TREATMENT OF SYPHILIS

Preventive treatment

is carried out to prevent syphilis for persons who have had sexual and close
household contact with patients with early forms of syphilis, if no more
than 2months have passed since the contact.

Preventive treatment is carried out for pregnant women who are sick or
have had syphilis and children born to these women

Specific treatment

is carried out with the aim of etiological cure of the patient by creating a
treponemocidal concentration of the antimicrobial drug in the blood and
tissues, and in the case of neurosyphilis - in the cerebrospinal fluid.

The following medications are used to treat syphilis:

1. Penicillins:

● Benzathine benzylpenicillin (durant)

● Benzathine benzylpenicillin + Benzylpenicillin procaine(4:1) (durant);
● Benzylpenicillin (benzylpenicillin novocaine salt)
● Benzylpenicillin(benzylpenicillin sodium salt)
● Ampicillin
● Oxacillin

2. Tetracyclines:
Doxycycline 0.1 gram , not recommended to be prescribed with iron
supplements and antacids

given orally during or immediately after meals.

3. Macrolides:

Erythromycin. 0.5 gram /// taken 0.5 hours before meals.

4. Cephalosporins: Ceftriaxone

The first choice drug for the treatment of syphilis

is benzylpenicillin.

Contraindications to the use of penicillin drugs sensitive to

beta-lactams (drugs of the penicillin group):

1. previous history of severe allergy to penicillin or its derivatives.

2. in patients with Stevens-Johnson syndrome

should be prescribed with caution

1. patients with severe hypertension

2. history of myocardial infarction
3. diseases of the endocrine glands
4. acute gastrointestinal diseases
5. active tuberculosis
6. diseases of the hematopoietic system.
Before starting treatment

1. you should find out the tolerability of penicillin drugs and make a note
about this in the medical history.
2. Before the first injection of penicillin drugs (bicillins, novocaine salt of
penicillin), 1 tablet of one of the antihistamines (diphenhydramine,
suprastin, diazolies, scholfen, tavegil, fenkarol) is prescribed

Treatment of syphilis in patients with concomitant HIV infection

is carried out in accordance with the same algorithms and methods that are
adopted for HIV-negative patients

PREVENTIVE TREATMENT

● Benzathine benzylpenicillin 2.4 million units// intramuscularly// once

(the drug is injected at 1.2 million units into each gluteus maximus
muscle)

OR

● Benzathine benzylpenicillin + Benzylpenicillin procaine 1.5 million

units // intramuscularly// 2 times a week, 2 injections per course

OR

● Benzylpenicillin (benzylpenicillin novocaine salt) 600 thousand units

// intramuscularly // 2 times a day for 7 days

when intolerance to penicillin drugs

● Ceftriaxone 1.0 g // intramuscularly // 1 time per day daily for 5 days

 OR

● Doxycycline 0.1 g // orally // 2 times a day in within 10 days

OR

● Erythromycin 0.5 g // orally // 4 times a day for 10 days

The drug of choice is

● durable penicillin (benzathine benzylpenicillin) - a single injection

TREATMENT OF PRIMARY SYPHILIS:

● Benzathine benzylpenicillin 2.4 million units// intramuscularly// once

every 5 days , for course of 3 injection

OR

● Benzathine benzylpenicillin + Benzylpenicillin procaine 1.5 million

units // intramuscularly// 2 times a week, 5 injections per course

OR

● Benzylpenicillin (benzylpenicillin novocaine salt) 600 thousand units

// intramuscularly // 2 times a day for 14 days

OR

● Benzylpenicillin** (benzylpenicillin sodium salt) 1 million units //

intramuscularly // every 4 hours (6 times a day) for 14 days
 when intolerance to penicillin drugs

● Ceftriaxone 1.0 g // intramuscularly // 1 time per day daily for 10 days

OR

● Doxycycline 0.1 g // orally // 2 times a day in within 15 days

OR

● Erythromycin 0.5 g // orally // 4 times a day for 20 days

The Drug Of Choice

is benzathine benzylpenicillin

Treat The Patient In A Hospital

Benzylpenicillin (benzylpenicillin novocaine salt); benzylpenicillin

(benzylpenicillin sodium salt) if it is necessary to treat the patient in a
hospital (in case of a complicated course of the disease, in somatically
aggravated patients, etc.)

TREATMENT OF SECONDARY SYPHILIS

● Benzathine benzylpenicillin 2.4 million units// intramuscularly// once

every 5 days , for course of 6 injection

● Benzylpenicillin (benzylpenicillin novocaine salt) 600 thousand units

// intramuscularly // 2 times a day for 28 days
 OR

● Benzylpenicillin** (benzylpenicillin sodium salt) 1 million units //

intramuscularly // every 4 hours (6 times a day) for 28 days

when intolerance to penicillin drugs

● Ceftriaxone 1.0 g // intramuscularly // 1 time per day daily for 20 days

OR

● Doxycycline 0.1 g // orally // 2 times a day in within 28days

OR

● Erythromycin 0.5 g // orally // 4 times a day for 30days

The Drugs Of Choice

○ IF disease duration of LESS than 6 months===>Benzathine

benzylpenicillin
○ IF disease duration of MORE than 6 months===> benzylpenicillin
sodium salt or benzylpenicillin novocaine salt

TREATMENT OF EARLY LATENT SYPHILIS

SAME OF SECONDARY SYPHILIS EXCEPT NOT USE Benzathine

benzylpenicillin
 TREATMENT OF TERTIARY, LATENT LATE AND LATENT

UNSPECIFIED SYPHILIS

● Benzylpenicillin (benzylpenicillin novocaine salt) 600 thousand units

// intramuscularly // 2 times a day for 28 days

after 2 weeks - a second course of treatment in similar doses for 14 days

OR

● Benzylpenicillin** (benzylpenicillin sodium salt) 1 million units //

intramuscularly // every 4 hours (6 times a day)for 28 days

after 2 weeks - a second course of treatment in similar doses for 14 days

when intolerance to penicillin drugs

● Ceftriaxone 1.0 g // intramuscularly // 1 time per day dailyfor 20days

after 2 weeks - a second course of treatment in similar doses for 10 days

OR

● Doxycycline 0.1 g // orally // 2 times a day in within for 28 days

after 2 weeks - a second course of treatment in similar doses for 14 days

OR

● Erythromycin 0.5 g // orally // 4 times a day for for 28 days

after 2 weeks - a second course of treatment in similar doses for 14 days

The Drugs Of Choice

benzylpenicillin sodium salt or benzylpenicillin novocaine salt

NOTE

Treatment of patients with late forms of syphilis with oral antibiotics is

less effective and often develops serological resistance.

Tablet drugs can be prescribed only if all antibiotics administered

parenterally are intolerant

TREATMENT OF EARLY VISCERAL SYPHILIS

SAME OF SECONDARY SYPHILIS AND EARLY LATENT BUT WITHOUT USE ORAL
MEDICINE

● Benzylpenicillin (benzylpenicillin novocaine salt) 600 thousand units

// intramuscularly // 2 times a day for 28 days

OR

● Benzylpenicillin** (benzylpenicillin sodium salt) 1 million units //

intramuscularly // every 4 hours (6 times a day) for 28 days

TREATMENT OF LATE VISCERAL (INCLUDING

CARDIOVASCULAR) SYPHILIS
SAME TREATMENT OF OF TERTIARY, LATENT LATE AND LATENT
UNSPECIFIED SYPHILIS BUT patients with late cardiovascular
SYPHILIS NEED SPECIAL PREPARATION

Treatment of patients with late cardiovascular syphilis

 BEGINS WITH : a 2-week preparation with broad-spectrum
antibacterial drugs: doxycycline 0.1 g ´ 2 times a day, tetracycline OR
erythromycin 0.5 g ´ 4 times a day

Before using a broad-spectrum antibiotic, prescribe potassium iodide

in the form of a solution in increasing concentrations (2-3-5%) 1 tbsp.
l. ´ 3 times a day after meals,

Duration of use - 1 week for each concentration. Then,IF NO

interruption, they proceed to penicillin therapy

TREATMENT OF NEUROSYPHILIS

If the organs of vision and hearing are affected by syphilis in

patients====>should be started intravenous antibiotic therapy
according regimen for neurosyphilis (early or late) immediately
regardless of the results of SCF examination BECAUSE When the
sensory organs are damaged========> cerebrospinal fluid can be
either pathological (more often) or normal

TREATMENT OF PATIENTS WITH EARLY NEUROSYPHILIS

● Benzylpenicillin** (benzylpenicillin sodium salt)

○ 12 million units
○ 2 times a day
○ intravenously
○ for 20 days.
 when intolerance to penicillin drugs

● Ceftriaxone** – 2.0 g once a day intravenously for 20 days,

● in severe cases (syphilitic meningoencephalitis, acute generalized
meningitis) the daily dose of the drug may be increased to 4 g

To prevent an exacerbation reaction

in the first 3 days of penicillin therapy, it is advisable to take

prednisolone** in a decreasing daily dose of 90–60–30 mg (once in the
morning) [28,29].

NOTE

Treatment of patients with clinically manifest forms of neurosyphilis is

carried out in a neurological/psychiatric hospital

Specific treatment is prescribed by a dermatovenerologist.

Patients with neurosyphilis without symptoms can receive full medical care
in a dermatovenerological hospital.

THE TREATMENT OF LATE NEUROSYPHILIS IN ADULT

PATIENTS

● Benzylpenicillin** (benzylpenicillin sodium salt)

○ 12 million units
○ 2 times a day
○ intravenously
○ for 20 days.
● After 2 weeks, a second course of treatment is carried out according to a
similar scheme FOR 10 DAYS
To prevent an exacerbation reaction

in the first 3 days of penicillin therapy, it is advisable to take

prednisolone** in a decreasing daily dose of 90–60–30 mg (once in the
morning) [28,29].

NOTE

The patient should be treated ALSO under the supervision of an

ophthalmologist or otolaryngologist.

Follow-up examinations after treatment: 6 months, 1 year and then when

deciding whether to terminate observation

TREATMENT OF SYPHILIS IN PREGNANT WOMEN

● detection of syphilis is not a medical indication for termination of

pregnancy.

● should be started before the 32nd week of pregnancy and carried out
with drugs:

● WITH benzylpenicillin sodium salt or benzylpenicillin novocaine salt in

the same way as treatment of non-pregnant women,
● for pregnant women with intolerance to penicillin (including
semi-synthetic) and ceftriaxone**, due to a contraindication to
tetracycline drugs OR prescribing erythromycin

Preventive treatment

● is carried out to prevent congenital syphilis:

a) pregnant women who were treated for syphilis before

pregnancy, BUT whose non-treponemal serological tests continue
to have positive results
 b) pregnant women who received specific treatment for syphilis
during pregnancy

● preventive treatment for pregnant women, starting from the 20th

week of pregnancy

● The drugs doses and frequency of administration correspond to those

for specific treatment in the absence of pregnancy.

● . The duration of preventive therapy is 10 days, and if inadequacy

preventive treatment should last 20 days

when a pregnant woman is diagnosed with “late syphilis or syphilis

unspecified as early or late,”

● a second course of specific treatment

● carried out at 20 or more weeks of pregnancy for the purpose of
preventive treatment.

In cases of specific and preventive treatment in full

delivery can occur in a general maternity hospital on a general basis.

A child born without signs of congenital syphilis AND does not need
treatment

TREATMENT OF CHILDREN WITH EARLY CONGENITAL

SYPHILIS

Depending on age:

(benzylpenicillin sodium salt)

 ● children under 1 month of age – 100 thousand units per kg of body
weight per day, divided into 4 injections (every 6 hours),
intramuscularly;

● children aged 1 to 6 months – 100 thousand units per kg of body

weight per day, divided into 6 injections (every 4 hours),
intramuscularly;

● children aged 6 to 12 months – 75 thousand units per kg of body

weight per day, intramuscularly;

● children over 1 year of age – 50 thousand units per kg of body weight

per day intramuscularly

Duration of administration to children - within 28 days - both with

manifest and latent early congenital syphilis, including with damage to the
central nervous system, confirmed by positive serological reactions of the
cerebrospinal fluid

when intolerance to penicillin drugs

– ceftriaxone

● for children in the first two months of life is prescribed at a dose of 50

mg per kg of body weight per day in 2 administrations,

● for children from two months to 2 years - at a dose of 80 mg per kg of

body weight per day in 2 administrations.

● Duration of treatment – 28 days for both manifest early congenital

syphilis (including those with central nervous system damage) and
latent early congenital syphilis
 TREATMENT OF CHILDREN WITH LATE CONGENITAL

SYPHILIS

benzylpenicillin sodium salt

50 thousand units per kg of body weight per day, divided into 6

injections (every 4 hours) intramuscularly for 28 days; after 2 weeks -

a second course of treatment with similar dose for 14 days

when intolerance to penicillin drugs

– ceftriaxone

● for children in the 2-12 YEARS of life is prescribed at a dose of 80 mg

per kg of body weight per day in 2 administrations,FOR 28 DAYS

● a second course of treatment with similar dose for 14 days

TO AVOID A TOXIC REACTION(HERXHEIMER REACTION)

● on the first day of treatment, a single dose of benzylpenicillin**

should not exceed 5000 units per injection.

● After each injection on the first day, control thermometry and

monitoring of the child’s somatic condition are necessary.
 PREVENTIVE TREATMENT

It is carried out according to the method of preventive treatment of

adults, based on age-specific doses of antibacterial drugs.

Indicated For preventive Treatment:

1. all children under 3 years of age.

2. For older children, the issue of treatment is decided individually,
taking into account the form of syphilis in a contact adult, the location
of the rash, and the degree of contact of the child with the patient.

3. newborns born without manifestations of syphilis from :

a. an untreated OR
b. inadequately treated mother during pregnancy OR
c. did not receive preventive treatment during pregnancy.

TREATMENT IS :

Drugs, doses and frequency of administration correspond to those for

specific treatment

● The duration of therapy for newborns whose mother during

pregnancy did not receive preventive treatment or received inadequate
treatment is 14 days,

● The duration of therapy for newborns born without manifestations of

syphilis from an untreated mother - 28 days.

● Children born to mothers who received specific treatment before

pregnancy and preventive treatment during pregnancy, who at the
time of birth continue to have positive non-treponemal tests with
 persistent low titers (RMP <1:2, RPR <1:4), prophylactic treatment is
not indicated if non-treponemal tests in the child are negative or their
titers do not exceed those in the mother.

● Confirmation of the treatment of the mother should be considered the

availability of medical documentation.

REINFECTION

Diagnosis of reinfection is based on a set of criteria, of which the first four

are mandatory:

1. the fact of the primary disease is confirmed by medical

documentation

2. full treatment has been carried out for the primary disease, which is
confirmed by medical documentation

3. during the primary treatment, there was a timely resolution of the

rashes

4. within 12 months after the end of treatment of the primary disease,

there was at least a fourfold decrease in titers, a decrease in positivity
or negativity of non-treponemal tests (BC or its analogues)

5. with the reappearance of syphilitic rashes (if any), Treponema

pallidum was detected in their discharge by dark-field microscopy

6. there are repeated positive indicators of previously negative

non-treponemal tests or at least a fourfold increase in their titer
compared to the initial one
 7. antitreponemal IgM antibodies were detected using IgM-ELISA or
IgM-IB; 8. a new source of infection has been identified, which has
been proven to have an early form of syphilis

ACTION TAKE

1. exclusion of reinfection and in the absence of specific pathology

of the nervous system and internal organs.
2. Additional treatment is usually carried out once with the
following drugs: (benzylpenicillin sodium salt) 12 million units 2
times a day intravenously for 20 days

OR

ceftriaxone 1.0 g 2 times a day intramuscularly for 20 days

EVALUATION OF TREATMENT RESULTS

● THE treatment results ===> negativity of non-treponemal

serological OR a decrease in antibody titer by 4 or more times
within 12 months after the end of specific therapy for early
forms syphilis

● SPECIFIC TROPONIMA SEROLOGY TEST (RIF, ELISA, and

RPGA) NOT become negative after treatment.

● negation of RIBT, but this usually AFTER 2-3 years the end of
therapy
 THE CRITERIA FOR THE EFFECTIVENESS OF TREATMENT

OF NEUROSYPHILIS

THE CRITERIA ARE

1. Normalization of pleocytosis within 6 months after the end of

therapy;
2. Reduction or normalization of protein levels - within 2 years after the
end of treatment;
3. Disappearance of antibodies determined in non-treponemal studies
from the cerebrospinal fluid within 6-12 months after the end of
therapy.
4. Absence of new neurological symptoms
5. Increase in existing neurological symptoms

THE CRITERIA FOR THE INEFFECTIVENESS OF TREATMENT

OF SYPHILIS

1. persistence or re-occurrence of clinical manifestations (clinical relapse),

2. a sustained increase of 4 times or more compared to the initial values of
the titer of nonspecific serological reactions
3. repeated positivity of non-treponemal tests after a period of temporary
negativity in the absence of data for reinfection (serological relapse),
4. persistent persistence of positive non-treponemal tests without a
tendency to decrease antibody titers within 12 months after the end of
specific therapy for early forms of syphilis (serological resistance)
 SIDE EFFECTS AND COMPLICATIONS OF THERAPY

1. EXACERBATION REACTION (JARISCH-HERXHEIMER)

● An exacerbation reaction is observed in 30% of patients with early

syphilis.
● clinical manifestations of an exacerbation reaction begin 2-4 hours
after the first administration of an antibacterial of the drug, reach
maximum severity after 5-7 hours, within 12-24 hours the condition
normalizes.
● The main clinical symptoms are
○ chills and a sharp increase in body temperature (up to 39°C,
sometimes higher).
○ general malaise, headache, nausea, pain in muscles, joints,
tachycardia, increased breathing, decreased blood pressure,
leukocytosis
○ With secondary syphilis, roseolous and papular rashes become
more numerous, brighter, edematous, sometimes the elements
merge due to abundance (the so-called local exacerbation
reaction).
○ against the background of an exacerbation reaction, secondary
syphilides first appear in places where they was not present
before the start of treatment.
○ patients may develop psychosis, stroke, seizure disorder, liver
failure.
● A rapidly transient exacerbation reaction usually does not require any
special treatment.

COMPLICATION

1. IN pregnant women, as it can provoke premature birth, toxic disorders in

fetus and stillbirth;

2. in patients with neurosyphilis, can provoke progressive development
neurological symptoms;
3. in patients with damage to the organ of vision: especially syphilitic
mesaortitis.
4. High fever and severe intoxication syndrome can be: dangerous in patients
withchronic pathology of the cardiovascular system, severe somatic
diseases in the stage of decompensation.

AVOID AN EXACERBATION REACTION

1. it is advisable to prescribe penicillin therapy in the first 3 days

orally or intramuscularly prednisolone** 90-60-30 mg per day (once in

the morning) OR in a decreasing dosage 75-50-25 mg per day