Aqueous benzyl penicillin or procaine penicillin is recommended in infants with confirmed congenital syphilis or infants who are clinically healthy but whose mothers had untreated syphilis, inadequately treated syphilis (including treatment within 30 days of delivery), or syphilis treated with non-penicillin regimens.
  • Aqueous benzyl penicillin 100,000-150,000 U/kg/day is administered intravenously for 10-15 days.
  • Procaine penicillin 50,000 U/kg/day as a single dose is administered intramuscularly for 10-15 days.
  • If an experienced venipuncturist is available, aqueous benzyl penicillin may be preferred over intramuscular injections of procaine penicillin.
  • In infants who are clinically healthy and whose mothers had syphilis that was adequately treated with no signs of reinfection, the guidelines suggest close monitoring of the infants.
  • The risk of syphilis transmission to the fetus depends on numerous factors, including maternal titers from non-treponemal tests (eg, RPR), timing of maternal treatment, and stage of maternal infection. If treatment is provided, benzathine penicillin G 50,000 U/kg/day as a single dose intramuscularly is an option.