All infants born to sero-positive mothers should be treated with a single intramuscular dose of benzathine benzylpenicillin, 50 000 IU/kg whether or not the mothers were treated during pregnancy (with or without penicillin). Hospitalisation is recommended for all symptomatic babies born to mothers who were sero-positive. Symptomatic infants and asymptomatic infants with abnormal CSF (up to 2 years of age) should be treated as early congenital syphilis.
a. Early congenital syphilis (up to 2 years of age)
Infants with abnormal cerebrospinal fluid:
• aqueous benzylpenicillin 100 000 - 150 000 IU/kg/day administered as 50 000 IU/kg/dose IV every 12 hours, during the first 7 days of life and every 8 hours thereafter for a total of 10 days.
• procaine benzylpenicillin, 50 000 IU/kg by intramuscular injection, as a single daily dose for 10 days.
Some experts treat all infants with congenital syphilis as if the cerebrospinal fluid findings were abnormal. Antibiotics other than penicillin (i.e. erythromycin) are not indicated for congenital syphilis except in cases of severe allergy to penicillin. Tetracyclines should not be used in young children.
b. Congenital syphilis of 2 or more years' duration:
• aqueous benzylpenicillin, 200 000 - 300 000 IU/kg/day by intravenous or intramuscular injection, administered as 50 000 IU/kg every 4-6 hours for 10-14 days.
Alternative regimen for penicillin-allergic patients, after the first month of life:
• erythromycin, 7.5-12.5 mg/kg orally, 4 times daily for 30 days.
Congenital syphilis may occur if the expectant mother has syphilis, but the risk is minimal if she has been given penicillin during pregnancy. All infants of seropositive mothers should be examined at birth and at monthly intervals for 3 months until it is confirmed that serological tests are, and remain, negative. Any antibody carried over from mother to baby usually disappears within 3 months of birth. Where available, IgM-specific serology may aid diagnosis.
Early congenital syphilis generally responds well, both clinically and serologically to adequate doses of penicillin. Recovery may be slow in seriously ill children with extensive skin, mucous membrane, bone or visceral involvement. Those in poor nutritional condition may succumb to concurrent infections, e.g. pneumonia.
Follow-up of Patients Treated for Syphilis
The follow-up of patients treated for early syphilis should be based on available medical services and resources. The clinical condition of the patients should be assessed and attempts made to detect reinfection during the first year after therapy. Patients with early syphilis who have been treated with appropriate doses and preparations of benzathine benzylpenicillin, should be evaluated clinically and serologically, using a non-treponemal test, after 3 months to assess the results of therapy. A second evaluation should be performed after 6 months and, if indicated by the results at 6 months, again after 12 months, to reassess the condition of the patient and detect possible reinfection.
All patients with cardiovascular syphilis and neurosyphilis should be followed for many years. The follow-up should include clinical, serological, cerebrospinal fluid and, where necessary, radiological examinations based on the clinician's assessment of the individual patient's condition and evaluation of the illness.
At all stages of the disease, repeat treatment should be considered when:
• clinical signs or symptoms of active syphilis persist or recur;
• there is confirmed increase in the titre of a non-treponemal test;
Examination of the cerebrospinal fluid should be undertaken before repeat treatment, unless reinfection and a diagnosis of early syphilis can be established.
Patients should be retreated with the schedules recommended for syphilis of more than two years' duration. In general, only one re-treatment course is indicated because adequately treated patients may maintain stable, low titres of non-treponemal tests.