Syphilis: Therapy

by John Fisher, MD

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    00:01 So in terms of treating syphilis, the treatment for the different stages is of note and could be important in terms of the patient care, number one, and test taking, number two.

    00:19 So first of all, let’s talk about the treatment of early syphilis and what we’re talking about is primary, secondary, and early latent syphilis.

    00:32 It should be remembered the Treponema pallidum thankfully remains very susceptible to penicillin G, my favorite antibiotic, and we can use a long-acting form of penicillin G, benzathine penicillin G, in a single dose of 2.4 million units intramuscularly.

    00:55 That’s the treatment for the vast majority of people.

    01:00 Alternatively, if a patient is allergic to penicillin, or can’t tolerate intramuscular penicillin, then doxycycline given twice a day for 2 weeks, or ceftriaxone given daily for 10-14 days is an appropriate alternative.

    01:24 Now if we’re talking about late latent syphilis, tertiary syphilis or syphilis of unknown duration, then we still use benzathine penicillin.

    01:38 But instead of a single dose, we use three doses separated by a week.

    01:44 And alternatively, we use in patients who can’t tolerate penicillin for some reason, 28 days of doxycycline.

    01:54 Neurosyphilis is a totally different animal.

    01:58 For neurosyphilis, what we’re going to be using is intravenous high-dose penicillin G, and that’s because it may be difficult to deliver penicillin across the blood-brain barrier in levels high enough to kill the spirochetes.

    02:22 So we use high-dose IV penicillin and we use it for 10-14 days.

    02:29 So this often requires hospitalization and set-up of home IV antibiotics.

    02:38 We can also give Procaine penicillin intramuscularly daily plus probenecid.

    02:45 Probenecid blocks the renal excretion of penicillin and keeps the levels of penicillin high enough.

    02:53 But to get injections once a day for 10-14 days is problematic and painful for patients.

    03:03 Alternatively, we can use ceftriaxone 2 grams IM or IV daily for 14 days.

    03:11 So pregnant patients with neurosyphilis should be treated as for non-pregnant patients.

    03:20 And let’s assume, for example, they’re allergic to penicillin.

    03:24 I’m sorry -- they still need high-dose IV penicillin.

    03:30 and they can’t take doxycycline.

    03:34 So the treatment would involve desensitizing them to penicillin so that you can use penicillin in these patients.

    03:43 And that concludes my discussion of syphilis.

    03:50 And please note this at the end - Antimicrobial therapy of all stages of syphilis can be complicated by the 'Jarish-Herxheimer reaction'. This means the manifestations of the disease may flair as antigens of dying organisms appear in the bloodstream.

    About the Lecture

    The lecture Syphilis: Therapy by John Fisher, MD is from the course Genital and Sexually Transmitted Infections.

    Included Quiz Questions

    1. High-dose intravenous penicillin for 10–14 days
    2. Oral penicillin V (500 mg) 4 times per day for 28 days
    3. High-dose intramuscular benzathine penicillin for 10-14 days
    4. Oral doxycycline (100mg) twice a day for 28 days
    5. A single dose of intravenous ceftriaxone (1 g)
    1. A single intramuscular dose of penicillin G benzathine 2.4 million units
    2. An intramuscular dose of penicillin G benzathine 2.4 million units once every week for 3 weeks
    3. A daily intramuscular dose of penicillin G benzathine 2.4 million units for 3 weeks
    4. Oral doxycycline (100 mg) twice a day for 28 days
    5. A single dose of intravenous ceftriaxone (1 g)
    1. Desensitizing to penicillin followed by treating with intravenous penicillin
    2. Ceftriaxone 1 g intramuscularly for 2 weeks
    3. Intramuscular procaine benzylpenicillin AND probenecid for 14 days
    4. Doxycycline 100mg orally twice a day for 14 days
    5. A single intramuscular dose of benzathine penicillin G 2.4 MU with close monitoring for 8 hours

    Author of lecture Syphilis: Therapy

     John Fisher, MD

    John Fisher, MD

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