Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents

The information in the brief version is excerpted directly from the full-text guidelines. The brief version is a compilation of the tables and boxed recommendations.

Syphilis

Last Updated: December 17, 2015; Last Reviewed: June 14, 2017

Recommendations for Treating Treponema pallidum Infections (Syphilis) to Prevent Disease
Empiric treatment of incubating syphilis is recommended to prevent the development of disease in those who are sexually exposed.

Indication for Treatment:
  • Persons who have had sexual contact with a person who receives a diagnosis of primary, secondary, or early latent syphilis within 90 days preceding the diagnosis should be treated presumptively for early syphilis, even if serologic test results are negative (AIII).
  • Persons who have had sexual contact with a person who receives a diagnosis of primary, secondary, or early latent syphilis >90 days before the diagnosis should be treated presumptively for early syphilis if serologic test results are not immediately available and the opportunity for follow-up is uncertain (AIII).
Treatment:
  • Same as for early stage syphilis listed below
General Considerations for Treating Syphilis:
  • The efficacy of non-penicillin alternatives has not been well evaluated in persons with HIV infection and should be undertaken only with close clinical and serologic monitoring.
  • The Jarisch-Herxheimer reaction is an acute febrile reaction accompanied by headache and myalgias that can occur within the first 24 hours after therapy. It occurs more frequently in persons with early syphilis, high non-treponemal antibody titers, and prior penicillin treatment. Patients should be warned about this reaction and informed it is not an allergic reaction to penicillin.
Treatment Recommendations Depending on Stage of Disease

Early Stage (Primary, Secondary, and Early-Latent Syphilis)

Preferred Therapy:
  • Benzathine penicillin G 2.4 million U IM for 1 dose (AII)
Alternative Therapy (For Penicillin-Allergic Patients):
  • Doxycycline 100 mg PO BID for 14 days (BII), or
  • Ceftriaxone 1 g IM or IV daily for 10–14 days (BII)or
  • Azithromycin 2 g PO for 1 dose (BII)
Note: Chromosomal mutations associated with azithromycin resistance and treatment failures have been reported, most commonly in MSM. Azithromycin should be used with caution and only when treatment with penicillin, doxycycline or ceftriaxone is not feasible. Azithromycin is not recommended for MSM or pregnant women (AII).

Note: Persons with penicillin allergy whose compliance or follow-up cannot be ensured and all pregnant women with penicillin allergy should be desensitized and treated with benzathine penicillin.

For pregnant women with early syphilis, a second dose of benzathine penicillin G 2.4 million units IM after one week the single dose treatment may be considered (BII).

Late-Latent (>1 year) or Latent of Unknown Duration

Preferred Therapy:
  • Benzathine penicillin G 2.4 million U IM weekly for 3 doses (AII)
Alternative Therapy (For Penicillin-Allergic Patients):
  • Doxycycline 100 mg PO BID for 28 days (BIII)
Note: Persons with penicillin allergy whose compliance or follow-up cannot be ensured should be desensitized and treated with benzathine penicillin.

Late-Stage (Tertiary—Cardiovascular or Gummatous Disease)
  • Perform CSF examination to rule out neurosyphilis and obtain infectious diseases consultation to guide management
Preferred Therapy:
  • Benzathine penicillin G 2.4 million U IM weekly for 3 doses (AII)
Neurosyphilis, Otic, or Ocular Disease

Preferred Therapy:
  • Aqueous crystalline penicillin G, 18–24 million U per day, administered as 3–4 million U IV q4h or by continuous IV infusion for 10–14 days (AII) +/- benzathine penicillin G 2.4 million U IM weekly for 1 to 3 doses after completion of IV therapy (CIII)
Alternative Therapy:
  • Procaine penicillin G 2.4 million U IM daily plus probenecid 500 mg PO QID for 10–14 days (BII) +/- benzathine penicillin G 2.4 million U IM weekly for up to 3 doses after completion of above (CIII)
  • Persons who are allergic to sulfa-containing medications should not be given probenecid, thus the procaine penicillin regimen is not recommended (AIII).
For Penicillin-Allergic Patients:
  • Desensitization to penicillin is the preferred approach; if not feasible, ceftriaxone 2 g IM or IV daily for 10–14 days (BII)
Key to AcronymsBID = twice a day; CSF = cerebrospinal fluid; IM = intramuscular; IV = intraveneously; MSM = men who have sex with men; PO = orally; QID = four times a day; q(n)h = every "n" hours; U = units

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