Treponema pallidum is known to be invariably sensitive to penicillin.

Primary and secondary syphilis are effectively treated by benzylpenicillin or procaine penicillin i.m. daily for 10-21 days. Tetracycline or erythromycin orally may be used for penicillin-allergic patients.

Tertiary syphilis should have the same treatment, ensuring that it continues for 3 weeks.

Congenital syphilis in the newborn should be treated with benzylpenicillin for 10 days at least. Some advocate that a pregnant woman with syphilis should be treated as for primary syphilis, in each pregnancy, in order to avoid all danger to children. Therapy is best given between the third and sixth month, as there may be a risk of abortion if it is given earlier.

Results of treatment of syphilis with penicillin are excellent. Follow-up of all cases is essential, for 5 years if possible.

The Herxheimer (or Jarisch-Herxheimer) reaction is probably caused by cytokine (mainly tumour necrosis factor) release following massive slaughter of spirochaetes. Presenting as pyrexia, it is common during the few hours after the first penicillin injection; other features include tachycardia, headache, myalgia and malaise which last up to a day. It cannot be avoided by giving graduated doses of penicillin. Prednisolone may prevent it and should probably be given if a reaction is specially to be feared, e.g. in a patient with syphilitic aortitis.

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