Syphilis%20-%20primary Management

• 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

• 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

• 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

Pregnancy

• 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

• 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