Pharmacologic Therapy

Parenterally administered penicillin is recommended for all stages of syphilis (Table 80—1). Although penicillin is the drug of choice, combinations of benzathine penicillin with procaine penicillin or oral penicillin preparations are not considered appropriate treatment regimens. Several reports have demonstrated the misuse of the benzathine-procaine combination (Bicillin C-R) instead of the standard benzathine

penicillin (Bicillin L-A). Pertinent information related to benzathine penicillin G is found in Table 80-1.

Alternative agents may be used in allergic individuals and include doxycycline, minocycline, tetracycline, or erythromycin base or stearate. Some patients (such as young children or pregnant women) may not respond favorably to alternative modalities or should not receive tetracyclines. Therefore, in patients who must be administered penicillin (i.e., patients who are pregnant or have CNS involvement) or are allergic, desensitization must be performed before the drug is initiated.

Patients may experience fever, chills, tachycardia, and tachypnea, a condition commonly known as the Jarisch-Herxheimer reaction. This reaction is postulated to occur secondary to spiro chete lysis and proinflammatory cytokine cascades. It may transpire as early as 2 hours after penicillin administration and usually resolves within 24 hours. Treatment is supportive and may include antipyretic and anti-inflammatory agents, as well as fluid resuscitation and bed rest.

Primary Syphilis

Drug of Choice

Adults. Benzathine penicillin, 2.4 million units intramuscularly as a single dose.

Children. Benzathine penicillin 50,000 units/kg intramuscularly, up to the adult dose of 2.4 million units in a single dose.

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