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SYPHILIS - PRIMARY
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.

Principles of Therapy

  • A treponemocidal level of antimicrobials needs to be achieved in the serum to provide effective treatment for primary syphilis
  • Follow recommendations for treatment of late syphilis if the stage of syphilis is unknown
  • Duration of treponemocidal level of antibiotic should be at least 7-10 days

Pharmacotherapy

Antibiotic Therapy

Penicillin

  • Eg Benzathine, aqueous procaine, aqueous crystalline penicillin, Amoxicillin
  • Preferred drug for the treatment of all stages of syphilis
    • Parenteral penicillin G is the only therapy with documented efficacy for syphilis during pregnancy
  • Adequate penicillin therapy ends infectivity within 24-48 hours
  • Parenteral route is preferred because it provides guaranteed bioavailability and supervised treatment
    • Oral penicillin preparations are not appropriate for the treatment of syphilis
  • Replacing half of the solvent by Lidocaine 1% solution may reduce injection-associated pain
  • Efficacy of penicillin is well established based on clinical experience, case series and clinical trials

Alternatives to Penicillin

  • May be used for the treatment of primary syphilis in patients who are non-pregnant, penicillin-allergic and inpatients who refuse parenteral treatment
  • Data to support the use of alternatives to penicillin in the treatment of early syphilis are limited; hence, patient streated with alternative agents to penicillin should be followed closely because efficacy of these regimens is not well documented

Tetracycline Derivatives

  • Eg Doxycycline, Tetracycline
  • Doxycycline can be given as an alternative to Penicillin in both early and late syphilis  
    • Avoid Doxycycline in pregnant women

Cephalosporin

  • Ceftriaxone
    • Penetrates blood-brain barrier well

Macrolides

  • May be considered if there is no other suitable treatment option and close follow-up can be done
  • Azithromycin  
    • Intrinsically resistant T pallidum strains have been detected
    • Also effective against C trachomatis, N gonorrhoeae and H ducreyi
  • Erythromycin
    • Least effective and does not penetrate blood-brain and placental barrier
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