A panel of experts generated 8 "key questions" in the management of adult
syphilis. A systematic literature review was conducted and tables of evidence were constructed to answer these important questions.
Penicillin is the
drug of choice to treat
syphilis.
Doxycycline to treat early and late
latent syphilis is an acceptable alternate option if
penicillin cannot be used. There is no added benefit to enhanced antimicrobial
therapy when treating human immunodeficiency virus-infected persons with
syphilis. If a patient misses a dose of
penicillin in a course of weekly
therapy for
late syphilis, clinical experience suggests that an interval of 10-14 days between doses might be acceptable before restarting the sequence of
injections. Pharmacologic considerations suggest that an interval of 7-9 days between doses, if feasible, may be more optimal. Missed doses are not acceptable for pregnant women. A cerebrospinal fluid examination to diagnose
neurosyphilis is recommended in persons diagnosed with
tertiary syphilis (eg,
cardiovascular syphilis or late benign
syphilis), persons with neurological signs or symptoms consistent with
neurosyphilis, and asymptomatic persons whose serological titers do not decline appropriately following recommended
therapy and in whom
reinfection is ruled out.
Infection and
reinfection rates, particularly among men who have sex with men, are high. Frequent serological screening of this population appears to be the most cost-efficient intervention. The Centers for Disease Control and Prevention continues to recommend the use of the traditional rapid plasma
reagin-based screening algorithm. The positive predictive value for
syphilis associated with an isolated unconfirmed reactive treponemal chemiluminescence assay or
enzyme immunoassay is low if the epidemiological risk and clinical probability for
syphilis are low. Among pregnant women with serodiscordant serologies (positive treponemal tests and a negative nontreponemal test), the risk of vertical transmission from mother to infant is low. Several important questions regarding the management of
syphilis remain unanswered and should be a priority for future research.