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 empiric antibiotics

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

consideration of empiric antibiotics

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

Intramuscular benzathine penicillin G 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

penicillin G benzathine: 2.4 million units intramuscularly as a single dose

Secondary options

doxycycline: 100 mg orally twice daily for 14 days

ACUTE

adults without neurosyphilis

1st line – intramuscular benzathine penicillin G

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

intramuscular benzathine penicillin G

The first-line treatment for primary, secondary, and early latent syphilis (without neurosyphilis) is intramuscular benzathine penicillin G 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 penicillin G (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 penicillin G, 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 penicillin G, as per the guidance for nonpregnant 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

penicillin G benzathine: primary/secondary/early latent syphilis (nonpregnant): 2.4 million units intramuscularly as a single dose; primary/secondary/early latent syphilis (pregnant): 2.4 million units intramuscularly as a single dose, may repeat in 1 week; late-latent/tertiary syphilis with normal cerebrospinal fluid examination: 2.4 million units intramuscularly once weekly for 3 weeks

Consider – prednisone

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

prednisone

Treatment recommended for SOME patients in selected patient group

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

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

prednisone: 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: nonpregnant
1st line – 

oral doxycycline

If the patient is allergic to penicillin, the first-line treatment in nonpregnant 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 coinfection, 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 – prednisone

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

prednisone

Treatment recommended for SOME patients in selected patient group

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

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

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

1st line – desensitization

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

desensitization

Penicillin desensitization is recommended for all patients with penicillin hypersensitivity in pregnancy. The evidence for the use of nonpenicillin 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.[98] Those who are skin-test negative can receive penicillin therapy. However, some clinicians perform desensitization without skin testing, particularly if the skin reagents for both minor and major determinants of penicillin allergy are not available.

Acute desensitization 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 desensitization can be performed, and is usually completed in 4 hours, following which the first dose of penicillin is administered.[99]

Plus – postdesensitization intramuscular benzathine penicillin G

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

postdesensitization intramuscular benzathine penicillin G

Treatment recommended for ALL patients in selected patient group

Desensitization is usually completed in 4 hours, following which the first dose of penicillin is administered.[99]

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 penicillin G, 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 penicillin G, as per the guidance for nonpregnant 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

penicillin G benzathine: primary/secondary/early latent syphilis: 2.4 million units intramuscularly as a single dose, may repeat in 1 week; late-latent/tertiary syphilis with normal cerebrospinal fluid examination: 2.4 million units intramuscularly once weekly for 3 weeks

adults with neurosyphilis

1st line – intravenous aqueous penicillin G

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

intravenous aqueous penicillin G

Central nervous system involvement can occur at any stage of syphilis and can range from asymptomatic meningeal involvement to dementia and sensory neuropathy.[16] First-line treatment for neurosyphilis is intravenous aqueous penicillin G.[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

penicillin G sodium: 18-24 million units/day intravenously given in divided doses every 4 hours (or by continuous infusion) for 10-14 days

Consider – subsequent intramuscular benzathine penicillin G

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

subsequent intramuscular benzathine penicillin G

Treatment recommended for SOME patients in selected patient group

Some specialists administer benzathine penicillin G once weekly for up to 3 weeks after the intravenous aqueous penicillin G 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

penicillin G benzathine: 2.4 million units intramuscularly once weekly for 1-3 weeks

Consider – prednisone

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

prednisone

Treatment recommended for SOME patients in selected patient group

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

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

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

2nd line – intramuscular procaine penicillin G plus oral probenecid

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

intramuscular procaine penicillin G plus oral probenecid

Second-line treatment for neurosyphilis is intramuscular procaine penicillin G 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

penicillin G procaine: 2.4 million units intramuscularly once daily for 10-14 days

and

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

Consider – prednisone

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

prednisone

Treatment recommended for SOME patients in selected patient group

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

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

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

1st line – desensitization

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

desensitization

Penicillin desensitization is recommended for all patients with neurosyphilis who have penicillin hypersensitivity. The evidence for the use of nonpenicillin 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.[98] Those who are skin-test negative can receive penicillin therapy. However, some clinicians perform desensitization without skin testing, particularly if the skin reagents for both minor and major determinants of penicillin allergy are not available.

Acute desensitization 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 desensitization can be performed, and is usually completed in 4 hours, following which the first dose of penicillin is administered.[99]

Plus – postdesensitization penicillin G

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

postdesensitization penicillin G

Treatment recommended for ALL patients in selected patient group

Desensitization is usually completed in 4 hours, following which the first dose of penicillin is administered.[99]

Primary options

penicillin G sodium: 18-24 million units/day intravenously given in divided doses every 4 hours (or by continuous infusion) for 10-14 days

Secondary options

penicillin G procaine: 2.4 million units intramuscularly once daily for 10-14 days

and

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

Consider – subsequent postdesensitization intramuscular benzathine penicillin G

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

subsequent postdesensitization intramuscular benzathine penicillin G

Treatment recommended for SOME patients in selected patient group

Some specialists administer benzathine penicillin G 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

penicillin G benzathine: 2.4 million units intramuscularly once weekly for 1-3 weeks

Consider – prednisone

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

prednisone

Treatment recommended for SOME patients in selected patient group

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

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

prednisone: 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 nonpenicillin regimens is relatively weak. However, high-dose doxycycline is used by some clinicians in this situation.[7][16]

Primary options

doxycycline: 200 mg orally twice daily for 28 days

Consider – prednisone

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

prednisone

Treatment recommended for SOME patients in selected patient group

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

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

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

congenital syphilis

1st line – intravenous aqueous penicillin G or intramuscular procaine penicillin G

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

intravenous aqueous penicillin G or intramuscular procaine penicillin G

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

Confirmed proven or highly probable syphilis includes any neonate with: an abnormal physical exam that is consistent with congenital syphilis (e.g., nonimmune hydrops, conjugated or direct hyperbilirubinemia or cholestatic jaundice or cholestasis, hepatosplenomegaly, rhinitis, skin rash, or pseudoparalysis of an extremity); a serum quantitative nontreponemal serologic titer that is fourfold (or greater) higher than the mother's titer at delivery (e.g., maternal titer = 1:2, neonatal titer ≥1:8 or maternal titer = 1:8, neonatal titer ≥1:32); or a positive dark-field test or polymerase chain reaction (PCR) of placenta, cord, lesions, or body fluids or a positive visualization 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 penicillin G or intramuscular procaine penicillin G.[8][100]​  

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

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

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

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

Primary options

penicillin G sodium: 100,000 to 150,000 units/kg/day intravenously, administered as 50,000 units/kg/dose every 12 hours during the first 7 days of life and then every 8 hours thereafter for a total of 10 days

OR

penicillin G procaine: 50,000 units/kg intramuscularly once daily for 10 days

1st line – intravenous aqueous penicillin G or intramuscular procaine penicillin G or intramuscular benzathine penicillin G

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

intravenous aqueous penicillin G or intramuscular procaine penicillin G or intramuscular benzathine penicillin G

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

Possible congenital syphilis includes any neonate who has a normal physical exam and a serum quantitative nontreponemal serologic titer equal to or less than fourfold of the maternal titer at delivery (e.g., maternal titer = 1:8, neonatal titer ≤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 Centers for Disease Control and Prevention (i.e., a nonpenicillin G regimen); the mother received the recommended regimen but treatment was initiated <30 days before delivery.[8]

Treatment of possible congenital syphilis is intravenous aqueous penicillin G, intramuscular procaine penicillin G, or intramuscular benzathine penicillin G.[8][100]

Single-dose benzathine penicillin G may be used if follow up is certain and the following investigations are normal: cerebrospinal fluid analysis for VDRL test, cell count, and protein; complete blood count including differential and platelet count; and long-bone radiographs.[8] Single-dose benzathine penicillin G may also be considered if the risk of untreated maternal syphilis is considered low and the neonate's nontreponemal test is nonreactive. 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 penicillin G should be considered, even if investigations are normal, nontreponemal test is nonreactive, and follow-up is assured.[8]

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

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

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

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

Primary options

penicillin G sodium: 100,000 to 150,000 units/kg/day intravenously, administered as 50,000 units/kg/dose every 12 hours during the first 7 days of life and then every 8 hours thereafter for a total of 10 days

OR

penicillin G procaine: 50,000 units/kg intramuscularly once daily for 10 days

OR

penicillin G benzathine: 50,000 units/kg intramuscularly as a single dose

1st line – intramuscular benzathine penicillin G

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

intramuscular benzathine penicillin G

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

Congenital syphilis is less likely in any neonate who has a normal physical exam and a serum quantitative nontreponemal serologic titer equal or less than fourfold of the maternal titer at delivery (e.g., maternal titer = 1:8, neonatal titer ≤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 reinfection or relapse.[8]

Recommended treatment is with intramuscular benzathine penicillin G.[8]

If the mother's nontreponemal titers decreased at least fourfold after therapy for early syphilis, or remained stable for low-titer, latent syphilis (e.g., VDRL test <1:2 or RPR <1:4), an alternative approach is to provide close serologic 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 pediatric specialist is recommended.

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

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

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

Primary options

penicillin G benzathine: 50,000 units/kg intramuscularly as a single dose

1st line – observation

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

observation

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

Congenital syphilis is unlikely if the neonate has a normal physical exam and a serum quantitative nontreponemal serologic titer equal to or less than fourfold of the maternal titer at delivery and both of the following are true: the mother's treatment was adequate before pregnancy; and the mother's nontreponemal serologic titer 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 nontreponemal tests should be followed up to ensure that the nontreponemal test returns to negative.[8]

Consider – intramuscular benzathine penicillin G

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

intramuscular benzathine penicillin G

Treatment recommended for SOME patients in selected patient group

Intramuscular benzathine penicillin G may be considered, particularly if the neonate has a reactive nontreponemal 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 desensitized and treated with penicillin.[8] The evidence for the use of nonpenicillin regimens is relatively weak.

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

Primary options

penicillin G benzathine: 50,000 units/kg intramuscularly as a single dose

1st line – intravenous aqueous penicillin G or intramuscular benzathine penicillin G

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

intravenous aqueous penicillin G or intramuscular benzathine penicillin G

​​Infants and children ages ≥1 month who have reactive serologic 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 serologic 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; complete 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 penicillin G. A single dose of intramuscular benzathine penicillin G may be considered after the 10-day treatment course of intravenous aqueous penicillin G 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 penicillin G.[8]

Infants and children ages >1 month with acquired primary or secondary syphilis should be managed by a pediatric 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 desensitized and treated with penicillin.[8] Skin testing may be used in children ages ≥2 years. The evidence for the use of nonpenicillin regimens is relatively weak.

Primary options

penicillin G sodium: 200,000 to 300,000 units/kg/day intravenously, administered as 50,000 units/kg/dose every 4-6 hours for 10 days

More

Secondary options

penicillin G benzathine: 50,000 units/kg intramuscularly once weekly for up to 3 weeks, maximum 2.4 million units/dose

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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

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