PRINCIPLES AND METHODS OF SYPHILIS THERAPY

Agents used in treating syphilitic patients are called specific, antisyphilitic. They are prescribed after the diagnosis has been made or as a measure for preventing the development of the disease. They are also used in ex juvantibus therapy as an aid in the diagnosis of doubtful cases (it is most frequently applied when syphilis of the internal organs or nervous system is suspected). Once the diagnosis of syphilis has been made, treatment should be started as soon as possible (within the first 24 hours in active forms). The earlier the treatment is begun, the better the prognosis and the more effective the treatment. According to order issued by Ukraine Ministry of Health and endorsed on June 06, 2004, besides antisyphilitic agents producing a direct effect on T. pallidum (mainly in the period of active reproduction), non-specific agents are widely used to produce a general invigorating effect and help the body to overcome the infection. Non-specific therapy is applied at the same time as the specific antisyphilitic agents. The later the treatment begins, the longer the causative agent remains in the patient's body, the more non-specific therapy is substantiated.

Penicillin and its derivatives are now the principal agents used in treating syphilis. Penicillin is used as a sodium or potassium salt. Its derivatives are long-acting agents. These are bicillin-1, bicillin-3 and bicillin-5.

Water-soluble penicillin is given as a single intramuscular injection every three hours around-the-clock in a dose of 500 000 U to 1 000 000 U. Duration of the therapy depends on stage of syphilis. This is the main method of treatment in the hospital. The novocaine salt of bensilpenicillin as its foreign analogue procaine-penicillin G is given as an intramuscular injection 1-2 times a day in a dose of 1 500 000 U to 3 000 000 U. The main preparation for treatment patients with early syphilis in out-patients' department is benzathine penicillin (bicillin-1, extencillin, retarpen, procaine-penicillin). They are given in a single intramuscular dose one time a week. Bismuth salts (bioquinol, bismoverol and a water-soluble agent pentabismol) and iodine preparations are used sometimes as group of reserve in the treatment of syphilis patients with late forms of syphilis.

Before use the flask with bioquinol or bismoverol is heated in 40-45°C water and the contents are shaken thoroughly till a homogeneous suspension is produced. Bioquinol and bismoverol, like the long-acting penicillin preparations, are injected with a pause into the muscles of the superolateral quadrant of the buttocks. Pentabismol is injected without a pause. Women in pregnancy (with latent or active syphilis) as well as patients suffering from syphilis and active forms of tuberculosis are not given bismuth preparations.

Iodine preparations are prescribed as potassium iodide or sodium iodide solutions. One tablespoonful is given on the first day, two tablespoonfuls on the second day and three tablespoonfuls three times a day on the third and following days. The solution is taken in half a glass of milk after a meal. Solutions of gradually increasing concentrations (from 2-3 to 7-8 per cent) are used. Treatment lasts 3 to 4 weeks.

The instructions issued by Ukraine Ministry of Public Health contain several schedules for antisyphilitic treatment.

Treatment of acquire syphilis of adults:

Stages	Penicillin	Procaine-penicillin G	Bicillin-1, -3, -5	Benzathin penicillin (extencilline, retarpen)
Period of infection less then 3 months (primary seronegative syphilis, primary seropositive syphilis, latent)	Every 3 hours around-the-clock I.M. in a dose 500 000 U to 1 000 000 U for 14 days	3 mega units daily I.M. for 14 days.	1, 2; 1, 8; and 1, 5 mega units correspondingly 2 times a week I.M. for 2 weeks.	2.4 mega units IM. 1 time a week for 2 weeks.
Period of infection from 3 to 6 months (secondary fresh syphilis, secondary recurrent syphilis, latent)	Every 3 hours around-the-clock I.M. in a dose 500 000 U to 1 000 000 U for 16 days	3 mega units daily I.M. for 16 days.	1, 2; 1, 8; and 1, 5 mega units correspondingly 1 time a three days I.M. 7 injection.	2.4 mega units IM. 1 time a week for 3 weeks.
Period of infection from 6 months to 1 year (secondary recurrent syphilis, latent)	Every 3 hours around-the-clock I.M. in a dose 1 000 000 U for 21 days	3 mega units daily I.M. for 21 days.	First day novocaine salt of penicillin 1, 2 mega units 2 times a day then from second day 1, 2; 1, 8; and 1, 5 mega units correspondingly 2 times a week I.M. for 4 weeks	First day procaine-penicillin G 3 mega units I.M 2 times a day, from second day benzathin penicillin 2.4 mega units IM. 1 time a week for 4 weeks.

 

Patients who are allergic to penicillin can be treated with either erythromycin macrolides, cephalosporins.

Erythromycin 2, 0-2, 5 g per day in divided doses for 14-28 days.

Azitromycin 1, 0 g per day in divided doses for 10-21 days.

Ceftriaxone 1, 0 g per day in divided doses for 8-14 days.

Most antibiotics except amino-glycoside group are trepanemocidal but are not thoroughly evaluated

The doses of penicillin, ecmonovocillin and bicillin for children are determined by their age according to the existing instructions.

Preventive treatment is applied for individuals who had close intimate contact or everyday contact with a patient with active form of syphilis. This is particularly important in regard to children whose parents have contagious syphilitic lesions. If no more than three months have passed from the time of contact (sexual intercourse or everyday contact), a preventive treatment with a single intramuscular dose of benzathine penicillin of 2, 4 mega units IM. is conducted. It may be used procaine-penicillin G as a intramuscular injection 1 time a day in a dose of 1, 5 mega units for 7 days or bicillin-1, -3, -5 as a intramuscular injection in a dose of 1, 2 mega units; 1, 8 mega units and 1, 5 mega units 3 times in 3-4 days. In hospital a sodium salt of penicillin is used in a dose of 500 000 U to 1 000 000 U every three hours around-the-clock for 7 days. In cases when more then 3 months have passed from the time of intimate contact with a patient suffering from contagious or early latent syphilis, full serological examination is applied. As results of examination are negative the treatment isn’t used.

Complications may occur in the treatment of syphilitic patients. Penicillin and its derivatives may cause allergic reactions and toxic phenomena. The allergic reactions include anaphylactic shock, toxicodermia, acute oedema, various eruptions; headache and hemopoietic disorders are the toxic phenomena. Penicillin drugs may impair the activity of the intestinal flora, which is conducive to the development of dysbacteriosis (inhibition of E. coli activity in particular). Dysbacteriosis, in turn, facilitates the development of candidiasis. Bismuth preparations may cause complications in the kidneys (protein, casts, and 'bismuth cells' appear in the urine) and irritation of the oral mucosa ('bismuth margin', gingivitis, stomatitis). Rhinitis, iodine acne, and conjunctivitis may develop under the effect of iodine drugs.

To prevent complications in antisyphilitic treatment, the patient must be examined carefully before therapy is begun, detailed information must be gained on antibiotic tolerance in the past, and tolerance of the drugs during treatment must be watched. The observance by the patient of the hygienic regimen (alternation of physical exertion and rest, abstinence from spicy foods, alcohol, etc.), a full-value calory diet, vitamins and proper care of the teeth and gums are also measures for preventing complications.

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