Treatment Guideline Chart
Syphilis is a vertically or sexually transmitted infection caused by Treponema pallidum subspecies pallidum.
In the primary stage of acquired syphilis, there is an appearance of a painless ulcer (chancre). Then in the secondary stage, there are skin rashes and sores on mucous membranes.
In the latent stage, it is asymptomatic and not communicable. It is in the tertiary or late stage that it is symptomatic but not communicable; it usually appears 10-20 years after 1st infection.

Syphilis%20-%20primary Management

Follow Up

  • Assessing response to treatment is often difficult and definitive criteria for cure or failure have not been established
  • Monitor patient for persistence and recurrence of symptoms
  • Watch out for disease progression and complications
Repeat Lab Exams
  • After 6 and 12 months of treatment, patients should be re-examined clinically and serologically
    • After treatment of early syphilis, the nontreponemal test (NTT) titer should decline 4-fold (2 dilution steps) within 6 months
    • Same NTT should be used to monitor treatment response during follow-up
  • More frequent evaluation should be done if follow-up is uncertain
Probable Treatment Failure or Reinfection
  • Consider in patients with persistent or recurrent symptoms and patients with NTT titers which do not decline 4-fold within 6 months after therapy for early syphilis
  • Patients with constant low titers for a long period of time (“serofast reaction”) should be retreated and re-assessed for human immunodeficiency virus (HIV) infection
  • These patients should have additional clinical and serological follow-up; if additional follow-up cannot be ensured, retreatment is recommended
    • Consider retreatment with Benzathine penicillin administered weekly x 3 weeks, unless cerebrospinal fluid (CSF) exam indicates presence of neurosyphilis
  • Perform CSF analysis to help distinguish reinfection from treatment failure
    • CSF exam may be needed to rule out unrecognized CNS infection
  • In rare instances, serologic titers do not decline despite a negative CSF exam and a repeated course of therapy; additional therapy or repeated CSF exams are not warranted in these situations


Human Immunodeficiency Virus (HIV) Counselling and Testing

  • Sexually transmitted infection (STI) consultation allows for an opportunity to discuss patient’s risk factors for STIs and HIV
  • Determine patient’s risk for HIV and discuss HIV testing
  • Testing for HIV is recommended and should be offered to all persons seeking evaluation and treatment for STIs
    • Pretest and post-test counseling as well as informed consent are part of the testing procedure
    • Concomitant infection with HIV may complicate management and control of some STIs
    • In areas with high HIV prevalence, patients with primary syphilis should be retested for HIV after 3 months of 1st negative HIV test
  • The presence of syphilitic chancres makes it easier to transmit and acquire HIV infection sexually
    • There is an estimated 2- to 5-fold increased risk of acquiring HIV infection when syphilis is present

Special Consideration


  • All pregnant patients should be screened for syphilis at the 1st antenatal visit
  • Benzathine or procaine penicillin therapy is given to pregnant patients  
    • Used with caution, alternative agents for early syphilis include Erythromycin, Ceftriaxone, or Azithromycin while for late syphilis Erythromycin 
  • Pregnant patients who are penicillin-allergic should be desensitized and managed with penicillin
    • When treatment is started in the last trimester, it is advised that a 2nd dose of Benzathine penicillin be given 1 week after the 1st dose
    • Placental penetration of penicillin alternatives, eg Erythromycin and Azithromycin, is unreliable; therefore, treatment of baby with penicillin upon delivery is advised
  • Pregnant women treated for early syphilis should have monthly NTT for the rest of their pregnancy
  • Risk of treatment failure increases with ultrasound signs of fetal ascites, hepatomegaly, placental thickening, etc
  • Referral to fetal medicine for evaluation of fetal involvement and monitoring for fetal distress during the early course of treatment is recommended after 26 weeks of gestation

Evaluation & Treatment of Sex Partners

  • Sex partners of sexually transmitted infection (STI) patients are likely to be infected and should be offered treatment to prevent further STI transmission and reinfection
  • Female partners of male STI patients may be asymptomatic, thus, the importance of partner notification and management
  • Patients and their sex partners should be instructed to abstain from sexual intercourse until they and their partners have completed the treatment
  • At-risk sex partners of patients with primary syphilis are those who had sexual contact with the patient during the period starting from 3 months before treatment plus the duration of the patient’s symptoms
    • These persons should be treated presumptively even if they are seronegative
    • Sex partners exposed >3 months before the diagnosis of primary syphilis in the patient should be treated presumptively if serologic test results are not immediately available and follow-up is uncertain
  • Preventive treatment for partners of patients with later latent syphilis is not recommended 
Editor's Recommendations
Special Reports