Simplified algorithm for clinical syphilis staging and treatment in adolescents and adults

Test Results

• Direct test: T. pallidium detected on an appropriate clinical specimen^{Footnote 2}
• Serology: First positive syphilis serology [treponemal test (TT)+/- non-treponemal test (NTT)^{Footnote 3}] OR In someone with prior syphilis^{Footnote 1}: reactive NTT in someone whose NTT reverted to non-reactive OR ≥ 4-fold increase in NTT^{Footnote 3}

Clinical Stage

• Direct test
  • Chancre = Primary syphilis
  • Rash or other symptoms^{Footnote 4}, = Secondary syphilis
  • In both cases, are there Neurological signs or symptoms?
    • yes
      • Treatment = Consult a specialist (ID or neurology)
    • no
      • Treatment = Benzathine penicillin G long-acting 2.4 million units IM x 1 dose^{Footnote 5}. For pregnant individuals, some experts recommend 2 doses, 1 week apart^{Footnote 5}.
        • Advise about possible Jarish-Herxheimer reaction
• Serology
  Characteristic signs and symptoms of primary syphilis, secondary syphilis or neurosyphilis?
  • yes
    • Follow the Direct test Clinical stage to treatment path
  • no
    Negative TT^{Footnote 2} result within 12 months OR In someone with prior syphilis^{Footnote 1}: Non-reactive or stable low NTT3 result within 12 months?
    • yes
      • Early latent syphilis
        • Treatment = Benzathine penicillin G long-acting 2.4 million units IM x 1 dose^{Footnote 5}. For pregnant individuals, some experts recommend 2 doses, 1 week apart^{Footnote 5}.
          • Advise about possible Jarish-Herxheimer reaction
    • no
      • Latent syphilis of unknown duration OR Late latent syphilis
        • Treatment = Benzathine penicillin G long-acting 2.4 million units IM weekly x 3 doses^{Footnote 5}.
          • Advise about possible Jarish-Herxheimer reaction