Scenario 1

• Infants with proven or highly probable disease and:

  1. an abnormal physical examination that is consistent with congenital syphilis;

  2. a serum quantitative nontreponemal serologic titer that is fourfold higher than the mother’s titer; or

  3. a positive darkfield test of body fluid(s).

• Recommended Evaluation

  • CSF analysis for VDRL, cell count, and protein

  • Complete blood count (CBC) and differential and platelet count

  • Other tests as clinically indicated (e.g., long-bone radiographs, chest radiograph, liver-function tests, cranial ultrasound, ophthalmologic examination, and auditory brain stem response)

• Recommended Regimens

  Aqueous crystalline penicillin G 100,000–150,000 units/kg/day, administered as 50,000 units/kg/dose IV every 12 hours during the first 7 days of life and every 8 hours thereafter for a total of 10 days

  OR

  Procaine penicillin G 50,000 units/kg/dose IM in a single daily dose for 10 days

​

Scenario 2

• Infants who have a normal physical examination and a serum quantitive nontreponemal serologic titer the same or less than fourfold the maternal titer and the:

  1. mother was not treated, inadequately treated, or has no documentation of having received treatment;

  2. mother was treated with erythromycin or another nonpenicillin regimen; or

  3. mother received treatment <4 weeks before delivery.​​

• Recommended Evaluation

  • CSF analysis for VDRL, cell count, and protein

  • Complete blood count (CBC) and differential and platelet count

  • Long-bone radiographs

• Recommended Regimens

  Aqueous crystalline penicillin G 100,000–150,000 units/kg/day, administered as 50,000 units/kg/dose IV every 12 hours during the first 7 days of life and every 8 hours thereafter for a total of 10 days

  OR

  Procaine penicillin G 50,000 units/kg/dose IM in a single daily dose for 10 daysORBenzathine penicillin G 50,000 units/kg/dose IM in a single dose​

 

Scenario 3

• Infants who have a normal physical examination and a serum quantitative nontreponemal serologic titer the same or less than fourfold the maternal titer and the:

  1. mother was treated during pregnancy, treatment was appropriate for the stage of infection, and treatment was administered >4 weeks before delivery and

  2. mother has no evidence of reinfection or relapse.

• Recommended Evaluation

  • No evaluation is required.

• Recommended Regimens

  Benzathine penicillin G 50,000 units/kg/dose IM in a single dose*

  * Another approach involves not treating the infant, but rather providing close serologic follow-up in those whose mother’s nontreponemal titers decreased fourfold after appropriate therapy for early syphilis or remained stable or low for late syphilis.

​

Scenario 4

• Infants who have a normal physical examination and a serum quantitative nontreponemal serologic titer the same or less than fourfold the maternal titer and the:

  1. mother’s treatment was adequate before pregnancy and

  2. mother’s nontreponemal serologic titer remained low and stable before and during pregnancy and at delivery (VDRL <1:2; RPR <1:4).

• Recommended Evaluation

  • No evaluation is required.

• Recommended Regimens

  • No treatment is required; however, benzathine penicillin G 50,000 units/kg as a single IM injection might be considered, particularly if follow-up is uncertain.

 

Older Infants and Children Aged ≥1 month

• Infants with proven or highly probable disease and:

  1. an abnormal physical examination that is consistent with congenital syphilis;

  2. a serum quantitative nontreponemal serologic titer that is fourfold higher than the mother’s titer; or

  3. a positive darkfield test of body fluid(s).

• Recommended Evaluation

  • CSF analysis for VDRL, cell count, and protein

  • CBC, differential, and platelet count

  • Other tests as clinically indicated (e.g., long-bone radiographs, chest radiograph, liver function tests, abdominal ultrasound, ophthalmologic examination, and auditory brain stem response)

• Recommended Regimens
  Aqueous crystalline penicillin G 200,000–300,000 units/kg/day IV, administered as 50,000 units/kg every 4–6 hours for 10 days