eMedicine Specialties > Infectious Diseases > Sexually Transmitted Diseases
Syphilis: Treatment & Medication
Updated: May 21, 2009
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Treatment
Medical Care
- Clinical and serologic conversions are the endpoints of medical treatment for syphilis.
- Obtain follow-up VDRL test levels to document treatment efficacy.
- Penicillin is the treatment of choice for treating syphilis. According to current CDC recommendations, patients with known penicillin allergies should undergo penicillin allergy skin testing and penicillin desensitization, if necessary.4
Surgical Care
- Surgical care is reserved for treating the complications of tertiary syphilis (eg, aortic valve replacement).
Consultations
- Consultation with an infectious diseases specialist may be required for difficult or complex cases of syphilis.
- Consult with a dermatologist, vascular surgeon, ophthalmologist, and neurologist, as necessary, to assist with the variable presentations of syphilis.
Medication
The goals of pharmacotherapy are to reduce morbidity and to prevent complications.
Penicillin is the treatment of choice for treating syphilis. According to current CDC recommendations, patients with known penicillin allergies should undergo penicillin allergy skin testing and penicillin desensitization, if necessary.4
Researchers are studying the efficacy of ceftriaxone5 and azithromycin in treating syphilis. CNS penetration and its similarity to penicillin support the use of ceftriaxone in the treatment of syphilis. Studies are presently inconclusive, and CDC guidelines neither support nor refute its use. Given the limited data available to support its efficacy, prudence dictates a 5- to 7-day course of treatment for early syphilis.
The long half-life of azithromycin and its clinical efficacy in vitro against syphilis support its use in treating early syphilis; however, clinical data are currently insufficient to recommend its use.
No good evidence indicates that the non–beta-lactam antibiotics, which are used as alternatives to penicillin, are clinically effective in syphilis.
Antibiotics
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
Benzathine penicillin G (Bicillin)
First-line agent for primary and secondary syphilis infection. Spirocheticide with in vivo activity against T pallidum. Interferes with cell wall mucopeptide synthesis during replication.
Adult
Primary/secondary syphilis: 2.4 million U IM in a single dose
Latent/unknown duration/tertiary syphilis (excluding neurosyphilis): 2.4 million U IM qwk for 3 wk
Pediatric
Primary/secondary syphilis: 50,000 U/kg IM single dose; not to exceed 2.4 million U
Latent/unknown duration/tertiary syphilis (excluding neurosyphilis): 50,000 U/kg IM qwk for 3 wk
Probenecid increases serum levels and effectiveness; tetracycline decreases effectiveness; may decrease efficacy of oral contraceptives
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in impaired renal function; seizures may occur at high doses
Penicillin G Procaine (Crysticillin)
First-line agent for treating late latent syphilis.
Adult
2.4 million U IM qd for 17-21 d
Neurosyphilis: Add probenecid 500 mg PO qid for 17-21 d
Pediatric
Neurosyphilis: Crystalline penicillin G 50,000 U/kg IM (up to 2.4 million U); give 3 doses at 1-wk intervals
Probenecid increases serum levels and effectiveness; tetracycline decreases effectiveness; may decrease efficacy of oral contraceptives
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Never use IV route to administer penicillin G procaine; caution in renal insufficiency because seizures occur at high doses secondary to impaired clearance
Doxycycline (Doryx, Vibramycin)
Alternative therapy for syphilis infection. Inhibits bacterial growth by binding to the 30S ribosomal unit, preventing protein synthesis.
Adult
Primary/secondary/early latent: 100 mg PO bid for 14 d
Late latent: 100 mg PO bid for 30 d
Neurosyphilis: 200 mg PO qid for 28 d
Pediatric
<8 years: Not recommended
>8 years ( <45 kg): 2-5 mg/kg/d PO in 1-2 divided doses; not to exceed 200 mg/d
>8 years (>45 kg): Administer as in adults
Antacids decrease efficacy (delay administration by > 1 h); carbamazepine, phenytoin, phenobarbital, decrease doxycycline levels and efficacy; methoxyflurane increases risk of fatal nephrotoxicity; may decrease efficacy of oral contraceptives; warfarin increases risk of bleeding
Documented hypersensitivity; children <8 y
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in renal dysfunction; elevates BUN; avoid contact with sunlight when taking medication; do not administer to breastfeeding mothers or to children under 8 y because it discolors teeth
Tetracycline (Sumycin)
Alternative therapy for syphilis infection. Inhibits bacterial growth by binding to the 30S ribosomal unit, preventing protein synthesis.
Adult
Primary/secondary/early latent: 500 mg PO qid for 14 d
Late latent: 500 mg PO qid for 30 d
Pediatric
<8 years: Not recommended
>8 years: 25-50 mg/kg/d PO divided qid
Antacids decrease tetracycline efficacy (delay administration by >1 h); carbamazepine, phenytoin, phenobarbital, decrease doxycycline levels and efficacy; methoxyflurane increased risk of fatal nephrotoxicity; may decrease efficacy of oral contraceptives; warfarin increases risk of bleeding
Documented hypersensitivity; children <8 y
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in renal dysfunction; elevates BUN; avoid contact with sunlight when taking medication; do not administer to breastfeeding mothers or to children under 8 y because it discolors teeth
Probenecid
Inhibits tubular secretion of penicillin, and usually increases penicillin plasma levels by any route the antibiotic is administered. A 2- to 4-fold elevation has been demonstrated for various penicillins. Used as an adjunct to penicillin in late latent and neurosyphilis.
Adult
500 mg PO qid for 21 d
Pediatric
<2 years: Not recommended
2-14 years: 25 mg/kg PO, then 40 mg/kg/d PO divided qid
>14 years: Administer as in adults
Salicylates at high dosages and nitrofurantoin may decrease effects; increases levels or toxicity of methotrexate, beta-lactam antibiotics, acyclovir, thiopental, clofibrate, dyphylline, pantothenic acid, ketorolac, benzodiazepines, rifampin, sulfonamide, dapsone, zidovudine, and sulfonylureas
Documented hypersensitivity; children <2 y; known blood dyscrasia or uric acid kidney stones; coadministration of ketorolac because levels or toxicity of ketorolac are significantly increased
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Crosses placental barrier; use of any drug in women of childbearing potential requires that anticipated benefit be weighed against possible hazards; caution in history of peptic ulcer; caution in renal impairment and peptic ulcer disease
Erythromycin (E.E.S., E-Mycin)
Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest. For treatment of staphylococcal and streptococcal infections. In children, age, weight, and severity of infection determine proper dosage. When bid dosing is desired, half-total daily dose may be taken q12h. For more severe infections, double the dose.
Adult
500 mg PO qid for 14 d
Pediatric
30-50 mg/kg/d PO divided qid
Warfarin increases risk of bleeding; theophylline, digoxin, carbamazepine, and cyclosporine toxicity may increase when coadministered; when taken concurrently with lovastatin and simvastatin, increase risks of rhabdomyolysis
Documented hypersensitivity; hepatic impairment
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in patients with liver disease; Pediazole is class C in pregnancy secondary to sulfisoxazole component; medication should be taken with food secondary to adverse GI effects (eg, nausea, vomiting, abdominal pain)
More on Syphilis |
| Overview: Syphilis |
| Differential Diagnoses & Workup: Syphilis |
 Treatment & Medication: Syphilis |
| Follow-up: Syphilis |
| Multimedia: Syphilis |
| References |
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References
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Further Reading
Keywords
syphilis, primary syphilis, secondary syphilis, latent syphilis, congenital syphilis, tertiary syphilis, venereal disease, Treponema pallidum, T pallidum, syphilemia, syphilid, syphiloderm, syphiloderma, syphiloma, syphilitic infection, sexually transmitted disease, STD, yaws, pinta, chancres, gumma, lues venerea, malum venereum, great imitator, gummatous syphilis, cardiovascular syphilis, meningovascular syphilis, paretic syphilis, late congenital syphilis, early congenital syphilis, late syphilis, early syphilis, acquired syphilis
