Treatment of neurosyphilis, ocular syphilis and otosyphilis

For clinical presentation of neurosyphilis, ocular syphilis and otosyphilis, see Clinical presentation of neurosyphilis, ocular syphilis and otosyphilis.

Repeat serology on the day of treatment so that an accurate peak rapid plasma reagin [RPR] test titre is recorded to enable monitoring of the treatment responseOng, 2023.

For treatment of neurosyphilis, ocular syphilis or otosyphilis, useWorkowski, 2021:

benzylpenicillin 1.8 g intravenously, 4-hourly for 14 days. For dosage adjustment in adults with kidney impairment, see benzylpenicillin dosage adjustment. benzylpenicillin benzylpenicillin benzylpenicillin

To avoid multiple-daily intermittent doses, benzylpenicillin can be given as a 24-hour continuous infusion (using the buffered solution; see Stability of drugs commonly administered by continuous intravenous infusion over 12 or 24 hours for ambulatory parenteral antimicrobial therapy in adults) and can be administered through an established ambulatory antimicrobial therapy program. The recommended dose for a 24-hour continuous infusion is the sum of intermittent doses given over 24 hours.

There are limited data supporting the use of nonpenicillin regimens for the treatment of syphilisOng, 2023. For patients who report penicillin hypersensitivity, verify their allergy. In some patients it may be appropriate to directly delabel their allergy by taking an extensive allergy history (see Clinical history for initial assessment of patients reporting penicillin hypersensitivity); in these patients benzathine benzylpenicillin should be used.

Seek expert advice for patients with a verified allergy. For patients who have had a nonsevere (immediate or delayed) or a severe (immediate)1 hypersensitivity reaction to a penicillin, options that an infectious diseases physician or clinical microbiologist may use include:

For patients who have had a severe (delayed)2 hypersensitivity reaction to a penicillin, desensitisation should not be performed; seek expert advice for alternative treatment.

Warn patients that they may experience a Jarisch–Herxheimer reaction – see Approach to managing syphilis for more information.

Corticosteroids have been used in combination with antibiotic therapy for complicated presentations, but clinical evidence to support this practice is limitedHamill, 2024. For neurosyphilis, especially early neurosyphilis with ocular or otological involvement, prednisolone (or prednisone) should be administered initially, starting 24 hours before penicillin to reduce the likelihood of a Jarisch–Herxheimer reaction and resultant worsening of symptomsBritish Association for Sexual Health and HIV (BASHH), 2019Dutta Majumder, 2019Tuddenham, 2016.

For follow-up investigations to check treatment response, see Follow-up investigations for syphilis.

If there is a possibility that the patient has early syphilis, perform contact tracing; see Management of sexual contacts of patients with early syphilis. For patients with other stages of syphilis, perform serological testing for current sexual partners and treat according to the results; use the sexual history to determine if further contact tracing is required. See also STI contact tracing.

1 Severe immediate hypersensitivity reactions include anaphylaxis, compromised airway, airway angioedema, hypotension and collapse.Return
2 Severe delayed hypersensitivity reactions include cutaneous adverse drug reactions (eg drug rash with eosinophilia and systemic symptoms [DRESS], Stevens–Johnson syndrome/toxic epidermal necrolysis [SJS/TEN], severe blistering or desquamative rash), and significant internal organ involvement (eg acute interstitial nephritis).Return