Treatment

A single intramuscular dose of long-acting benzathine penicillin with lidocaine is recommended for people who have had syphilis for less than 1 year and longer courses for people with late latent syphilis (1) and treatment depends on the disease stage: (1)

• seek expert advice

• Primary, secondary, early latent syphilis: benzathine penicillin 2.4 mega units (intramuscular (IM), single dose)
• Late latent syphilis: benzathine penicillin weekly for three weeks is first-line, or doxycycline 100mg twice daily for 28 days
• Neurosyphilis: procaine penicillin 1.8-2.4 units once daily (IM, for 14 days) with oral probenecid 500 mg four times a day.
• Treatment in pregnancy depends upon the presenting trimester. In the first and second trimesters give single dose benzathine penicillin. In the third trimester give two doses of benzathine penicillin one week apart.

Macrolides are no longer an option for treatment due to antimicrobial resistance. Ceftriaxone is an alternative treatment and is appropriate in most cases where penicillin cannot be used.

The Jarisch-Herxheimer reaction may occur when any stage of syphilis is treated. It is seen in 50% of patients with primary syphilis and 90% of patients with secondary syphilis.

Steroid therapy is recommended when managing neurological (both early and tertiary) or cardiovascular syphilis to prevent potentially serious consequences of the Jarisch-Herxheimer reaction: 40–60 mg prednisolone OD for 3 days starting 24 hours before anti-treponemal antibiotics. (1)

Reference

1. Kingston M et al. BASHHUK. Guidelines for the management of syphilis 2024. International Journal of STD & AIDS 2024, Vol. 0(0) 1–19