Acceptability and compliance with daily injections of procaine penicillin in the outpatient treatment of syphilis-treponemal infection

2020 European guideline on the management of syphilis

The 2020 edition of the European guideline on the management of syphilis is an update of the 2014 edition. Main modifications and updates include: -The ongoing epidemics of early syphilis in Europe, particularly in men who have sex with men (MSM) -The development of dual treponemal and non-treponemal point-of-care (POC) tests -The progress in non-treponemal test (NTT) automatization -The regular episodic shortage of benzathine penicillin G (BPG) in some European countries -The exclusion of azithromycin as an alternative treatment at any stage of syphilis -The pre-exposure or immediate post-exposure prophylaxis with doxycycline in populations at high risk of acquiring syphilis.

Procaine penicillin alters swimming behaviour and physiological parameters of Daphnia magna

Procaine penicillin (PP) is a β-lactam antibiotic widely used in human and veterinary medicine. Although PP is detected in surface water, little is known on its effects on aquatic invertebrates. Our aim was to determine the influence of PP on swimming behaviour (track density, swimming speed, turning angle, hopping frequency) and physiological activity (oxygen consumption, heart rate, thoracic limb movement) of a freshwater invertebrate Daphnia magna exposed to PP at concentrations of 11.79 mg/L, 117.9 mg/L and 1179 mg/L for 2 h and 24 h. The results showed no mortality; however, reduction of swimming activity manifested by the decreased track density, swimming speed and turning angle noted in Daphnia exposed to all the concentrations of PP. Increase of oxygen consumption was observed after 2-h exposure; however, decrease of this parameter was found after 24 h. PP also reduced heart rate and thoracic limb movement in a concentration-dependent manner. The results suggest that the antibiotic should not induce mortality; however, it may affect swimming behaviour and physiological parameters of Daphnia magna particularly inhabiting aquaculture facilities with intensive antibiotic treatment. On the basis of the present results, we also suggest higher sensitivity of behavioural and physiological parameters of cladocerans than the commonly used endpoints: mortality or immobilisation and their possible application as a part of early warning systems in monitoring of surface water toxicity.

UK national guidelines on the management of syphilis 2015

These guidelines are an update for 2015 of the 2008 UK guidelines for the management of syphilis. The writing group have piloted the new BASHH guideline methodology, notably using the GRADE system for assessing evidence and making recommendations. We have made significant changes to the recommendations for screening infants born to mothers with positive syphilis serology and to facilitate accurate and timely communication between the teams caring for mother and baby we have developed a birth plan. Procaine penicillin is now an alternative, not preferred treatment, for all stages of syphilis except neurosyphilis, but the length of treatment for this is shortened. Other changes are summarised at the start of the guideline.

Current standards for syphilis treatment: comparing the russian and foreign guidelines (part II)

The introduction of penicillin has been a breakthrough in the treatment of syphilis. For 70 years, penicillin remains the preferred drug for the treatment of all forms of the disease; its effectiveness has been proven by wide experience gained from clinical observations. However, a very limited number of published meta-analyzes, systematic reviews and data from randomized controlled trials on the comparative assessment of the effectiveness of various antibiotics and treatment regimens are currently available. Some aspects of syphilis treatment are insufficiently developed, particularly, the treatment schedules for neurosyphilis, syphilis in pregnancy, syphilis in HIV-infected individuals and persons allergic to penicillin. There are disagreements in the assessment of the clinical significance of serofast state after a course of antibiotic therapy. There is no uniform approach to the management of patients with treatment failures. This article compares the Russian standards for syphilis treatment set out in the «Federal guidelines for the management of patients with syphilis» with the current European recommendations of the International Union against Sexually Transmitted Infections (IUSTI) and the recommendations of the US Centers for Disease Control and Prevention (CDC). The peculiarities of these guidelines, their strengths and shortcomings, as well as controversial issues of syphilis therapy are discussed. The differences between the domestic and foreign recommendations are more significant in the section concerning the treatment of syphilis than in the section of diagnosis.

Management of syphilis in HIV-positive individuals

Since the turn of the millennium a sustained outbreak of syphilis among men who have sex with men continues, approximately 20–50% of whom have concurrent HIV infection. In this paper we aim to explore the controversies that exist around the management of syphilis in HIV-positive individuals. Not only do HIV-positive people have different clinical manifestations of syphilis they have higher rates of asymptomatic neurological involvement, slower serological response to treatment and higher serological failure than HIV-negative individuals in most studies. Whether long-term clinical outcomes are different or affected by the antibiotic regimen selected remains to be established. The optimal antimicrobial regimen to treat syphilis in HIV is unknown due to a dearth of randomised controlled trial data. International guidelines state that the antibiotic management of syphilis is the same regardless of HIV status, with early syphilis treated with a single dose of benzathine penicillin G 2.4mU intrmuscularly. In practice, however, the majority of surveyed clinicians do treat HIV-positive people with more intensive antibiotics suggesting a lack of faith in guidelines. Factors which appear to affect the likelihood of developing neurological disease include CD4+ count of <350 cells/μL, absence of antiretroviral therapy, rapid plasma regain (RPR) or venereal diseases reference laboratory titre (VDRL) >1 : 32, late-latent disease or lack of response to standard antibiotic treatment. We recommend a low-threshold for offering antibiotic treatment effective against neurosyphilis in HIV-positive people with syphilis, especially if they exhibit any of the above factors.

Syphilis treatment: old and new

Syphilis has challenged scientists and clinicians since its first appearance in the late 1400s and debate continues to surround the best practice in management. Difficulties in defining the goals of successful treatment have contributed to problems in determining recommendations for the ideal management. Treatment regimens currently in use were developed before randomised controlled trials became standard. This, combined with national differences in disease definition, staging and varying interpretations of the studies, as well as the emergence of complicating comorbid conditions, such as HIV, has resulted in a lack of consensus for treatment. This paper will discuss the history and current treatment of syphilis focusing on dilemmas faced by clinicians today, including the emergence of a resistant strain. Despite the difference between current national guidelines, penicillin G largely remains the treatment of choice. Close follow up, monitoring and ensuring adequate compliance remain the most important aspects in the treatment of syphilis.

Ocular syphilis: the new epidemic

AIM

To present the clinical presentation, diagnosis, and management of syphilitic uveitis in the context of an epidemic of syphilis in the UK.

METHOD

Retrospective clinical case series.

RESULTS

Six new cases of syphilitic uveitis presented to the Manchester Uveitis Clinic in 2004, after a 15-fold increase in the incidence of syphilis in the UK, including 615 cases in Greater Manchester in the 5 years to 2004. Four cases had secondary syphilis, two had latent disease, two had no rash, and two were HIV positive. Ocular involvement included anterior or panuveitis, retinitis, retinal vasculitis, and papillitis. All resolved on treatment including intramuscular procaine penicillin G with oral probenecid.

CONCLUSIONS

Syphilis is much more common recently and syphilitic uveitis should be considered in all patients with rash and/or headache, where there is retinitis and/or retinal vasculitis, or in any uveitis of uncertain origin. Treatment is that of neurosyphilis.

Antibacterial therapy of neurosyphilis: lack of impact of new therapies

Neurosyphilis is caused by the spirochete Treponema pallidum. These organisms divide slowly, requiring long exposure to antibacterials for treatment success. In order for an antibacterial to be effective in the therapy of neurosyphilis, it must achieve treponemicidal concentrations in the CSF, have a long half-life and be given in a treatment regimen that favours compliance. Penicillin was first introduced for the treatment of syphilis in 1943, and despite interest in the use of amoxicillin, erythromycin, tetracycline, doxycycline, ceftriaxone and azithromycin, penicillin remains the only recommended antibacterial agent for neurosyphilis.

Treatment of sexually transmitted infections with single-dose therapy: a double-edged sword

Since the advent of the antimicrobial era, single-dose therapy has been a valuable tool in the management of genital infection. Most of the common sexually transmitted infections (STIs) such as gonorrhoea, syphilis, trichomoniasis and chancroid can be treated in this way, as can genital infections which are not sexually transmitted such as bacterial vaginosis and genital tract candidiasis. Until recently, treatment for Chlamydia trachomatis infection required a multi-dose regimen, but single-dose azithromycin has now been shown to be an effective and acceptable alternative to this. Unfortunately, eradicative therapy has proven to be elusive for the viral STIs such as genital herpes simplex infection, human papilloma virus infection and human immunodeficiency virus (HIV) infection. The main advantage of single-dose therapy lies in its convenience and in its ability to ensure virtually 100% compliance. This addresses the problems of reduced clinical efficacy and the difficulties in assessing the response to therapy which complicates poor treatment compliance. However, some single-dose regimens for STIs do have drawbacks, particularly in certain situations. This may be with respect to efficacy, for example in syphilis with single-dose benzathine penicillin therapy, particularly for pregnant women and individuals infected with HI. Alternatively, it may involve toxicity, for example with single-dose metronidazole therapy for trichomoniasis or bacterial vaginosis where a higher rate of gastrointestinal adverse effects may be expected than if a lower multi-dose regimen is used. In addition, single-dose therapy, for example with nevirapine, given to the mother in labour and to the baby after delivery significantly reduces the risk of mother to child HIV transmission, but resistance mutations are frequently detected in the viral genome after the brief exposure to the drug, which could jeopardise its future use. Single-dose therapy clearly has both advantages and disadvantages. We have reviewed a range of these in a variety of situations, focussing on their applications, effectiveness, compliance and toxicity, highlighting how single-dose therapy may be a double-edged sword.

Antibiotics for syphilis diagnosed during pregnancy

BACKGROUND

Congenital syphilis is an increasing problem in many developing countries and in the transitional economies of Eastern Europe and the former Soviet Union. In several countries this increase has been aggravated by HIV/AIDS. While the effectiveness of penicillin in the treatment of syphilis in pregnant women and the prevention of congenital syphilis was established shortly after the introduction of penicillin in the 1940s, there is uncertainty about the optimal treatment regimens.

OBJECTIVES

To identify the most effective antibiotic treatment regimen (in terms of dose, length of course and mode of administration) of syphilis with and without concomitant infection with HIV for pregnant women infected with syphilis.

SEARCH STRATEGY

MEDLINE 1966 to March 2000; EMBASE 1974 to March 2000, the Cochrane Controlled Trials Register (last searched March 2001), the Cochrane Pregnancy and Childbirth group trials register (last searched March 2001) and the references of traditional reviews were searched. Experts in specialist units were contacted.

SELECTION CRITERIA

It was planned that any trial in which an attempt is made to allocate treatment for syphilis during pregnancy by a random or quasi-random method would be included in this review.

DATA COLLECTION AND ANALYSIS

Information was extracted using a data extraction sheet and this included entry criteria, the source of controls, and whether the authors stratified by the stage of pregnancy when the diagnosis of syphilis was made.

MAIN RESULTS

Twenty six studies met the criteria for detailed scrutiny. However, none of these met the pre-determined criteria for comparative groups and none included comparisons between randomly allocated groups of pregnant women.

REVIEWER'S CONCLUSIONS

While there is no doubt that penicillin is effective in the treatment of syphilis in pregnancy and the prevention of congenital syphilis, uncertainty remains about what are the optimal treatment regimens. Further studies are needed to evaluate treatment failure cases with currently recommended regimens and this should include an assessment of the role of HIV infection in cases of prenatal syphilis treatment failure. The effectiveness of various antibiotic regimens for the treatment of primary and secondary syphilis in pregnant women need to be assessed using randomised controlled trials which compare them with existing recommendations.

Syphilis management and treatment

Syphilis poses a serious health problem in many developing countries and in some areas of North America and Europe, especially Eastern Europe. This article initially addresses the state of the art regarding the interaction between syphilis and HIV infection and its consequences for management and treatment. Further attention is given to laboratory diagnosis of syphilis and false-positive and false-negative serologic reactions. The diagnosis and management of neurosyphilis, ocular, cardiovascular, and congenital syphilis are addressed, as well as management of syphilis patients allergic to penicillin and the Jarisch-Herxheimer reaction. Finally, the role of partner(s) and contact tracing is discussed.