39 TREATMENT OF SPECIFIC ed as congenital fi and needs to be cient, fi ) or acquired (through sex or blood ) or acquired (through in utero ). The can be classi ). The infection T. pallidum ( provide effective treatment for . A uid (CSF) to fl GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES level of greater than 0.018 mg per litre is considered suf maintained for at least 7–10 days in early syphilis, and for a longer duration in maintained for at least 7–10 days in early syphilis, and at a dose of 2.4 million late syphilis. Long-acting benzathine , A treponemicidal level of antimicrobials needs to be achieved in the serum and A treponemicidal level of antimicrobials needs to be achieved cerebrospinal Therapeutic considerations Therapeutic (transmitted from mother to child (transmitted from CLINICAL PRESENTATION SUMMARY PRESENTATION CLINICAL and is caused by the , disease from the outset Syphilis is a systemic pallidum 3.4. SYPHILIS In the early phase of primary syphilis the /non-treponemal tests, such as In the early phase of primary syphilis the cardiolipin/non-treponemal (RPR) the Venereal Disease Research Laboratory (VDRL) and as absence of syphilis tests may be negative and should, therefore, not be interpreted infection. As its name implies, latent syphilis has no clinical manifestations. Early latent As its name implies, latent syphilis two years duration. An infection of more than two syphilis is infection of less than evidence of treponemal infection is referred to as years duration without clinical based this division on the infectiousness of syphilis late latent syphilis. WHO has Early stages are more infectious but respond better to and its response to therapy. treatment. Primary syphilis is characterised by an or at the site of infection or Primary syphilis is characterised manifestations include a , condylomata . Secondary syphilis and generalised . lata, mucocutaneous Acquired syphilis is divided into early and late syphilis. Early syphilis comprises the into early and late syphilis. Early syphilis comprises Acquired syphilis is divided latent stages. Late syphilis refers to late latent syphilis, primary, secondary and early cardiovascular syphilis. gummatous, neurological and transfusion). H. ducreyi , rst year after therapy. fi C. trachomatis increase in the titre of a non-treponemal test. rmed fi GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES there is con clinical signs or symptoms of active syphilis persist or recur; clinical signs or symptoms of active syphilis persist or Examination of the CSF should be undertaken before repeat treatment, unless Examination of the CSF should be undertaken before repeat Patients should be reinfection and a diagnosis of early syphilis can be established. of more than two years’ re-treated with the schedules recommended for syphilis because adequately duration. In general, only one re-treatment course is indicated tests. treated patients often maintain stable, low titres of non-treponemal ■ ■ Follow-up of patients treated for syphilis Follow-up for early syphilis should be based on available The follow-up of patients treated The clinical condition of the patients should be medical services and resources. to detect reinfection during the assessed and attempts made Management of patients with cardiovascular syphilis should include consultation cardiovascular syphilis should include consultation Management of patients with with cardiovascular syphilis and with a cardiologist. All patients years. The follow-up should include clinical, should be monitored for many on the clinician’s assessment of the individual patient’s serological, CSF and, based condition, radiological examinations. and the gonococcus. Parenteral, rather than oral, penicillin treatment is preferred as it provides is preferred as it provides than oral, penicillin treatment Parenteral, rather required treatment. More data are and supervised guaranteed bioavailability can be generally recommended. or oral azithromycin before either effective against has the advantage of being Azithromycin units, provides a treponemicidal penicillinaemia for up to three weeks and is weeks and for up to three penicillinaemia a treponemicidal units, provides for late syphilis treatment. recommended At all stages of the disease, repeat treatment should be considered when: At all stages of the disease, repeat treatment should be Patients with early syphilis who have been treated with appropriate doses and Patients with early syphilis benzylpenicillin should be evaluated clinically and preparations of benzathine of test, after three months to assess the results serologically, using a non-treponemal six months and, if indicated therapy. A second evaluation should be performed after the condition of the by the results at this point, again after 12 months to reassess patient and detect possible reinfection.

40 TREATMENT OF SPECIFIC INFECTIONS 41 TREATMENT OF SPECIFIC INFECTIONS and HIV, T. pallidum neurosyphilis is probably low. Although data are cacy in fi GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES Penicillin desensitisation of pregnant women with syphilis requires that the Penicillin desensitisation of pregnant women with syphilis feasible at most primary procedure be performed in a hospital setting. This is not procedure. health care settings and cannot be recommended as a routine lacking, consideration should probably be given to using an extended course of a lacking, consideration should probably be given to using penicillin allergy is not third-generation in pregnant women whose manifested by anaphylaxis. The effectiveness of in all stages of syphilis and its ability to prevent The effectiveness of erythromycin in all stages of syphilis and many failures the stigmata of are both highly questionable, have been reported. Its ef SYPHILIS IN regarded as a separate group, requiring close Pregnant women should be detect possible reinfection after treatment has been surveillance, in particular to treat their sexual partner(s). Pregnant patients at given. It is also important to are not allergic to penicillin, should be treated with all stages of pregnancy, who schedules recommended for the treatment of non- penicillin according to the dosage pregnant patients at a similar stage of the disease. Recommended therapy for early syphilis in HIV-infected patients is no different Recommended therapy for with HIV. However, some authorities advise from that in patients not infected more intensive treatment with a regimen examination of the CSF and/or with the dual infections of appropriate for all patients SYPHILIS AND SYPHILIS HIV INFECTION HIV infection to undergo testing for syphilis should be encouraged All patients with clinical and its implications for high frequency of dual infection because of the the differential should be considered in management. Neurosyphilis assessment and of congenital individuals. In cases disease in HIV-infected diagnosis of neurological if her test is to undergo testing for HIV; should be encouraged syphilis, the mother follow-up. should be referred for positive, the infant regardless of the clinical stage of syphilis. In all cases, careful follow-up is necessary of syphilis. In all cases, careful follow-up is necessary regardless of the clinical stage to ensure adequacy of treatment. and late (becomes rst two years of life) fi c may aid diagnosis. fi have found it rst prenatal visit. Some programmes fi remain, negative. Any rmed that serological tests are, and fi GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES of pregnancy and at delivery in populations cial to repeat the tests at 28 weeks fi carried over from mother to baby usually disappears within three months mother to baby usually disappears within three months antibody carried over from of birth. Where available, IgM-speci Congenital syphilis may occur if the expectant mother has syphilis, but the Congenital syphilis may occur given penicillin during pregnancy. All infants of risk is minimal if she has been be examined at birth and at monthly intervals for three seropositive mothers should months until it is con clinically and serologically, Early congenital syphilis generally responds well, both in seriously ill children with to adequate doses of penicillin. Recovery may be slow Those in poor extensive skin, , bone or visceral involvement. such as pneumonia. nutritional condition may succumb to concurrent infections, with a high incidence of congenital syphilis. with a high incidence of congenital with a single All infants born to seropositive mothers should be treated IU/kg whether or not the intramuscular dose of benzathine benzylpenicillin, 50 000 penicillin). Hospitalization mothers were treated during pregnancy (with or without who were seropositive. is recommended for all symptomatic babies born to mothers CSF (up to two years Symptomatic infants and asymptomatic infants with abnormal of age) should be treated as for early congenital syphilis. Prevention of congenital syphilis is feasible. Programmes should implement Prevention of congenital syphilis for syphilis in pregnant women. Screening for syphilis effective screening strategies should be conducted at the apparent later in life). bene Congenital syphilis is divided into early ( Congenital syphilis CONGENITAL SYPHILIS CONGENITAL Follow-up Follow-up be serological tests should quantitated non-treponemal Following treatment, be and re-treatment should monthly intervals until delivery, performed at of reinfection or relapse. there is serological evidence undertaken if

42 TREATMENT OF SPECIFIC INFECTIONS 43 TREATMENT OF SPECIFIC INFECTIONS 2.4 million IU by , at a 2.4 million IU by intramuscular 8 1.2 million IU by intramuscular injection, daily for 10 1.2 million IU by intramuscular 9 GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES single session. Because of the volume involved, this dose is usually given as two single session. Because of the injections at separate sites consecutive days benzathine benzylpenicillin, 2.4 million IU by intramuscular injection, once benzathine benzylpenicillin, 2.4 million IU by intramuscular weekly for 3 consecutive weeks erythromycin, 500 mg orally, 4 times daily for 14 days , 100 mg orally, twice daily for 14 days doxycycline, 100 mg orally, 4 times daily for 14 days , 500 mg orally, procaine benzylpenicillin, benzathine benzylpenicillin, Benzathine benzylpenicillin synonyms: benzathine penicillin G; benzylpenicillin benzathine; benzathine penicillin. Benzathine benzylpenicillin synonyms: benzathine penicillin G; benzylpenicillin benzylpenicillin synonyms: procaine penicillin G. Procaine ■ Recommended regimen LATE LATENT SYPHILIS LATENT LATE of treponemal (infection of more than two years’ duration without evidence infection) ■ Alternative regimen for penicillin-allergic pregnant patients Alternative regimen for penicillin-allergic OR ■ Alternative regimen for penicillin-allergic non-pregnant patients Alternative regimen for penicillin-allergic ■ Alternative regimen ■ ■ Recommended regimen Recommended EARLY SYPHILIS EARLY not more than two years’ duration) or latent syphilis of (primary, secondary, TREATMENT REGIMEN FOR SYPHILIS REGIMEN TREATMENT 8 9 12–24 million IU by intravenous injection, 12–24 million IU by intravenous 10 GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES Aqueous benzylpenicillin synonyms: benzylpenicillin potassium; benzylpenicillin sodium; crystalline penicillin, Aqueous benzylpenicillin synonyms: benzylpenicillin potassium; benzylpenicillin Some authorities recommend adding benzathine benzylpenicillin, 2.4 million IU Some authorities recommend adding benzathine benzylpenicillin, weekly, after completing by intramuscular injection, in 3 consecutive doses once Benzathine these regimen, but there are no data to support this approach. does not give adequate benzylpenicillin, 2.4 million IU by intramuscular injection therapeutic levels in the CSF. procaine benzylpenicillin, 1.2 million IU by intramuscular injection, once daily, procaine benzylpenicillin, 1.2 4 times daily, both for 10–14 days and probenecid, 500 mg orally, aqueous benzylpenicillin, erythromycin, 500 mg orally, 4 times daily for 30 days erythromycin, 500 mg orally, tetracycline, 500 mg orally, 4 times daily for 30 days tetracycline, 500 mg orally, doxycycline, 100 mg orally, twice daily for 30 days mg orally, twice daily for doxycycline, 100 procaine benzylpenicillin, 1.2 million IU by intramuscular injection, once daily for by intramuscular injection, 1.2 million IU procaine benzylpenicillin, days 20 consecutive administered daily in doses of 2–4 million IU, every 4 hours for 14 days administered daily in doses Note ■ This regimen should be used only for patients whose outpatient compliance can be This regimen should be used only for patients whose outpatient assured. ■ Alternative regimen ■ NEUROSYPHILIS Recommended regimen ■ Alternative regimen for penicillin-allergic pregnant patients Alternative regimen for penicillin-allergic OR ■ Alternative regimen for penicillin-allergic non-pregnant patients for penicillin-allergic Alternative regimen ■ Alternative regimen Alternative ■ penicillin G potassium; penicillin G sodium. 10

44 TREATMENT OF SPECIFIC INFECTIONS 45 TREATMENT OF SPECIFIC INFECTIONS ndings fi cacy is not yet well fi of life and every 8 hours rst 7 days fi GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES AND Infants with abnormal CSF were abnormal. Antimicrobials other than penicillin (e.g. erythromycin) are not were abnormal. Antimicrobials other than penicillin (e.g. Some experts treat all infants with congenital syphilis as if the CSF Some experts treat all infants with congenital syphilis as procaine benzylpenicillin, 50 000 IU/kg by intramuscular injection, as a single procaine benzylpenicillin, 50 000 IU/kg by intramuscular daily dose for 10 days aqueous benzylpenicillin 100 000–150 000 IU/kg/day administered as 50 000 aqueous benzylpenicillin 100 000–150 000 IU/kg/day administered IU/kg/dose IV every 12 hours, during the thereafter for a total of 10 days The may be involved during any stage of syphilis. Clinical may be involved during any stage of syphilis. Clinical The central nervous system (e.g. optic or auditory symptoms, or cranial evidence of neurological involvement of the CSF. However, examination of the nerve palsies) warrants examination in all patients with syphilis of more than two years’ CSF is also highly desirable in order to evaluate the possible presence of duration, or of uncertain duration, Some experts recommend consulting a neurologist asymptomatic neurosyphilis. neurosyphilis. Careful follow-up is essential. when caring for a patient with tetracycline, 500 mg orally, 4 times daily for 30 days mg orally, 4 times daily tetracycline, 500 have not treatment of neurosyphilis to penicillin for the The above alternatives studies. Although their ef been evaluated in systematic doxycycline, 200 mg orally, twice daily for 30 days mg orally, twice daily for doxycycline, 200 documented, third-generation may be useful in the treatment of documented, third-generation neurosyphilis. A. Early congenital syphilis (up to 2 years of age) A. Early congenital syphilis (up Note ■ OR ■ ■ CONGENITAL SYPHILIS CONGENITAL ■ ■ Note OR ■ Alternative regimen for penicillin-allergic non-pregnant patients patients non-pregnant penicillin-allergic regimen for Alternative ■ Recommended regimen . H. ducreyi rst month of life fi GUIDELINES FOR THE MANAGEMENT OF SEXUALLY TRANSMITTED INFECTIONS TRANSMITTED OF SEXUALLY THE MANAGEMENT FOR GUIDELINES erythromycin, 7.5–12.5 mg/kg orally, 4 times daily for 30 days erythromycin, 7.5–12.5 mg/kg aqueous benzylpenicillin, 200 000–300 000 IU/kg/day by intravenous or IU/kg/day by intravenous 200 000–300 000 aqueous benzylpenicillin, hours for 50 000 IU/kg/dose every 4–6 injection, administered as intramuscular 10–14 days recommended for congenital syphilis except in cases of allergy to penicillin. to penicillin. of allergy except in cases syphilis for congenital recommended children. should not be used in young Follow-up Follow-up of improvement or All patients should be followed up until there is clear evidence to be less effective, but cure. In patients infected with HIV, treatment may appear syphilis. Since this may be a result of coinfection with or failure is likely to be seen and HIV infection are closely associated, and therapeutic up weekly until there is clear with increasing frequency, patients should be followed evidence of improvement. The infection is common in several parts of the world including Africa, the The infection is common in Owing to widespread in all Caribbean and south-east Asia. and are not recommended for treatment geographical areas, tetracyclines single-dose treatments with effective of chancroid. To enhance compliance, are preferred. Management of lesions be kept clean. Fluctuant No special treatment is required. Ulcerative lesions should the surrounding healthy lymph nodes should be aspirated as required through healing and is not skin. Incision and drainage or excision of nodes may delay recommended. The causative organism is a Gram-negative facultative anaerobic bacillus, The causative organism is a 3.5. CHANCROID ■ Alternative regimen for penicillin-allergic patients, after the Alternative regimen for penicillin-allergic Recommended regimen Recommended ■ B. Congenital syphilis of 2 or more years B. Congenital syphilis

46 TREATMENT OF SPECIFIC INFECTIONS