What is the treatment for congenital syphilis in a newborn?

From the Guidelines

Treatment of congenital syphilis in newborns requires immediate intervention with parenteral penicillin G, specifically 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, as recommended by the most recent guidelines 1.

Key Considerations

• For confirmed or highly suspected cases, a thorough evaluation, including CSF analysis, complete blood count, and differential and platelet count, should be performed to guide treatment decisions 1.
• If more than one day of therapy is missed, the entire course should be restarted to ensure adequate treatment and prevent long-term complications 1.
• Close monitoring for Jarisch-Herxheimer reaction, a potential side effect of penicillin treatment, is essential, especially in the first 24 hours 1.
• Follow-up serologic testing should be performed at 3,6, and 12 months after treatment to ensure adequate response and prevent long-term complications, including neurological damage, bone deformities, and developmental issues 1.

Treatment Options

• 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 1.
• Procaine penicillin G 50,000 units/kg/dose IM in a single daily dose for 10 days, as an alternative to aqueous crystalline penicillin G 1.
• Benzathine penicillin G 50,000 units/kg IM, as a single dose, may be considered for infants with normal CSF findings and negative serology, but only if follow-up is certain and the mother's risk for untreated syphilis is low 1.

Important Notes

• Penicillin is highly effective against Treponema pallidum because it disrupts cell wall synthesis during bacterial replication, making it the preferred treatment for congenital syphilis 1.
• Early treatment is crucial to prevent long-term complications, including neurological damage, bone deformities, and developmental issues, emphasizing the need for prompt intervention and careful monitoring 1.

From the FDA Drug Label

Syphilis (congenital and neurosyphilis) after the newborn period 200,000 to 300,000 units/kg/day (administered as 50,000 units/kg every 4 to 6 hours) for 10 to 14 days

The treatment for congenital syphilis in a newborn is 200,000 to 300,000 units/kg/day of penicillin G, administered as 50,000 units/kg every 4 to 6 hours for 10 to 14 days 2.

From the Research

Treatment for Congenital Syphilis in Newborns

The standard treatment for congenital syphilis in newborns is:

• 10 days of intravenous aqueous crystalline penicillin G 3 Other potential therapeutic alternatives include:
• Ceftriaxone as a parenteral candidate 3
• Amoxicillin as an oral candidate 3
• Cefotaxime (where available) 3
• Ampicillin 3
• Doxycycline 3
• Cefixime 3
• Linezolid 3

Effectiveness of Penicillin Treatment

Studies have shown that penicillin administration may reduce the proportion of neonates with clinical manifestations of congenital syphilis and increase serological cure at the third month 4

• Low-quality evidence suggests that benzathine penicillin administration may not decrease the rate of neonatal death due to any cause, but may reduce the proportion of neonates with clinical manifestations of congenital syphilis 4
• High- and moderate-quality evidence suggests that there are probably no differences between benzathine penicillin and procaine benzylpenicillin administration for the outcomes of absence of clinical manifestations of syphilis or serological cure 4

Administration of Intravenous Benzylpenicillin

Intravenous benzylpenicillin has been used in 13 infants born to mothers with syphilis infection, with a treatment duration of 10 days 5

• The administration of benzylpenicillin in low-risk infants resulted in an extended duration of parent-to-infant separation and increased the infants' exposure to invasive procedures 5

Treatment Guidelines

The Centers for Disease Control and Prevention treatment guidelines recommend 10-14 days of intravenous penicillin G for the treatment of congenital syphilis 6

• A thorough maternal history and complete infant physical evaluation at birth is recommended for all neonates born to mothers diagnosed with and treated for syphilis 6
• Close follow-up with repeat nontreponemal titers is recommended, as outlined by the Centers for Disease Control and Prevention and American Academy of Pediatrics guidelines 6