Category | Definition | Additional evaluation to perform | Treatment | Follow-up testing (applies to all categories) |
Proven or highly probable congenital syphilis (scenario 1) |
Plus |
| 10 days of IV penicillin G |
|
Possible congenital syphilis (scenario 2) | All of the following:
| We further classify newborns in the "possible" category as higher or lower risk:
| ||
Higher risk:
| Higher risk:
| |||
Lower risk:
| Lower risk:
| |||
Less likely congenital syphilis (scenario 3) | All of the following:
| Not required | Single dose of IM penicillin benzathine¥ | |
Unlikely congenital syphilis (scenario 4) | All of the following:
| Not required | Not required‡ |
ABR: auditory brainstem response; CBC: complete blood count; CDC: Centers for Disease Control and Prevention; CSF: cerebrospinal fluid; DFA: direct fluorescent antibody; IM: intramuscular; IV: intravenous; LFTs: liver function tests; LP: lumbar puncture; PCR: polymerase chain reaction; RPR: rapid plasma regain; VDRL: venereal disease research laboratory.
* Findings of congenital syphilis may include hepatosplenomegaly, rash, condyloma lata, snuffles, jaundice (nonviral hepatitis), pseudoparalysis, pallor (anemia), or edema (nephrotic syndrome and/or malnutrition). Refer to UpToDate topic on congenital syphilis for additional details.
¶ A 4-fold titer is equivalent to two dilutions (eg, newborn's titer 1:32 when birthing parent's titer is 1:8).
Δ These tests are not available in many clinical settings.
◊ Adequate treatment is defined as completion of a penicillin-based regimen, in accordance with CDC treatment guidelines, appropriate for stage of infection and initiated ≥4 weeks before delivery. Relapse or reinfection after treatment is suggested by a 4-fold increase of the birthing parent's VDRL or RPR titers after treatment. Inadequate/suboptimal therapy includes any of the following:
§ The CDC guidelines include a caveat that additional evaluation may not be necessary for neonates in the "possible" category if a 10-day treatment course is planned. Nevertheless, we suggest performing the evaluation in higher-risk neonates (as defined above) since the evaluation may inform decisions regarding treatment and follow-up.
¥ Some specialists opt not to treat infants in this category if the birthing parent was treated adequately and close follow-up of the infant is certain. If this approach is chosen, close serologic follow-up (ie, monthly) is necessary, and treatment should be provided if the infant's titers do not decline as expected over the first few months after birth.
‡ If follow-up is uncertain, some specialists would provide a single dose of IM benzathine penicillin to protect the infant in the unlikely event that the birthing parent was reinfected.