{"id":596,"date":"2015-02-17T11:00:38","date_gmt":"2015-02-17T11:00:38","guid":{"rendered":"http:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/?p=596"},"modified":"2017-08-21T11:59:05","modified_gmt":"2017-08-21T11:59:05","slug":"primary-care-corner-with-geoffrey-modest-md-syphilis-treatment-in-hiv-positive-patients","status":"publish","type":"post","link":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2015\/02\/17\/primary-care-corner-with-geoffrey-modest-md-syphilis-treatment-in-hiv-positive-patients\/","title":{"rendered":"Primary Care Corner with Geoffrey Modest MD: Syphilis treatment in HIV positive patients"},"content":{"rendered":"

By: Dr. Geoffrey Modest<\/strong><\/p>\n

A recent article assessed retrospectively the utility of a single shot of benzathine penicillin 2.4 M units\u00a0(BPG) for the treatment of early syphilis in HIV positive patients (see\u00a0DOI: 10.1093\/cid\/ciu888<\/strong>\u200b), as is recommended by the CDC.<\/p>\n

\"Untitled\"<\/a><\/p>\n

Baseline:<\/p>\n

–US Military HIV Natural History Study cohort of 350 people\u00a0with 478 cases of early syphilis diagnosed between 2002-2009\u00a0(median year 2006)<\/p>\n

–median\u00a0age 28, 22% white\/63% African American,\u00a099% male, and median\u00a0CD4 count at HIV diagnosis 506 (348-649) and at first syphilis case of 483 (376-636), 59% on HAART at syphilis diagnosis<\/p>\n

–30% were\u00a0treated with one dose of BPG and 52% with >= 2 doses<\/p>\n

–early syphilis was\u00a0defined as converting to a positive nontreponemal test, confirmed by treponemal test, within 365 days of a negative test<\/p>\n

–response to treatment at 13 months was defined as a >= 4-fold decline in nontreponemal titers<\/p>\n

Results:<\/p>\n

–91% responded to treatment by 13 months, 97% by 24 months<\/p>\n

–median time to treatment response was\u00a05 months<\/p>\n

–no difference in response to treatment by numbers of BPG shots<\/p>\n

–multivariate analysis: older age was\u00a0associated with delayed response; higher pretreatment nontreponemal titer and higher CD4 at time of syphilis diagnosis was associated with shorter time to treatment response. HAART use and HIV viral load were not related to response<\/p>\n

The authors note that the CDC recommendations are based on pretty poor data,\u00a0and that there are no good randomized controlled trials on the\u00a0question of the best treatment regimen.<\/p>\n

So, I remain unconvinced that a single BPG injection\u00a0should be standard therapy, for the following reasons.<\/p>\n

–this is a retrospective analysis. Were there clinical differences between the patients that led the treating provider to choose 1 vs 2+ injections of BPG?? Were those given only one shot fundamentally different\/healthier than\u00a0those given more?<\/p>\n

–this group had largely preserved immunologic function, with >50% having CD4 counts of >500, the lowest CD4 count being 348, and had\u00a0a low viral load (median log of 2.4 copies\/ml). And even with that,\u00a0the study did find\u00a0that those with lower CD4 counts in this pretty healthy group took\u00a0longer to respond to\u00a0treatment. What if their CD4 count were 58?? Would one shot work???<\/p>\n

–\u200bthere were several case reports awhile ago (probably 20+ years and, as i recollect, prior to HAART) of very rapid progression from syphilis infection to clinical neurosyphilis within 1-2 years in patients treated with only 1-2 shots of BPG (I did find one reference for rapid development of neurosyphilis:\u00a0Ann Intern Med. 1990;113(11):872). As a result of these early\u00a0reports, I have been using 3 shots (the same as required for late syphilis)\u00a0for the few cases I have seen\u200b<\/p>\n

–the reason I bring this up is, first, that there has been a significant\u00a0increase in syphilis cases over the last several years, and, second,\u00a0that there seems to be a lot of chatter on the internet about how we can now use one one shot of BPG to treat early syphilis in HIV patients, based on the above article. And, it may be true that one shot is sufficient, especially in the era of HAART, but I do not think this article proves it…..<\/p>\n","protected":false},"excerpt":{"rendered":"

By: Dr. Geoffrey Modest A recent article assessed retrospectively the utility of a single shot of benzathine penicillin 2.4 M units\u00a0(BPG) for the treatment of early syphilis in HIV positive patients (see\u00a0DOI: 10.1093\/cid\/ciu888\u200b), as is recommended by the CDC. Baseline: –US Military HIV Natural History Study cohort of 350 people\u00a0with 478 cases of early syphilis […]<\/p>\n

Read More…<\/a><\/p>\n","protected":false},"author":148,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[14283],"tags":[],"class_list":["post-596","post","type-post","status-publish","format-standard","hentry","category-archive"],"jetpack_featured_media_url":"","jetpack_sharing_enabled":true,"_links":{"self":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/596","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/users\/148"}],"replies":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/comments?post=596"}],"version-history":[{"count":0,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/596\/revisions"}],"wp:attachment":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/media?parent=596"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/categories?post=596"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/tags?post=596"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}