Syphilis management for primary and secondary stages: Difference between revisions
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*Patients who have syphilis and [[Neurosyphilis#Clinical presentation: Four clinical types|symptoms or signs suggesting neurologic disease]] (e.g., [[meningitis]] and [[hearing loss]]) or ophthalmic disease (e.g., [[uveitis]], [[iritis]], [[neuroretinitis]], and [[optic neuritis]]) should have an evaluation that includes [[Syphilis laboratory tests#CSF analysis|CSF analysis]], [[Syphilis physical examination#Ophthalmic examination|ocular slit-lamp ophthalmologic examination]], and otologic examination. Treatment should be guided by the results of this evaluation. | *Patients who have syphilis and [[Neurosyphilis#Clinical presentation: Four clinical types|symptoms or signs suggesting neurologic disease]] (e.g., [[meningitis]] and [[hearing loss]]) or ophthalmic disease (e.g., [[uveitis]], [[iritis]], [[neuroretinitis]], and [[optic neuritis]]) should have an evaluation that includes [[Syphilis laboratory tests#CSF analysis|CSF analysis]], [[Syphilis physical examination#Ophthalmic examination|ocular slit-lamp ophthalmologic examination]], and otologic examination. Treatment should be guided by the results of this evaluation. | ||
*Invasion of [[CSF]] by T. pallidum accompanied by [[Syphilis laboratory tests#CSF analysis|CSF laboratory abnormalities]] is common among adults who have [[Syphilis pathophysiology#Primary syphilis|primary]] or [[Syphilis pathophysiology#Secondary syphilis|secondary]] syphilis.<ref name=" | *Invasion of [[CSF]] by T. pallidum accompanied by [[Syphilis laboratory tests#CSF analysis|CSF laboratory abnormalities]] is common among adults who have [[Syphilis pathophysiology#Primary syphilis|primary]] or [[Syphilis pathophysiology#Secondary syphilis|secondary]] syphilis.<ref name="pmid3056164">Lukehart SA, Hook EW, Baker-Zander SA, Collier AC, Critchlow CW, Handsfield HH (1988) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=3056164 Invasion of the central nervous system by Treponema pallidum: implications for diagnosis and treatment.] ''Ann Intern Med'' 109 (11):855-62. PMID: [http://pubmed.gov/3056164 3056164]</ref> Therefore, in the absence of clinical neurologic findings, no evidence exists to support variation from the recommended treatment regimen for early syphilis. | ||
*[[Neurosyphilis#Clinical presentation: Four clinical types|Symptomatic neurosyphilis]] develops in only a limited number of persons after treatment with the penicillin regimens recommended for [[Syphilis pathophysiology#Primary syphilis|primary]] and [[Syphilis pathophysiology#Secondary syphilis|secondary]] syphilis. Therefore, unless clinical signs or symptoms of neurologic or ophthalmic involvement are present or treatment failure is documented, routine [[Syphilis laboratory tests#CSF analysis|CSF analysis]] is not recommended for persons who have [[Syphilis pathophysiology#Primary syphilis|primary]] or [[Syphilis pathophysiology#Secondary syphilis|secondary]]. | *[[Neurosyphilis#Clinical presentation: Four clinical types|Symptomatic neurosyphilis]] develops in only a limited number of persons after treatment with the penicillin regimens recommended for [[Syphilis pathophysiology#Primary syphilis|primary]] and [[Syphilis pathophysiology#Secondary syphilis|secondary]] syphilis. Therefore, unless clinical signs or symptoms of neurologic or ophthalmic involvement are present or treatment failure is documented, routine [[Syphilis laboratory tests#CSF analysis|CSF analysis]] is not recommended for persons who have [[Syphilis pathophysiology#Primary syphilis|primary]] or [[Syphilis pathophysiology#Secondary syphilis|secondary]]. | ||
==Follow-Up== | |||
*'''''Treatment failure''''' can occur with any regimen. However, assessing response to treatment frequently is difficult, and definitive criteria for cure or failure have not been established. | |||
:*In addition, [[Syphilis laboratory tests#Nontreponemal test|nontreponemal test titers]] might decline more slowly for persons who previously have had syphilis.<ref name="pmid16943224">Ghanem KG, Erbelding EJ, Wiener ZS, Rompalo AM (2007) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16943224 Serological response to syphilis treatment in HIV-positive and HIV-negative patients attending sexually transmitted diseases clinics.] ''Sex Transm Infect'' 83 (2):97-101. [http://dx.doi.org/10.1136/sti.2006.021402 DOI:10.1136/sti.2006.021402] PMID: [http://pubmed.gov/16943224 16943224]</ref> | |||
:*[[Syphilis physical examination#Physical examination|Clinical]] and [[Syphilis laboratory tests#Serology|serologic]] evaluation should be performed 6 months and 12 months after treatment; more frequent evaluation might be prudent if follow-up is uncertain. | |||
:*Patients who have [[Syphilis physical examination#Physical examination|signs]] or [[Syphilis history and symptoms|symptoms]] that persist or recur or who have a sustained fourfold increase in [[Syphilis laboratory tests#Nontreponemal test|nontreponemal test titer]] (i.e., compared with the maximum or baseline titer at the time of treatment) probably failed treatment or were reinfected. These patients should be retreated and reevaluated for [[HIV|HIV infection]]. | |||
:*Because treatment failure usually cannot be reliably distinguished from reinfection with T. pallidum, a [[Syphilis laboratory tests#CSF analysis|CSF analysis]] also should be performed. | |||
*Although failure of [[Syphilis laboratory tests#Nontreponemal test|nontreponemal test titers]] to decline fourfold within 6-12 months after therapy for [[Syphilis pathophysiology#Primary syphilis|primary]] or [[Syphilis pathophysiology#Secondary syphilis|secondary]] syphilis might be indicative of treatment failure. | |||
:*Clinical trial data have demonstrated that greater than 15% of patients with early syphilis treated with the recommended therapy will not achieve the two dilution decline in [[Syphilis laboratory tests#Nontreponemal test|nontreponemal titer]] used to define response at 1 year after treatment.<ref name="pmid9235493">Rolfs RT, Joesoef MR, Hendershot EF, Rompalo AM, Augenbraun MH, Chiu M et al. (1997) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9235493 A randomized trial of enhanced therapy for early syphilis in patients with and without human immunodeficiency virus infection. The Syphilis and HIV Study Group.] ''N Engl J Med'' 337 (5):307-14. [http://dx.doi.org/10.1056/NEJM199707313370504 DOI:10.1056/NEJM199707313370504] PMID: [http://pubmed.gov/9235493 9235493]</ref> | |||
:*Persons whose titers do not decline should be reevaluated for [[HIV|HIV infection]]. | |||
:*Optimal management of such patients is unclear. | |||
:*At a minimum, these patients should receive additional [[Syphilis physical examination#Physical examination|clinical]] and [[Syphilis laboratory tests#Serology|serologic]] follow-up. | |||
:*If additional follow-up cannot be ensured, [[Syphilis medical therapy#Pharmacotherapy|retreatment]] is recommended. | |||
:*Because treatment failure might be the result of unrecognized CNS infection, [[Syphilis laboratory tests#CSF analysis|CSF examination]] can be considered in such situations. | |||
*For '''''retreatment''''', weekly injections of [[Penicillin#Benzylpenicillin (penicillin G)|benzathine penicillin G]] 2.4 million units IM for 3 weeks is recommended, unless [[Syphilis laboratory tests#CSF analysis|CSF examination]] indicates that [[neurosyphilis]] is present. | |||
*In rare instances, [[Syphilis laboratory tests#Serology|serologic titers]] do not decline despite a negative [[Syphilis laboratory tests#CSF analysis|CSF examination]] and a repeated course of therapy. In these circumstances, the need for additional therapy or repeated CSF examinations is unclear, but is not generally recommended. | |||
==References== | ==References== |
Revision as of 18:43, 16 February 2012
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Lakshmi Gopalakrishnan, M.B.B.S. [2]
Overview
- Parenteral penicillin G has been used effectively for more than 50 years to achieve clinical resolution (i.e., the healing of lesions and prevention of sexual transmission) and to prevent late sequelae. However, no comparative trials have been adequately conducted to guide the selection of an optimal penicillin regimen (i.e., the dose, duration, and preparation). Substantially fewer data are available for non-penicillin regimens.
- Available data demonstrate that additional doses of benzathine penicillin G, amoxicillin, or other antibiotics in (primary, secondary, and early latent syphilis do not enhance efficacy, regardless of HIV status.
- Infants and children aged more than 1 month diagnosed with syphilis should have a CSF examination to detect asymptomatic neurosyphilis, and birth & maternal medical records should be reviewed to assess whether such children have congenital or acquired syphilis. Children with acquired primary or secondary syphilis should be evaluated (e.g., through consultation with child-protection services) and treated by using the following pediatric regimen.
CDC Recommendations: Pharmacotherapy [3]
“ |
Recommended Regimen for Adults1. Benzathine penicillin G 2.4 million units IM in a single dose. Recommended Regimen for Infants and Children1. Benzathine penicillin G 50,000 units/kg IM, up to the adult dose of 2.4 million units in a single dose. |
” |
Other Management Considerations
HIV-infection
- All persons who have syphilis should be tested for HIV infection.
- In geographic areas in which the prevalence of HIV is high, persons who have primary syphilis should be retested for HIV after 3 months if the first HIV test result was negative.
Neurosyphilis
- Patients who have syphilis and symptoms or signs suggesting neurologic disease (e.g., meningitis and hearing loss) or ophthalmic disease (e.g., uveitis, iritis, neuroretinitis, and optic neuritis) should have an evaluation that includes CSF analysis, ocular slit-lamp ophthalmologic examination, and otologic examination. Treatment should be guided by the results of this evaluation.
- Invasion of CSF by T. pallidum accompanied by CSF laboratory abnormalities is common among adults who have primary or secondary syphilis.[1] Therefore, in the absence of clinical neurologic findings, no evidence exists to support variation from the recommended treatment regimen for early syphilis.
- Symptomatic neurosyphilis develops in only a limited number of persons after treatment with the penicillin regimens recommended for primary and secondary syphilis. Therefore, unless clinical signs or symptoms of neurologic or ophthalmic involvement are present or treatment failure is documented, routine CSF analysis is not recommended for persons who have primary or secondary.
Follow-Up
- Treatment failure can occur with any regimen. However, assessing response to treatment frequently is difficult, and definitive criteria for cure or failure have not been established.
- In addition, nontreponemal test titers might decline more slowly for persons who previously have had syphilis.[2]
- Patients who have signs or symptoms that persist or recur or who have a sustained fourfold increase in nontreponemal test titer (i.e., compared with the maximum or baseline titer at the time of treatment) probably failed treatment or were reinfected. These patients should be retreated and reevaluated for HIV infection.
- Because treatment failure usually cannot be reliably distinguished from reinfection with T. pallidum, a CSF analysis also should be performed.
- Although failure of nontreponemal test titers to decline fourfold within 6-12 months after therapy for primary or secondary syphilis might be indicative of treatment failure.
- Clinical trial data have demonstrated that greater than 15% of patients with early syphilis treated with the recommended therapy will not achieve the two dilution decline in nontreponemal titer used to define response at 1 year after treatment.[3]
- Persons whose titers do not decline should be reevaluated for HIV infection.
- Optimal management of such patients is unclear.
- If additional follow-up cannot be ensured, retreatment is recommended.
- Because treatment failure might be the result of unrecognized CNS infection, CSF examination can be considered in such situations.
- For retreatment, weekly injections of benzathine penicillin G 2.4 million units IM for 3 weeks is recommended, unless CSF examination indicates that neurosyphilis is present.
- In rare instances, serologic titers do not decline despite a negative CSF examination and a repeated course of therapy. In these circumstances, the need for additional therapy or repeated CSF examinations is unclear, but is not generally recommended.
References
- ↑ Lukehart SA, Hook EW, Baker-Zander SA, Collier AC, Critchlow CW, Handsfield HH (1988) Invasion of the central nervous system by Treponema pallidum: implications for diagnosis and treatment. Ann Intern Med 109 (11):855-62. PMID: 3056164
- ↑ Ghanem KG, Erbelding EJ, Wiener ZS, Rompalo AM (2007) Serological response to syphilis treatment in HIV-positive and HIV-negative patients attending sexually transmitted diseases clinics. Sex Transm Infect 83 (2):97-101. DOI:10.1136/sti.2006.021402 PMID: 16943224
- ↑ Rolfs RT, Joesoef MR, Hendershot EF, Rompalo AM, Augenbraun MH, Chiu M et al. (1997) A randomized trial of enhanced therapy for early syphilis in patients with and without human immunodeficiency virus infection. The Syphilis and HIV Study Group. N Engl J Med 337 (5):307-14. DOI:10.1056/NEJM199707313370504 PMID: 9235493