Clinical Management of Early Syphilis

Katherine M Holman; Edward W HookIII


Expert Rev Anti Infect Ther. 2013;11(8):839-843. 

In This Article

Present Treatment Recommendations

Syphilis definitions and treatment guidelines vary throughout the world: North American guidelines are different than those used in Europe. However, even within Europe, guidelines differ and even the WHO approaches treatment slightly differently from recommendations made in some European nations. This review will focus on syphilis management in North America. Treatment of early (primary, secondary or early latent) syphilis in non-pregnant immunocompetent individuals has changed little in the past few decades.[14–17] Intramuscular (IM) benzathine penicillin remains the mainstay of therapy. Recommended treatment regimens are based on syphilis stage at diagnosis, reflecting assumptions that more recently acquired infections (primary, secondary or early latent) may be reliably treated for shorter durations than more long-standing infections (late latent or tertiary). Among persons with latent syphilis, classification into early or late stages is necessary for determination of duration of therapy. Early latent syphilis is defined as latent syphilis (i.e., a person without clinical signs of infection) in a person documented to have developed a reactive serology for syphilis, who had classical signs of primary or secondary syphilis, or who is a documented sexual contact of a patient with early syphilis, in the past year. If this cannot be established, persons with latent syphilis should be treated for a longer, 3-week course as late latent syphilis. For this review, the authors will focus on early syphilis (primary, secondary and early latent). Routine cerebrospinal fluid (CSF) evaluation is not recommended in patients with early syphilis, despite the fact that CSF abnormalities are commonly present in persons with early syphilis most often in the absence of clinically apparent neurological abnormalities. There are no data to conclusively show that the presence of abnormal CSF findings in persons with early syphilis changes the outcomes of therapy. If signs/symptoms of neurosyphilis are present, further evaluation is recommended. The 2010 CDC STD Treatment Guidelines recommend a single administration of 2.4 million units of benzathine penicillin intramuscularly or doxycycline 100 mg orally twice-daily for 14 days for penicillin allergic patients.[17] Tetracycline remains in the guidelines, however, doxycycline is preferred on the assumption that medication adherence is improved with twice-daily dosing. Data on ceftriaxone and azithromycin will be discussed later in the review.