What is the recommended treatment for a syphilis throat infection?

Treatment of Syphilis Throat Infection

Benzathine penicillin G, 2.4 million units administered intramuscularly in a single dose, is the recommended first-line treatment for syphilis throat infection, which is classified as early syphilis. 1

Treatment Algorithm

First-Line Treatment

• Benzathine penicillin G: 2.4 million units IM as a single dose
  • This is the treatment of choice regardless of HIV status
  • Penicillin remains the only therapy with well-documented efficacy for all stages of syphilis

For Penicillin-Allergic Patients

• Doxycycline: 100 mg orally twice daily for 14 days 1, 2
  • Alternative for non-pregnant patients with penicillin allergy
  • Requires close clinical and serologic monitoring

Special Considerations

HIV-Infected Patients

• Some specialists recommend three weekly injections of benzathine penicillin G (2.4 million units each) for HIV-infected patients, although the benefit remains unproven 1
• Closer follow-up is recommended for HIV-infected patients to detect potential treatment failure

Pregnant Patients

• Penicillin is the only recommended treatment during pregnancy
• Penicillin-allergic pregnant patients should undergo desensitization and then receive penicillin 1

Clinical Evaluation and Follow-Up

Initial Assessment

• Confirm diagnosis through dark-field examination and/or serologic testing
• Test all patients with syphilis for HIV infection
• Evaluate for other sexually transmitted infections

Follow-Up

• Clinical and serologic follow-up at 3,6,9,12, and 24 months after therapy 1
• Treatment failure or reinfection should be suspected if:
  • Signs or symptoms persist or recur
  • Sustained fourfold increase in nontreponemal test titer
  • Failure of nontreponemal test titers to decline fourfold within 3 months

Partner Management

• Sexual partners exposed within 90 days preceding diagnosis should be treated presumptively
• For primary syphilis, identify and evaluate partners from the 3 months plus duration of symptoms before treatment 1

Important Considerations and Pitfalls

Jarisch-Herxheimer Reaction

• Acute febrile reaction that may occur within 24 hours of treatment
• Characterized by fever, headache, and myalgia
• Patients should be advised about this possible reaction
• Antipyretics may be recommended, but there are no proven prevention methods 1

Azithromycin Caution

• Despite some evidence suggesting efficacy of azithromycin for early syphilis, molecular resistance of T. pallidum to macrolides and clinical treatment failures have been reported 1
• Not recommended as first-line treatment in the United States due to concerns about macrolide resistance

Treatment Failure

• If treatment failure is suspected, patients should be:
  • Re-evaluated for HIV infection
  • Undergo lumbar puncture (unless reinfection is likely)
  • Re-treated with appropriate regimen based on clinical stage and CSF findings 1

The evidence strongly supports benzathine penicillin G as the treatment of choice for syphilis throat infection, with doxycycline as an acceptable alternative for penicillin-allergic patients. Close follow-up is essential to ensure treatment success and prevent progression to later stages of disease.