Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

adults with suspected early infection or sexual contacts of patients with confirmed infection

1st line – consideration of empirical antibiotics

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INITIAL
|
adults with suspected early infection or sexual contacts of patients with confirmed infection
1st line – 

consideration of empirical antibiotics

Empirical therapy may be considered in those with suspected early infection (a rash or ulceration) before results of serology are available. Empirical therapy may be appropriate if there are concerns regarding re-attendance. The benefits of empirical therapy (prompt therapy) and risks (potentially unnecessary treatment) should be discussed with the patient.

Intramuscular benzathine benzylpenicillin as a single dose is given. If the patient is allergic to penicillin and is not pregnant, oral doxycycline may be offered.

Sexual contacts of patients with confirmed syphilis should be screened and offered presumptive treatment if follow-up may be problematic.

Primary options

benzathine benzylpenicillin: 1.8 g intramuscularly as a single dose

Secondary options

doxycycline: 100 mg orally twice daily for 14 days

ACUTE

adults without neurosyphilis

1st line – intramuscular benzathine benzylpenicillin

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ACUTE
|
adults without neurosyphilis
|
without penicillin allergy
1st line – 

intramuscular benzathine benzylpenicillin

The first-line treatment for primary, secondary, and early latent syphilis (without neurosyphilis) is intramuscular benzathine benzylpenicillin as a single dose.[8] Note that the dose may be split and administered at two discrete injection sites.

The first-line treatment of late latent and tertiary (gummatous, cardiovascular, psychiatric manifestations, late neurosyphilis) syphilis with normal cerebrospinal fluid (CSF) examination is intramuscular benzathine benzylpenicillin (once weekly for 3 weeks).

All patients who have tertiary syphilis should undergo cerebrospinal fluid examination before treatment is started. Patients with abnormal CSF findings should be treated with a neurosyphilis regimen.[8]

Pregnant women should receive penicillin-based treatment according to their stage of syphilis. For pregnant women with primary, secondary, or early latent syphilis, certain evidence suggests that administering two injections of intramuscular benzathine benzylpenicillin, rather than one, can help prevent congenital syphilis. Pregnant women with late latent or tertiary syphilis with normal CSF examination should receive three injections of intramuscular benzathine benzylpenicillin, as per the guidance for non-pregnant individuals.[8] 

Most clinicians treat HIV-positive and HIV-negative individuals with the same penicillin regimens, according to the stage of syphilis.[8]

Antibiotic therapy for cardiovascular syphilis does not reverse cardiovascular disease, which may continue to progress after treatment. Discussion with a cardiologist is advised.

Primary options

benzathine benzylpenicillin: primary/secondary/early latent syphilis (non-pregnant): 1.8 g intramuscularly as a single dose; primary/secondary/early latent syphilis (pregnant): 1.8 g intramuscularly as a single dose, may repeat in 1 week; late-latent/tertiary syphilis with normal cerebrospinal fluid examination: 1.8 g intramuscularly once weekly for 3 weeks

Consider – prednisolone

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ACUTE
|
adults without neurosyphilis
|
without penicillin allergy
Consider – 

prednisolone

Additional treatment recommended for SOME patients in selected patient group

Corticosteroid therapy may be considered to minimise the risk of Jarisch-Herxheimer reaction in patients with cardiovascular syphilis.[4] However, evidence of effectiveness is unclear and it is not routinely recommended in some countries.

Jarisch-Herxheimer reaction is an acute febrile illness that can occur within the first 24 hours after initiation of antibiotic treatment for syphilis. Symptoms include acute fever, headache, and myalgia, usually occurring in patients with early syphilis.[8]  

Primary options

prednisolone: 40-60 mg orally once daily for 3 days; start 24 hours before penicillin

1st line – oral doxycycline

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ACUTE
|
adults without neurosyphilis
|
with penicillin allergy: non-pregnant
1st line – 

oral doxycycline

If the patient is allergic to penicillin, the first-line treatment in non-pregnant patients is oral doxycycline.

Adherence and patient compliance may influence treatment outcome if oral therapy is administered.

Patients who are allergic to penicillin, with primary or secondary syphilis and HIV co-infection, should receive antibiotic therapy as recommended for penicillin-allergic, HIV-negative patients.[8] 

Antibiotic therapy for cardiovascular syphilis does not reverse cardiovascular disease, which may continue to progress after treatment. Discussion with a cardiologist is advised.

Primary options

doxycycline: 100 mg orally twice daily for 14 days (primary/secondary/early latent syphilis) or 28 days (late latent/tertiary syphilis with normal cerebrospinal fluid examination)

Consider – prednisolone

Back
ACUTE
|
adults without neurosyphilis
|
with penicillin allergy: non-pregnant
Consider – 

prednisolone

Additional treatment recommended for SOME patients in selected patient group

Corticosteroid therapy may be considered to minimise the risk of Jarisch-Herxheimer reaction in patients with cardiovascular syphilis.[4] However, evidence of effectiveness is unclear and it is not routinely recommended in some countries.

Jarisch-Herxheimer reaction is an acute febrile illness that can occur within the first 24 hours after initiation of antibiotic treatment for syphilis. Symptoms include acute fever, headache, and myalgia, usually occurring in patients with early syphilis.[8]  

Primary options

prednisolone: 40-60 mg orally once daily for 3 days; start 24 hours before doxycycline

1st line – densensitisation

Back
ACUTE
|
adults without neurosyphilis
|
with penicillin allergy: pregnant
1st line – 

densensitisation

Penicillin desensitisation is recommended for all patients with penicillin hypersensitivity in pregnancy. The evidence for the use of non-penicillin regimens is relatively weak.[8]  

Penicillin allergy skin testing identifies patients at high risk for penicillin reactions. Skin reagents used should include major and minor allergens.[101] Those who are skin-test negative can receive penicillin therapy. However, some clinicians perform desensitisation without skin testing, particularly if the skin reagents for both minor and major determinants of penicillin allergy are not available.

Acute desensitisation can be performed in patients who have a positive skin test to one of the penicillin determinants, and should be performed in a hospital setting. Oral or intravenous desensitisation can be performed, and is usually completed in 4 hours, following which the first dose of penicillin is administered.[102]

Plus – post-desensitisation intramuscular benzathine benzylpenicillin

Back
ACUTE
|
adults without neurosyphilis
|
with penicillin allergy: pregnant
Plus – 

post-desensitisation intramuscular benzathine benzylpenicillin

Treatment recommended for ALL patients in selected patient group

Desensitisation is usually completed in 4 hours, following which the first dose of penicillin is administered.[102]

Pregnant women should receive penicillin-based treatment according to their stage of syphilis. For pregnant women with primary, secondary, or early latent syphilis, certain evidence suggests that administering two injections of intramuscular benzathine benzylpenicillin, rather than one, can help prevent congenital syphilis. Pregnant women with late latent or tertiary syphilis with normal cerebrospinal fluid examination should receive three injections of intramuscular benzathine benzylpenicillin, as per the guidance for non-pregnant individuals.[8] 

Antibiotic therapy for cardiovascular syphilis does not reverse cardiovascular disease, which may continue to progress after treatment. Discussion with a cardiologist is advised.

Primary options

benzathine benzylpenicillin: primary/secondary/early latent syphilis: 1.8 g intramuscularly as a single dose, may repeat in 1 week; late-latent/tertiary syphilis with normal cerebrospinal fluid examination: 1.8 g intramuscularly once weekly for 3 weeks

adults with neurosyphilis

1st line – intravenous aqueous benzylpenicillin

Back
ACUTE
|
adults with neurosyphilis
|
without penicillin allergy
1st line – 

intravenous aqueous benzylpenicillin

Central nervous system involvement can occur at any stage of syphilis and can range from asymptomatic meningeal involvement to dementia and sensory neuropathy.[20] First-line treatment for neurosyphilis is intravenous aqueous benzylpenicillin.[8] 

Pregnant women should receive penicillin-based treatment according to their stage of syphilis.

Most clinicians treat HIV-positive and HIV-negative patients with the same penicillin regimens, according to the stage of syphilis.[8] 

Primary options

benzylpenicillin sodium: 10.8 to 14.4 g/day intravenously given in divided doses every 4 hours for 10-14 days

Consider – subsequent intramuscular benzathine benzylpenicillin

Back
ACUTE
|
adults with neurosyphilis
|
without penicillin allergy
Consider – 

subsequent intramuscular benzathine benzylpenicillin

Additional treatment recommended for SOME patients in selected patient group

Some specialists administer benzathine benzylpenicillin once weekly for up to 3 weeks after the intravenous aqueous benzylpenicillin regimen for neurosyphilis has been completed.

This ensures the duration of treatment is comparable with that of late syphilis in the absence of neurosyphilis.[8] 

Primary options

benzathine benzylpenicillin: 1.8 g intramuscularly once weekly for 1-3 weeks

Consider – prednisolone

Back
ACUTE
|
adults with neurosyphilis
|
without penicillin allergy
Consider – 

prednisolone

Additional treatment recommended for SOME patients in selected patient group

Corticosteroid therapy may be considered to minimise the risk of Jarisch-Herxheimer reaction in patients with non-pregnant patients with neurosyphilis.[4] However, evidence of effectiveness is unclear and it is not routinely recommended in some countries.

Jarisch-Herxheimer reaction is an acute febrile illness that can occur within the first 24 hours after initiation of antibiotic treatment for syphilis. Symptoms include acute fever, headache, and myalgia, usually occurring in patients with early syphilis.[8] 

Primary options

prednisolone: 40-60 mg orally once daily for 3 days; start 24 hours before penicillin

2nd line – intramuscular procaine benzylpenicillin plus oral probenecid

Back
ACUTE
|
adults with neurosyphilis
|
without penicillin allergy
2nd line – 

intramuscular procaine benzylpenicillin plus oral probenecid

Second-line treatment for neurosyphilis is intramuscular procaine benzylpenicillin plus oral probenecid.

Most clinicians treat HIV-positive and HIV-negative patients with the same penicillin regimens according to the stage of syphilis.

Pregnant women should receive penicillin-based treatment according to their stage of syphilis.[8] 

Primary options

procaine benzylpenicillin: 2.4 g intramuscularly once daily for 10-14 days

and

probenecid: 500 mg orally four times daily for 10-14 days

Consider – prednisolone

Back
ACUTE
|
adults with neurosyphilis
|
without penicillin allergy
Consider – 

prednisolone

Additional treatment recommended for SOME patients in selected patient group

Corticosteroid therapy may be considered to minimise the risk of Jarisch-Herxheimer reaction in non-pregnant patients with neurosyphilis.[4] However, evidence of effectiveness is unclear and it is not routinely recommended in some countries.

Jarisch-Herxheimer reaction is an acute febrile illness that can occur within the first 24 hours after initiation of antibiotic treatment for syphilis. Symptoms include acute fever, headache, and myalgia, usually occurring in patients with early syphilis.[8]  

Primary options

prednisolone: 40-60 mg orally once daily for 3 days; start 24 hours before penicillin

1st line – desensitisation

Back
ACUTE
|
adults with neurosyphilis
|
with penicillin allergy
1st line – 

desensitisation

Penicillin desensitisation is recommended for all patients with neurosyphilis who have penicillin hypersensitivity. The evidence for the use of non-penicillin regimens is relatively weak.[8] 

Penicillin allergy skin testing identifies patients at high risk for penicillin reactions. Skin reagents used should include major and minor allergens.[101] Those who are skin-test negative can receive penicillin therapy. However, some clinicians perform desensitisation without skin testing, particularly if the skin reagents for both minor and major determinants of penicillin allergy are not available.

Acute desensitisation can be performed in patients who have a positive skin test to one of the penicillin determinants, and should be performed in a hospital setting. Oral or intravenous desensitisation can be performed, and is usually completed in 4 hours, following which the first dose of penicillin is administered.[102]

Plus – post-desensitisation benzylpenicillin

Back
ACUTE
|
adults with neurosyphilis
|
with penicillin allergy
Plus – 

post-desensitisation benzylpenicillin

Treatment recommended for ALL patients in selected patient group

Desensitisation is usually completed in 4 hours, following which the first dose of penicillin is administered.[102]

Primary options

benzylpenicillin sodium: 10.8 to 14.4 g/day intravenously given in divided doses every 4 hours for 10-14 days

Secondary options

procaine benzylpenicillin: 2.4 g intramuscularly once daily for 10-14 days

and

probenecid: 500 mg orally four times daily for 10-14 days

Consider – subsequent post-desensitisation intramuscular benzathine benzylpenicillin

Back
ACUTE
|
adults with neurosyphilis
|
with penicillin allergy
Consider – 

subsequent post-desensitisation intramuscular benzathine benzylpenicillin

Additional treatment recommended for SOME patients in selected patient group

Some specialists administer benzathine benzylpenicillin once weekly for up to 3 weeks after the treatment regimen for neurosyphilis has been completed (only if first-line intravenous therapy was chosen as the initial therapy).

This ensures the duration of treatment is comparable with that of late syphilis in the absence of neurosyphilis.[8]  

Primary options

benzathine benzylpenicillin: 1.8 g intramuscularly once weekly for 1-3 weeks

Consider – prednisolone

Back
ACUTE
|
adults with neurosyphilis
|
with penicillin allergy
Consider – 

prednisolone

Additional treatment recommended for SOME patients in selected patient group

Corticosteroid therapy may be considered to minimise the risk of Jarisch-Herxheimer reaction in non-pregnant patients with neurosyphilis.[4] However, evidence of effectiveness is unclear and it is not routinely recommended in some countries.

Jarisch-Herxheimer reaction is an acute febrile illness that can occur within the first 24 hours after initiation of antibiotic treatment for syphilis. Symptoms include acute fever, headache, and myalgia, usually occurring in patients with early syphilis.[8]   

Primary options

prednisolone: 40-60 mg orally once daily for 3 days; start 24 hours before penicillin

2nd line – high-dose oral doxycycline

Back
ACUTE
|
adults with neurosyphilis
|
with penicillin allergy
2nd line – 

high-dose oral doxycycline

The evidence for the use of non-penicillin regimens is relatively weak. However, high-dose doxycycline is used by some clinicians in this situation.[7][20]

Primary options

doxycycline: 200 mg orally twice daily for 28 days

Consider – prednisolone

Back
ACUTE
|
adults with neurosyphilis
|
with penicillin allergy
Consider – 

prednisolone

Additional treatment recommended for SOME patients in selected patient group

Corticosteroid therapy may be considered to minimise the risk of Jarisch-Herxheimer reaction in non-pregnant patients with neurosyphilis.[4] However, evidence of effectiveness is unclear and it is not routinely recommended in some countries.

Jarisch-Herxheimer reaction is an acute febrile illness that can occur within the first 24 hours after initiation of antibiotic treatment for syphilis. Symptoms include acute fever, headache, and myalgia, usually occurring in patients with early syphilis.[8]    

Primary options

prednisolone: 40-60 mg orally once daily for 3 days; start 24 hours before doxycycline

congenital syphilis

1st line – intravenous aqueous benzylpenicillin or intramuscular procaine benzylpenicillin

Back
ACUTE
|
congenital syphilis
|
neonate: confirmed proven or highly probable congenital syphilis
1st line – 

intravenous aqueous benzylpenicillin or intramuscular procaine benzylpenicillin

All neonates born to mothers who have reactive non-treponemal and treponemal tests results should be evaluated with a quantitative non-treponemal serological test (rapid plasma reagin tests [RPR] or Venereal Disease Research Laboratory [VDRL]) performed on the neonate's serum. The non-treponemal test performed on the neonate should be the same type of non-treponemal test performed on the mother.[8]    

Confirmed proven or highly probable syphilis includes any neonate with: an abnormal physical examination that is consistent with congenital syphilis (e.g. non-immune hydrops, conjugated or direct hyperbilirubinaemia or cholestatic jaundice or cholestasis, hepatosplenomegaly, rhinitis, skin rash, or pseudoparalysis of an extremity); a serum quantitative non-treponemal serological titre that is fourfold (or greater) higher than the mother's titre at delivery (e.g., maternal titre = 1:2, neonatal titre ≥1:8 or maternal titre = 1:8, neonatal titre ≥1:32); or a positive darkfield test or polymerase chain reaction (PCR) of placenta, cord, lesions, or body fluids or a positive visualisation of stained treponemal spirochetes in the placenta or cord using immunohistochemistry.[8]

First-line treatment of confirmed proven or highly probable congenital syphilis is intravenous aqueous benzylpenicillin or intramuscular procaine benzylpenicillin.[8][103]

Discussion with an obstetric specialist and neonatologist is recommended. Subsequently, close clinical and serological follow-up by a paediatric specialist is recommended.

Neonates with reactive non-treponemal tests should be followed up to ensure that the non-treponemal test returns to negative.[8]

Neonates with a penicillin allergy or those who develop an allergic reaction presumed secondary to penicillin should be desensitised and treated with penicillin.[8] The evidence for the use of non-penicillin regimens is relatively weak.

Skin testing is not possible in neonates with congenital syphilis as the procedure has not been standardised in this age group.[8]

Primary options

benzylpenicillin sodium: consult specialist for guidance on neonatal doses

OR

procaine benzylpenicillin: consult specialist for guidance on neonatal doses

1st line – intravenous aqueous benzylpenicillin or intramuscular procaine benzylpenicillin or intramuscular benzathine benzylpenicillin

Back
ACUTE
|
congenital syphilis
|
neonate: possible congenital syphilis
1st line – 

intravenous aqueous benzylpenicillin or intramuscular procaine benzylpenicillin or intramuscular benzathine benzylpenicillin

All neonates born to mothers who have reactive non-treponemal and treponemal test results should be evaluated with a quantitative non-treponemal serological test (rapid plasma reagin [RPR] or Venereal Disease Research Laboratory [VDRL]) performed on the neonate's serum. The non-treponemal test performed on the neonate should be the same type of non-treponemal test performed on the mother.

Possible congenital syphilis includes any neonate who has a normal physical examination and a serum quantitative non-treponemal serological titre equal to or less than fourfold of the maternal titre at delivery (e.g., maternal titre = 1:8, neonatal titre ≤1:16) and one of the following: the mother was not treated, was inadequately treated, or has no documentation of having received treatment; the mother was treated with erythromycin or a regimen other than those recommended by the US Centers for Disease Control and Prevention (i.e., a non-benzylpenicillin regimen); the mother received the recommended regimen but treatment was initiated <30 days before delivery.[8]

Treatment of possible congenital syphilis is intravenous aqueous benzylpenicillin, intramuscular procaine benzylpenicillin, or intramuscular benzathine benzylpenicillin.[8][103]

Single-dose benzathine benzylpenicillin may be used if follow up is certain and the following investigations are normal: cerebrospinal fluid analysis for VDRL test, cell count, and protein; full blood count including differential and platelet count; and long-bone radiographs.[8] Single-dose benzathine benzylpenicillin may also be considered if the risk of untreated maternal syphilis is considered low and the neonate's non-treponemal test is non-reactive. If the mother had untreated early syphilis at the time of delivery, the neonate is at increased risk for congenital syphilis and the 10-day course of aqueous benzylpenicillin should be considered, even if investigations are normal, non-treponemal test is non-reactive, and follow-up is assured.[8]

Discussion with an obstetric specialist and neonatologist is recommended. Subsequently, close clinical and serological follow-up by a paediatric specialist is recommended.

Neonates with reactive non-treponemal tests should be followed up to ensure that the non-treponemal test returns to negative.[8]

Neonates with a penicillin allergy or those who develop an allergic reaction presumed secondary to penicillin should be desensitised and treated with penicillin.[8] The evidence for the use of non-penicillin regimens is relatively weak.

Skin testing is not possible in neonates with congenital syphilis as the procedure has not been standardised in this age group.[8]

Primary options

benzylpenicillin sodium: consult specialist for guidance on neonatal doses

OR

procaine benzylpenicillin: consult specialist for guidance on neonatal doses

OR

benzathine benzylpenicillin: consult specialist for guidance on neonatal doses

1st line – intramuscular benzathine benzylpenicillin

Back
ACUTE
|
congenital syphilis
|
neonate: congenital syphilis less likely
1st line – 

intramuscular benzathine benzylpenicillin

All neonates born to mothers who have reactive non-treponemal and treponemal test results should be evaluated with a quantitative non-treponemal serological test (rapid plasma reagin [RPR] or Venereal Disease Research Laboratory [VDRL]) performed on the neonate's serum. The non-treponemal test performed on the neonate should be the same type of non-treponemal test performed on the mother.

Congenital syphilis is less likely in any neonate who has a normal physical examination and a serum quantitative non-treponemal serological titre equal or less than fourfold of the maternal titre at delivery (e.g., maternal titre = 1:8, neonatal titre ≤1:16) and both of the following are true: the mother was treated during pregnancy, treatment was appropriate for the infection stage, and the treatment regimen was initiated ≥30 days before delivery; the mother has no evidence of re-infection or relapse.[8]

Recommended treatment is with intramuscular benzathine benzylpenicillin.[8]

If the mother's non-treponemal titres decreased at least fourfold after therapy for early syphilis, or remained stable for low-titre, latent syphilis (e.g., VDRL test <1:2 or RPR <1:4), an alternative approach is to provide close serological follow-up every 2-3 months for 6 months.[8]

Discussion with an obstetric specialist and neonatologist is recommended. Subsequently, close clinical and serologic follow-up by a paediatric specialist is recommended.

Neonates with reactive non-treponemal tests should be followed up to ensure that the non-treponemal test returns to negative.[8]

Neonates with a penicillin allergy or those who develop an allergic reaction presumed secondary to penicillin should be desensitised and treated with penicillin.[8] The evidence for the use of non-penicillin regimens is relatively weak.

Skin testing is not possible in neonates with congenital syphilis as the procedure has not been standardised in this age group.[8]

Primary options

benzathine benzylpenicillin: consult specialist for guidance on neonatal doses

1st line – observation

Back
ACUTE
|
congenital syphilis
|
neonate: congenital syphilis unlikely
1st line – 

observation

All neonates born to mothers who have reactive non-treponemal and treponemal test results should be evaluated with a quantitative non-treponemal serological test (rapid plasma reagin [RPR] or Venereal Disease Research Laboratory [VDRL]) performed on the neonate's serum. The non-treponemal test performed on the neonate should be the same type of non-treponemal test performed on the mother.

Congenital syphilis is unlikely if the neonate has a normal physical examination and a serum quantitative non-treponemal serological titre equal to or less than fourfold of the maternal titre at delivery and both of the following are true: the mother's treatment was adequate before pregnancy; and the mother's non-treponemal serological titre remained low and stable (i.e., serofast) before and during pregnancy and at delivery (e.g., VDRL test ≤1:2 or RPR ≤1:4).[8]

No treatment is required. However, neonates with reactive non-treponemal tests should be followed up to ensure that the non-treponemal test returns to negative.[8]

Consider – intramuscular benzathine benzylpenicillin

Back
ACUTE
|
congenital syphilis
|
neonate: congenital syphilis unlikely
Consider – 

intramuscular benzathine benzylpenicillin

Additional treatment recommended for SOME patients in selected patient group

Intramuscular benzathine benzylpenicillin may be considered, particularly if the neonate has a reactive non-treponemal test and follow up is not certain.[8]

Neonates with a penicillin allergy or those who develop an allergic reaction presumed secondary to penicillin should be desensitised and treated with penicillin.[8] The evidence for the use of non-penicillin regimens is relatively weak.

Skin testing is not possible in neonates with congenital syphilis as the procedure has not been standardised in this age group.[8]

Primary options

benzathine benzylpenicillin: consult specialist for guidance on neonatal doses

1st line – intravenous aqueous benzylpenicillin or intramuscular benzathine benzylpenicillin

Back
ACUTE
|
congenital syphilis
|
infant or child
1st line – 

intravenous aqueous benzylpenicillin or intramuscular benzathine benzylpenicillin

​Infants and children aged ≥1 month who have reactive serological tests for syphilis (e.g., serum rapid plasma reagin reactive, serum treponemal enzyme immunoassay reactive, or serum Treponema pallidum particle agglutination reactive) should be examined thoroughly for clinical manifestations of congenital syphilis.[8]​ Maternal records should be reviewed for evidence of maternal infection. Maternal serological tests may have been negative in cases of extremely early or incubating syphilis.[8]

Evaluation should include: cerebrospinal fluid analysis for Venereal Disease Research Laboratory test, cell count, and protein; full blood count, including differential and platelet count; and other tests if clinically indicated (e.g., long-bone x-rays, chest x-ray, liver enzymes, neuroimaging, auditory brain-stem response).[8]

Infants and children with clinical manifestations of congenital syphilis or abnormal evaluation should be treated with intravenous aqueous benzylpenicillin. A single dose of intramuscular benzathine benzylpenicillin may be considered after the 10-day treatment course of intravenous aqueous benzylpenicillin to provide a more comparable duration as treatment for late syphilis.[8]

Infants and children with no clinical manifestations of congenital syphilis and normal evaluation (including normal cerebrospinal fluid evaluation) may be treated with up to 3 weekly doses of intramuscular benzathine benzylpenicillin.[8] 

Infants and children aged >1 month with acquired primary or secondary syphilis should be managed by a paediatric infectious disease specialist and evaluated for sexual abuse.[8] See Sexual abuse and assault.

Infants and children with a penicillin allergy or those who develop an allergic reaction presumed secondary to penicillin should be desensitised and treated with penicillin.[8] Skin testing may be used in children aged ≥2 years. The evidence for the use of non-penicillin regimens is relatively weak.

Primary options

benzylpenicillin sodium: consult specialist for guidance on dose

Secondary options

benzathine benzylpenicillin: consult specialist for guidance on dose

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Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

Use of this content is subject to our disclaimer