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Syphilis in Pregnancy
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10. Infant clinical examples: Revised CDC guidelines
Appropriate treatment of the infant
depends on whether or not it has clinical signs, as well as on the maternal history and titers. The 2002 CDC guidelines provide four clinical examples:
Infant example 1
In infants with an abnormal physical examination, or a non-treponemal serology titer than is fourfold greater than the mother's titer, a clinical diagnosis of active disease can be made. CSF analysis for VDRL, cell count, and protein, along with a CBC and platelet count should be carried out. Other studies such as long bone radiographs, chest X-Ray, LFTs, and neurologic evaluation, should be ordered as indicated. Treatment is then begun with aqueous penicillin 50,000 units/kg/dose IV q12h x 7 days, followed by q8h for a total of 10 days. Alternatively these infants may receive procaine penicillin 50,000 units IM daily for 10 days.
Infant example 2
Infants with a normal physical exam and a titer less than fourfold the maternal titer, but whose mother appear to have received suboptimal treatment, or who have not had an appropriate serologic response (fourfold reduction in titer), should also have a CSF evaluation. They should then be treated with IV aqueous penicillin or IM procaine penicillin as above. If the CSF evaluation is able to be successfully carried out and is normal, these infants may alternatively be treated with a single dose of IM benzathine penicillin 50,000 units/kg.
Infant example 3
Infants with a more reassuring maternal history (appropriate treatment >4 weeks prior to delivery with a fourfold decline in maternal titer), who have a serum quantitative non-treponemal titer the same, or less than fourfold, the maternal titer, need not have an LP. They may be treated with the single dose LA Bicillin treatment as above.
Infant example 4
Infants in whose mothers received adequate treatment prior to pregnancy and have a stable low titer (VDRL<1:2 or RPR<1;4) are at low risk for infection. If they have a normal physical exam, and titers less than fourfold the maternal titer, no further evaluation is required, and no treatment is required. Some authorities would recommend single dose IM treatment as above if follow-up is uncertain.
All infants with a positive serology, or whose mothers had a positive serology at delivery, should have non-treponemal testing done every 2-3 months until the test becomes nonreactive or the titer decreases fourfold. All titers should be nonreactive by 6 months of age if the infant is not infected and/or has been adequately treated.
