What is the recommended dose of Ceftriaxone (a third-generation cephalosporin antibiotic) for the treatment of neurosyphilis?

From the Guidelines

Ceftriaxone should be administered at a dose of 2 grams intravenously once daily for 10-14 days for the treatment of neurosyphilis. This regimen is an alternative to the preferred treatment of aqueous crystalline penicillin G, which is given as 3-4 million units IV every 4 hours for 10-14 days 1. Ceftriaxone is particularly useful for patients with penicillin allergies or when compliance with multiple daily dosing might be challenging. The high-dose ceftriaxone is necessary to ensure adequate penetration across the blood-brain barrier to effectively treat the Treponema pallidum infection in the central nervous system.

Some key points to consider when using ceftriaxone for neurosyphilis treatment include:

• The possibility of cross-reactivity between ceftriaxone and penicillin exists, and skin testing should be performed to confirm penicillin allergy if concern exists regarding the safety of ceftriaxone 1.
• Other regimens have not been adequately evaluated for treatment of neurosyphilis, and therefore, ceftriaxone 2 g daily either IM or IV for 10–14 days is the recommended alternative treatment 1.
• Patients should undergo lumbar puncture for CSF analysis to confirm the diagnosis, and should be monitored clinically and with follow-up CSF examinations at 6-month intervals until the CSF cell count normalizes.
• Sexual partners should also be evaluated and treated appropriately, and neurosyphilis treatment requires hospitalization for initial management and careful monitoring for potential Jarisch-Herxheimer reactions, which can occur within the first 24 hours of treatment.

It's worth noting that the recommended dose and duration of ceftriaxone treatment for neurosyphilis have been consistently reported in the literature, with multiple studies suggesting that 2 g daily for 10-14 days is an effective regimen 1. However, the most recent and highest quality study, which is the 2010 guidelines for the treatment of sexually transmitted diseases, recommends this dose and duration 1.

From the Research

Ceftriaxone Dose for Neurosyphilis

• The optimal dose of ceftriaxone for neurosyphilis is not well established, but studies suggest that a dose of 1-2 g daily for 10-14 days may be effective 2, 3.
• A study published in 2021 found that ceftriaxone was similarly effective to benzylpenicillin in the treatment of neurosyphilis, with a shorter hospital stay 3.
• Another study published in 2003 reported a case of successful treatment of symptomatic neurosyphilis with parenteral ceftriaxone 4.
• A randomized controlled trial published in 2022 compared the efficacy of ceftriaxone with penicillin G for the treatment of neurosyphilis, with results showing no significant difference in clinical efficacy between the two treatments 5, 6.
• The clinical efficacy of penicillin and ceftriaxone sodium in the treatment of neurosyphilis with psychiatric symptoms was compared in a study published in 2022, with results showing no significant differences in efficacy between the two treatments 6.

Key Findings

• Ceftriaxone may be an effective alternative to penicillin for the treatment of neurosyphilis 2, 3, 4.
• The optimal dose and duration of ceftriaxone treatment for neurosyphilis require further study 2, 3, 5.
• Ceftriaxone may have a shorter hospital stay compared to benzylpenicillin 3.
• Penicillin and ceftriaxone sodium may have similar efficacy in the treatment of neurosyphilis with psychiatric symptoms 6.