This protocol covers the management of latent syphilis where acquisition occurred more than 2 years ago — classified as late stage — in a pregnant patient. Staging determines the appropriate treatment regimen when a confirmed prior treatment history is absent.
Pregnancy is the central comorbidity shaping this scenario. Without a confirmed history of treatment, syphilis must be staged as early or late in order to select the correct regimen. Here the late stage applies — more than 2 years since acquisition — and pregnancy restricts which antibiotic classes may be used.
Treatment centres on a benzathine penicillin G regimen staged for late latent disease; where penicillin allergy is present, defined alternative pathways exist, though several antibiotic classes are not suitable during pregnancy. The full sequencing, dosing schedule, and allergy management steps are in the complete protocol.
The clinical target is a four-fold drop in RPR titre following treatment. Monitoring in pregnancy has specific timing considerations outlined in the protocol.
For those without a confirmed history of treatment, syphilis should be staged as early (within 2 years of acquisition) or late (more than 2 years since acquisition) in order to determine the recommended penicillin regimen.
Patients should be treated appropriately for the stage of disease, according to the BASHH UK national guidelines on the management of syphilis 2023.
In the absence of allergy to penicillin, standard benzathine penicillin G treatment should be given.
The non-penicillin alternative is ceftriaxone, for which limited data are available.
If a patient is allergic to penicillin but not ceftriaxone, ceftriaxone can be used or penicillin desensitisation and immediate penicillin treatment can be considered.
It may take several months to observe a 4-fold drop in RPR titre and in many pregnancies delivery will occur beforehand.
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