DR10.6 | Syphilis Treatment Workflow — Summary & Reflection

KEY TAKEAWAYS

Syphilis is reliably cured by benzathine penicillin G, matched to the stage diagnosed in the previous SDL. Primary, secondary, and early latent syphilis (within two years) need a single dose of 2.4 million units IM; late latent and tertiary non-neurological disease need three weekly doses; neurosyphilis needs intravenous aqueous crystalline penicillin G because benzathine does not reach the CSF. T. pallidum has no meaningful penicillin resistance, and its slow division explains why the long-acting depot form is essential. In pregnancy, penicillin is the only accepted treatment — a penicillin-allergic mother is desensitised, never given doxycycline — and congenital syphilis is treated with aqueous or procaine penicillin over ten days. Genital ulcer disease is managed syndromically, with NACO Kit 3 (white) covering syphilis and chancroid empirically (per current NACO guidance). Treatment is monitored by the non-treponemal titre (a fourfold fall by 6–12 months indicates success), and the Jarisch-Herxheimer reaction — a self-limiting febrile response to dying spirochaetes — is managed symptomatically without ever stopping penicillin.

REFLECT

Return to the pregnant woman whose antenatal VDRL was reactive. If she told you she was allergic to penicillin, how would you explain to her — clearly and without alarming her — why you must still treat her with penicillin (after desensitisation) rather than a different drug? Now imagine a different patient who phones you, frightened, with fever and chills the evening after his first injection for early syphilis: how would you reassure him that this is the infection dying rather than a dangerous reaction, and what would you have told him in advance to prevent the call? Thinking through how you would communicate in these two situations is what turns a correct regimen into safe, humane care.