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The syphilitic chancre may be confused with chancroid (usually painful), lymphogranuloma venereum (uncommon in the United States), genital herpes, or neoplasm Any lesion on the genitalia should be considered a possible primary syphilitic lesion Simultaneous evaluation for herpes simplex virus types 1 and 2 using polymerase chain reaction (PCR) or culture should also be done in cases of genital ulcer disease
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Avoidance of sexual contact is the only completely reliable method of prophylaxis but is an impractical public health measure for obvious reasons The standard latex condom is effective but protects covered areas only Screening every 6 12 months for syphilis among men who have sex with men has been recommended based on preliminary data suggesting that this may decrease the rate of transmission High-risk individuals (those who have multiple encounters with anonymous partners or who have sex in conjunction with the use of drugs) should be screened every 3 6 months Patients treated for other sexually transmitted diseases should also be tested for syphilis, and persons who have known or suspected contact with patients who have syphilis should be evaluated and treated to abort development of infectious syphilis (see Treating Syphilis Contacts)
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A Antibiotic Therapy
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Penicillin remains the preferred treatment for syphilis, since there are no documented cases of penicillin resistant T palli-
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dum Benzathine penicillin G, 24 million units intramuscularly in the gluteal area, is given once For the nonpregnant penicillin-allergic patient, doxycycline, 100 mg orally twice daily for 2 weeks, or tetracycline, 500 mg orally four times a day for 2 weeks, can be used There is limited data for ceftriaxone, although optimum dose and duration are not well defined While azithromycin was previously recommended as a possible alternative treatment, increasing resistance may limit its effectiveness All patients treated with a non-penicillin regimen must have close clinical and serologic follow up, as noted below Pregnant women must be treated with penicillin (see below)
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Follow-Up Care
Because treatment failures can occur and reinfection is always a possibility, patients treated for syphilis should be monitored clinically and serologically at 3 6 month intervals Response to therapy is difficult to assess, and no definite criteria exist for cure in patients with primary or secondary syphilis In primary and secondary syphilis, failure of nontreponemal antibody titers to decrease fourfold by 6 months may identify a group at high risk for treatment failure Optimal management of these patients is unclear, but at a minimum, close clinical and serologic follow-up is indicated If titers fail to decrease fourfold by 6 months, an HIV test should be repeated (all patients with syphilis should have an HIV test at the time of diagnosis); a lumbar puncture should be considered since unrecognized neurosyphilis can be a cause of treatment failure; and, if careful follow-up cannot be ensured (3-month intervals for HIV-positive individuals and 6-month intervals for HIV-negative patients), treatment should be repeated with 24 million units of benzathine penicillin intramuscularly weekly for 3 weeks If symptoms or signs persist or recur after initial therapy or there is a fourfold or greater increase in nontreponemal titers, therapy has either failed or the patient has been reinfected In those individuals, an HIV test should be performed, a lumbar puncture done (unless reinfection is a certainty), and re-treatment given as indicated above The natural course of untreated syphilis is described in Table 34 3
B Local Measures (Mucocutaneous Lesions)
Local treatment is usually not necessary No local antiseptics or other chemicals should be applied to a suspected syphilitic lesion until specimens for microscopy have been obtained
C Public Health Measures
Patients with infectious syphilis must abstain from sexual activity until rendered noninfectious by antibiotic therapy All cases of syphilis must be reported to the appropriate local public health agency for assistance in identifying and treating contacts In addition, all patients with syphilis should have an HIV test at the time of diagnosis In areas of high HIV prevalence, a repeat HIV test should be performed in 3 months if the initial test result was negative
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