STD

[|CDPH STD Treatment Guidelines] : Clinics offering STD testing and treatment in the bay area : List of test based on sexual activity

The Contra Costa Public Health HIV/STD Program maintains historical testing and treatment information on syphilis patients. Please call 925-313-6750 to find out if your patient has tested positive or been treated for syphilis in the past. The HIV/STD Program also offers clinical guidance. Or you can see the CDPH STD Treatment Guidelines referenced above or the [|CDC STD Treatment Guidelines]
 * Diagnosis and Treatment of Syphilis**


 * Syphilis staging**
 * **Stage** || **Clinical Manifestations** || **Serology testing results** ||
 * Primary || Lesion at site of infection || Positive RPR and VDRL, TP-PA may be negative in early disease ||
 * Secondary || Rash, mucocutaneaous lesions, lymphadenopathy || Positive RPR, VDRL and TP-PA ||
 * Early latent || No evidence of primary or secondary syphilis with negative syphilis serology within past year || Positive RPR, VDRL and TP-PA ||
 * Late latent || No evidence of primary or secondary syphilis with positive syphilis serology of unknown duration || Positive RPR, VDRL and TP-PA. Treat if greater than 4 fold increase in VDRL titer (e.g. 1:4 to 1:16) or if patient never treated ||
 * Neurosyphilis or ocular syphilis || Cognitive deficits, ophthalmic or auditory sxs, cranial nerve palsies, signs or sxs of meningitis or stroke || Variable, see full CDC STD Treatment Guidelines ||


 * Congenital Syphilis staging**
 * **Stage** || **Clinical Manifestations** || **Evaluation** ||
 * Early (up to 2 years of life) || Asymptomatic or with symptoms that overlap with other TORCH infections || Please refer to Fig 3.12: [|Algorithm for Evaluation and Treatment of Infants Born to Mothers with Reactive Serologic Tests for Syphilis] and discuss with peds ID. ||
 * Late (can appear up to 2 decades after birth) || Multiple manifestations, mainly nose, teeth and bone manifestations ||^  ||

2.4 million units IM x1
 * Syphilis treatment**
 * **Stage** || **Preferred treatment** || **Alternative treatment** ||
 * Primary, secondary and early latent syphilis || Benzathine penicillin G

Pediatric dose: 50,000 U/Kg IM x 1 up to adult dose 2.4 million units || Doxycycline 100mg po bid x14 days or tetracycline 500mg po qid x14 days or Ceftriaxone 1 gram (IM or IV) daily x10-14 days || 2.4 million units IM weekly x3 weeks
 * Late latent || Benzathine penicillin G

Pediatric dose: 50,000 U/Kg IM up to 2.4 million units weekly x 3 weeks || Doxycycline 100mg po bid x28 days or tetracycline 500mg po qid x28 days ||
 * Neurosyphilis or ocular syphilis || Aqueous crystalline penicillin G 18-24 million U/day, administered as 3-4 million units IV q4 hours or continuous infusion for 10-14 days

Pediatric dose: 200,000-300,000 U/Kg/day IV every 4-6 hours x 10-14 days (no dot exceed adult dose) || Procaine penicillin G 2.4 million units IM per dayx10-14 days PLUS Probenicid 500 mg po qid x 10-14 days ||
 * Congenital syphilis || Depends on Red Book algorithm (see above) Aqueous crystalline penicillin x 10 days or Benzathine penicillin x 1 dose ||  ||

Parenteral penicillin G is the only therapy known to be effective in pregnancy. Pregnant women with penicillin allergy should be desensitized and treated with penicillin. For pregnant patients with late latent syphilis, the dosing interval for penicillin //must// be 7 days. If any dose is missed, therapy must be re-started.
 * Syphilis treatment in pregnancy**

Usually acquired in utero at any gestational age in untreated or inadequately treated mothers, but may be acquired at time of delivery too. Symptoms may not be present at time of birth or are non-specific (similar to other intrauterine infections). In-utero death is also possible. Most important part of the evaluation of these infants is to know mom’s syphilis status during pregnancy and if syphilis positive during pregnancy – clinician needs to: 1) Review mother’s medical history including initial serologic results, treatment and follow up serologic results to determine if mother was treated appropriately, untreated or inadequately treated; and 2) Needs to compare mother’s results with neonates’ results and based on these, follow Red Book’s algorithm (see above) in conjunction with ID expert. Prevention: Early detection and treatment of maternal infection at least 30 days before delivery.
 * Congenital syphilis**

Clinical and serologic evaluation should be performed at 6 and 12 months after treatment; more frequent evaluation might be prudent if follow-up is uncertain or if repeat infection is a concern. Serologic response (i.e., titer) should be compared with the titer at the time of treatment. However, assessing serologic response to treatment can be difficult, and definitive criteria for cure or failure have not been well established. In addition, nontreponemal test titers might decline more slowly for persons previously treated for syphilis (//[|408,409] [|(https://www.cdc.gov/std/tg2015/references.htm#408)] //). Persons who have signs or symptoms that persist or recur and those with at least a fourfold increase in nontreponemal test titer persisting for >2 weeks likely experienced treatment failure or were re-infected. These persons 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; treatment should be guided by CSF findings. 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. However, clinical trial data have demonstrated that 15%–20% of persons with primary and secondary syphilis treated with the recommended therapy will not achieve the fourfold decline in nontreponemal titer used to define response at 1 year after treatment (//[|406] [|(https://www.cdc.gov/std/tg2015/references.htm#406)] ,[|409] [|(https://www.cdc.gov/std/tg2015/references.htm#409)] //). Serologic response to treatment appears to be associated with several factors, including the person’s stage of syphilis (earlier stages are more likely to decline fourfold and become negative) and initial nontreponemal antibody titers (lower titers are less likely to decline fourfold than higher titers) (//[|409] [|(https://www.cdc.gov/std/tg2015/references.htm#409)] //). Optimal management of persons who have less than a fourfold decline in titers after treatment of syphilis is unclear. At a minimum, these persons should receive additional clinical and serologic follow-up and be evaluated for HIV infection. 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.
 * Follow-up and monitoring after treatment:**

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