Congenital Syphilis

Maternal History Assessment

• Evaluate maternal nontreponemal (RPR/VDRL) and treponemal (FTA-ABS/TP-PA) test results
• Ascertain adequacy of maternal treatment (must be Penicillin G, initiated >30 days prior to delivery, with appropriate titer decrease)
• Evaluate newborn physical examination (often asymptomatic at birth; may show snuffles, hepatosplenomegaly, rash/desquamation on palms/soles, pseudoparalysis of Parrot)

Newborn Evaluation

• Obtain infant serum nontreponemal test (RPR/VDRL) using same method as mother's (do NOT use cord blood)
• If infant titer is >= 4-fold maternal titer OR exam is abnormal: Full evaluation required
• Full Evaluation includes: CSF analysis (VDRL, cell count, protein), CBC, long-bone radiographs

Treatment Protocol

• Proven/Highly Probable Disease (Scenario 1): Aqueous Crystalline Penicillin G IV for 10 days
• Possible Disease (Scenario 2 - maternal treatment inadequate, but infant titer < 4-fold): Pen G IV for 10 days OR single dose Penicillin G Benzathine IM (if full evaluation is strictly normal)
• Less Likely Disease (Scenario 3 - maternal treatment adequate before delivery): Single dose Penicillin G Benzathine IM OR clinical monitoring
• Strict clinical and serologic follow-up at 2-3, 6, and 12 months

Infection Control & Pharmacokinetics

• Ampicillin dosing (<7 days, >2kg): 100 mg/kg/dose IV q8h for meningitis coverage; 50mg/kg/dose q12h for bacteremia.
• Gentamicin dosing: 4-5 mg/kg/dose IV q24h; MUST check trough levels prior to 3rd dose (Target trough < 1.0 mcg/mL).
• Strict contact and droplet precautions until specific viral/bacterial pathogen is ruled out.
• Assess for osteomyelitis/septic arthritis with thorough physical exam including joint mobility and symmetry.
• LP execution: Defer lumbar puncture ONLY if infant is hemodynamically unstable or profoundly thrombocytopenic.

Standardized Discharge & Follow-Up Criteria

• Adequate weight gain explicitly > 15-30g/day over a continuous 3-5 day period.
• Maintenance of temperature in an open crib with standard clothing for 48 hours.
• Successful completion of the 90-120 minute Infant Car Seat Challenge.
• Caregiver successfully completed CPR training, rooming-in, and independent medication administration.
• Referrals placed for High-Risk Infant Follow-Up Clinic, Early Intervention (PT/OT), and appropriate sub-specialists.

Diagnostic & Management Algorithm

• Congenital Syphilis Evaluation Algorithm: [START] Maternal RPR Positive -> [DECISION] Treated with Penicillin >4 weeks prior? -> [YES] RPR Titer check -> [NO] Full workup (CSF, Bones, Blood) + 10 days Aqueous Pen G

References

1. Centers for Disease Control and Prevention (CDC). Sexually Transmitted Infections Treatment Guidelines: Congenital Syphilis.
2. American Academy of Pediatrics (AAP) Red Book. Syphilis.