How to treat congenital syphilis when aqueous penicillin is not available_?
Ira Shah
Medical Sciences Department, Pediatric Oncall, Mumbai, India

Address for Correspondence: Dr Ira Shah, 1, B Saguna, 271, B St Francis Road, Vile Parle {W}, Mumbai 400056

Clinical Problem :
A 3 days old baby is diagnosed to have congenital syphilis on testing with VDRL. The child is asymptomatic and had normal birth with birth weight of 3kg. Cerebrospinal fluid {CSF} VDRL is negative. Injectable crystalline penicillin and procaine penicillin is not available.

Question :
How should this child be treated_?

Expert Opinion :
Congenital syphilis, either proved or presumed, is treated with a 10-day course of aqueous penicillin G {100,000–150,000 U, kg, day, administered as 50,000 U, kg per dose, intravenously, every 12 hours during the first 7 days of life and every 8 hous thereafter for a total of 10 days} or procaine penicillin G {daily single dose of 50 000 U, kg per day, intramuscularly for 10 days}. In case of shortage of aqueous penicillin, CDC recommends that some or all daily doses should be substituted with procaine penicillin G {50,000 U, kg, dose IM a day in a single dose for 10 days}. If both aqueous or procaine penicillin G are not available, ceftriaxone may be considered with careful clinical and serologic follow-up. Ceftriaxone must be used with caution in jaundiced infants. For infants = 30 days old, it is given in dose of 75 mg, kg IV, IM, day in a single dose for 10-14 days. For older infants, this dose should be 100 mg, kg, day in a single dose. Studies that strongly support ceftriaxone for the treatment of congenital syphilis have not been done. In case of abnormal CSF examination at the beginning, a repeat CSF exam at 6 months of age if the initial exam was abnormal is recommended. {1}
In patients, if the diagnosis of congenital syphilis is not completely established, then benzathine penicillin G, 50,000 U, kg IM as a single dose can be used.
Treated infants should be followed-up at 3, 6 and 12 months of age, until serologic non-treponemal tests become non-reactive or the titre has decreased fourfold. With adequate treatment or in cases in which antibody is transplacentally acquired in the absence of congenital infection, non-treponemal antibody titres should decrease by 3 months of age and be non- reactive by 6 months of age. Previously treated infants at 6–12 months of age with increasing or persistent titres should be re-evaluated, including CSF examination, and treated with a further 10-day course of if the results are abnormal.

1. CDC. 2002 CDC Sexually Transmitted Diseases Treatment Guidelines. MMWR 2002 `51 {RR-6}:1-80.

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