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8/14/2019 Bacterial infections - Pediatrics part 2
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1 | B a c t - P e d i a
Bacterial Infections(Part 2)
Ma.AnnaP.Baez,M.D.
DepartmentofChildHealth
Neisseria gonorrheae
Nonmotile,aerobic,
nonsporeforming,
gramnegative,
intracellular
diplococcus with
flattenedadjacent
surfaces
Epidemiology Infectiononlyinhumans
Transmission: intimatecontact; rarely,fomites
Infectioninnewborngenerallyacquiredduringdelivery
Acuteinfectionbegins25daysafterbirth
MostcommonSTIinsexuallyabusedchildren
Pathogenesis InfectsprimarilyColumnarEpithelium
Mucosalinvasion localinflammatoryresponse
purulentexudate (PMN,serumanddesquamatedepithelium)
Gonococcal LipoOligosaccharide(Endotoxin)exhibitsdirectcytotoxicity ciliastasisandsloughingofciliatedepithelialcells
Gonococcustransversesthemucosalbarrier,thelipooligosaccharidebindsbactericidalIgM antibodyandserumcomplement acuteinflammatoryresponseinthesubepithelialspace
TNFandothercytokinesarethoughttomediatethecytotoxicity ofgonococcal infections
ClinicalManifestations
AsymptomaticGonorrhea Pharyngealgonococcal infection
Rectalcarriage
(40
60%)
Clinical Manifestation Uncomplicatedgonorrhea
Genital
Primaryinfectionin urethrainmales,vulvaand
vaginainprepubertalfemales,cervixpostpubertal
females
IP25days
in
men;
510
days
in
females
Urethritis
Purulentdischarge,dysuria withouturgencyor
frequency
Untreatedcasesresolvespontaneouslyinseveral
weeksorcomplicatedbyepididymitis,penileedema,
lympangitis,prostatitis,seminalvesiculitis
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2 | B a c t - P e d i a
Clinical Manifestation Uncomplicatedgonorrhea
Vulvovaginitis:
Purulentvaginaldischargewithswollen,erythematous,
tender,andexcoriatedvulva
Dysuria,dyspareunia,intermenstrual bleeding
Cervixmaybeinflamedandtender
Purulentmaterialcanbeexpressedfromurethraor
ductsofBartholin gland
Rectalgonorrhea:
Oftenasymptomatic
Maycauseproctitis withsymptomsofanaldischarge,
pruritus,bleeding,pain,tenesmus andconstipation
Clinical Manifestation Uncomplicatedgonorrhea
Gonococcal Ophthalmitis
Unilateralorbilateral
Occur14daysafterbirth
Beginswithmildinflammationanda
serosanguinous discharge Within24hours thickand
purulent,tenseedemaoftheeyelidsandmarkedchemosisoccur
Withouttreatment cornealulceration,ruptureandblindness
Clinical Manifestation Disseminated Gonococcal Infection
13%ofgonococcal infection
Afterasymptomaticprimaryinfectioninwomen
Begin730daysafterinfectionandwithin7daysaftermenstruation
Aspolyarticular septicarthritisinneonate
CommonManifestation:
Acutepolyarthralgia andfever(mostcommon)
Skinlesionsin25%(acral petechiae /pustular)
Tenosynovitis
Suppurative arthritis
Rarely
carditis,
osteomyelitis,
and
osteitis
Clinical Manifestation Disseminated Gonococcal Infection
Tenosynovitis DermatitisSyndrome
Morecommon
Fever,chills,skinlesions,andpolyarthralgias
predominantlyinvolvingthewrist,handsand
fingers
BCS(+)3040%
Synovial fluidCSalmostuniformlynegative
Suppurative ArthritisSyndrome
Systemicsignsandsymptomsarelessprominent
Monarticular arthritis ofteninvolvingtheknee
Synovial fluidCS(+)in4555%
BloodCS
()
Diagnosis
Dependsonisolationoforganism
Urethritis
Gram()intracellulardiplococci
PRESUMPTIVEDXinsymptomaticmales
Not
sufficient
in
females;
similar
to
Mimapolymorpha &Moraxella
Otherinfectionswithpurulence:
C.trachomatis,M.hominis,T.vaginalis,C.albicans
Evaluateforconcurrentsyphilis,hepatitisB,HIVandC.trachomatis infection
Treatment
Dueto increaseprevalenceofpenicillin
resistantN.gonorrheae,Ceftriaxone isrecommendedasinitialtherapyforallages
Patientbeyond
the
neonatal
period
should
also
betreatedpresumptivelyforC.trachomatis
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Treatment Infant and
UncomplicatedInfection
Ceftriaxone 50mg/kg/insingledoseIM;maximum
125mg
Bacteremia orArthritis
Ceftriaxone 50mg/kg/24hrforaminimumof7days
>45kgs 10
14
days
Meningitis
Ceftriaxone 50mg/kg/doseq12hr1014days
Ophthalmia Neonatorum
Ceftriaxone 50mg/kg/insingledoseIM;maximum
125mg
Cefotaxime 100mg/kg/daysingledoseIM
Pediatric Infections
Endocarditis
Ceftriaxone 50mg/kg/doseq12hr28days
NeonatalSepsis
Should
be
treated
parentally
for
minimum
of
7days
Cefotaxime isrecommendedforpatientwith
hyperbilirubinemia
Treatment Infant and
Pediatric Infections
Treatment for Adolescent and
Adult Infection
Singledoseofceftriaxone 125mgIM
eradicatespharyngealanduncomplicated
urogenital infections
Safeinpregnantwomen
Otheralternatives:
Cefixime 400mgPOassingledose
Ciprofloxacin500mgassingledose
Ofloxacin 400mgPO
Regardlessofregimenchosen,treatment
shouldbefollowed byregimenactive
againstC.trachomatis
Doxycycline 100mgBIDx7days
Azithromycin 1gminsingledosepo
Erythromycin forpregnantwomenx710day
Treatment for Adolescent and
Adult Infection
DisseminatedGonococcal Infection
Ceftriaxone 1gram/24hrIVrecommendedasinitialtherapy
Alternativeregimen
Cefotaxime 1gmIVq8
Ciprofloxacin500mg/IVq12
Ofloxacin 400mg/IVq12
Spectinomycin 2
gm
q12
Examineforclinicalsignsofmeningitisandendocarditis
Switchtooral2448hrsafterimprovement:
Cefixime 400mgbid
Ciprofloxacin500mgbid x7days
Ofloxacin 400mgbid
Gonococcal Conjunctivitis
Ceftriaxone 1gmIM,singledose
Treatment for Adolescent and Adult Infection
Complications
PelvicInflammatoryDisease
Aspectrumofinfectiousdiseasesofuppergenital
tractduetoN.gonorrhea,C.trachomatis and
endogenousflora(Streptococci,Anaerobes,gram
()bacilli
RecommendedRegimen:
Cefoxitin 2gIVq6orCefotetan 2gq12+
Doxycycline
AlternativeRegimen:
Clindamycin +Gentamycin +Doxycycline
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Other Complications
PID
Endometritis
Ectopic regnancy
Perihepatitis Chorioamnionitis
Septicabortion
p
Prevention
Education
Useofbarriercontraceptive
Earlyidentificationandtreatment
Gonococcal Ophthalmia Neonatorum
2drops
1%
solution
of
silver
nitrate
into
eachconjunctival sacshortlyafterbirth
Erythromycin(0.5%)
TetracyclineOphthalmicointment
Syphilis Treponema pallidum:thin,motile,fastidiousspirochete
CongenitalSyphilis
viatransplacental transmission,atanytimeduring
pregnancyoratbirth
Moistsecretionsarehighly infectious
AcquiredSyphilis
sexualcontact;suspectsexualabuseinachild(+)for
acquiredSY
IP:3wks(1090d)
Openmoistlesionsof1o &2o stagesarehighly
infectious
Congenital Syphilis
Up100%transmissionrateduringpregnancy
Fetalorperinatal deathin40%ofaffected
infants
EarlySigns:
1st 2yearsoflife
Transplacental spirochetemia,analogousto
secondarystageofAcquiredSyphilis
2/3asymptomatic,identifiedthruscreening
Congenital Syphilis EarlySigns
Hepatosplenomegaly
Jaundice
Diffuselymphadenopathy
Coombs negativehemolyticanemia
Thrombocytopenia
Osteochondritis:painful,multiple,causingirritabilityandpseudoparalysis ofParrot
Periostitis oflongbone
Erythematous maculopapular &bullous lesionswithdesquamationonhandsandfeet
Mucouspatches,rhinitis(snuffles),condylomatous lesions
CNSabnormalities,failuretothrive,chorioretinitis,nephritisandnephrotic syndrome
Congenital SyphilisLateSigns Secondarytochronicinflammationofbone,teethandCNS
FrontalbossofParrott
Shortmaxilla
Highpalatalarch
Hutchinsons Triad:hutchinson teeth,interstitialkeratitis,8th nerve
deafness
Saddlenose
Mulberry
molars Higoumenakis sign
Relativeprotruberance ofthemandible
Rhagades linearscarsfrompreviousmucocutaneous fissureson
mouth,anusandgenitalia
Sabershin
Scaphoid scapulae
Clutton joint
JuvenileParesis adolescenceasbehavioralchanges,focalseizure,
lossofintellectualfunction
JuvenileTabes rare,spinalcord&CVinvolvementwithaortitis
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Acquired Syphilis: 3 Stages Primary:painlessindurated ulcers(chancres)on
genitalia
Secondary:begins12mos later
Mucocutaneous lesions,lymphadenopathy
Rash:maculopapular,generalized
Condylomata lata (graywhite/erythematous plaquesaroundanusorvagina)
Latent:period
after
infection
when
seroreactive but
asymptomatic
EarlylatentSyphilis:acquiredwithintheprecedingyear
Late latentSyphilis:asymptomatic
Tertiary:latelatentbutsymptomaticwithcardiovascular&gummatous lesions(granuloma ofskinandmusculoskeletalsystem)
Neurosyphilis
InfectionoftheCNS
OccuratanystageespeciallyinHIVpatients
Acquired Syphilis: 3 Stages Diagnosis Demonstratedbydarkfieldmicroscopy
Serology:principalmeansfordiagnosis
NonTreponemal Tests
VDRL,RPR
Detectantibodiesagainstacardiolipincholesterollecithincomplex
notspecificforSyphilis
Correlatew/diseaseactivity:forscreening
Nonreactivew/in1yearoftreatmentforprimarysyphilis,2yearsforsecondarysyphilis,fewmonthsincongenitalsyphilis
False
(+)in
autoimmune
diseases
Diagnosis
SpecificTreponemal AntibodyTests
Confirmatorybutremainpositiveforlife
T.pallidum immobilization(TPI)
Fluorescent
treponemal antibody
absorptiontest(FTAABS)
Microhemagglutination assayfor
antibodiestoT.pallidum (MHATP)
FTAABS19SIgM
Stage TreatmentandDosage AlternativesPrimary,secondary,or
earlylatent(1yr),
latentofunknown
duration,ortertiary
(gumma or
cardiovascularsyphilis)
PenicillinGbenzathine (2.4millionU
IM)weeklyfor3doses
Tetracycline(500 mgPOqid
for4wk)ordoxycycline
(100mgPObidfor4wk)
Neurosyphilis AqueouscrystallinepenicillinG(1224
millionU/24
hr
IV
given
as
2.4
million
Uevery4hr)for1014daysFor
children:Aqueouscrystallinepenicillin
G(200,000300,000U/kgeveryday
IV,givenevery46hr)for1014days
PenicillinGprocaine(2.4
millionU/day
IM)
plus
probenicid (500 mgPOqid).
Bothfor1014days
Congenitalsyphilis AqueouscrystallinepenicillinG
(100,000150,000 U/kg/24hr,givenas
50,000U/kgIVevery12hrforthefirst
7daysandevery8hrthereafter)for
1014daysorProcainepenicillinG
(50,000U/kgIMdailyinasingledose)
for1014days
*Enlargedtable,seelastpage
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SalmonellaInfections
Gramnegativebacilli
Incubationperiod
Gastroenteritis:648hrs
Entericfever:360days(usually714days)
>2460Salmonella
serotypes:most humandiseasecausedbyGroupsAE
SerotypeTyphi isclassifiedinSerogroup D
Salmonella Infections NonTyphoidal Salmonella
Reservoirs:poultry,livestock,reptiles,pets
Vehiclesoftransmission:poultry,beef,fish,eggs,dairyproducts,fruits,vegetables,bakeryproducts
Othermodesoftransmission:ingestionofcontaminatedwater,contactwithreptiles,contaminatedmedications,dyes,medicalinstruments
S
Serotype
Typhi:
found
only
in
humans Infection:direct/indirect contactwithaninfected
person
MOT:Ingestionofwater/foodcontaminatedwithhumanfeces
Highinoculum 106108requiredtocausedisease,contaminatedfoodamajorsourceofhumaninfections
Persontopersontransmissionbydirectfecaloralspreadisunusual,mayoccurinyoungchildren
Salmonella Infections Riskoftransmission:throughouttheduration
offecalexcretionoforganism
ChronicCarrier:1%ofpatientscontinueto
excreteSalmonella for>1yr
Clinical Manifestation of
Non-Typhoidal SalmonellosisAcuteGastroenteritis
Mostcommonpresentation
IP:672hrs(mean,24hrs)
Abruptonsetofnausea,vomiting,
abdominalcrampsfollowedbywateryor
bloody,mucoid diarrhea
70%withTemp38.539C
Stoolexam:moderatePMNandoccultblood
Recoveryin27days
Clinical Manifestation of
Non-Typhoidal SalmonellosisBacteremia
RiskFactors:
Neonatesandyounginfants
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Enteric Fever or Typhoid Fever
Insidiousonsetwithfever,malaise,anorexia,
myalgia,headacheandabdominalpainover 23
days
Diarrheaorconstipation
Cough,epistaxis
Temperatureincreases,becomingunremitting,highwithin1wk
On2nd wk,highfever,fatigue,anorexia&abdominal
symptomsincrease
Appearill,disoriented,lethargic
Enteric Fever or Typhoid Fever
Relativebradycardia,hepatosplenomegaly,
abdominaldistentionandtenderness
Rosespotsonlowerchestandabdomen
Ifuncomplicated,symptomsandPEfindings
graduallyresolvein24wks
Malaiseandlethargyfor12months
Complications mayoccurafter1st weekasintestinal
hemorrhageorperforation
Othercomplications:hepatitis,cholecystitis,
pyelonephritis,nephrotic syndrome,meninigitis,
endocarditis
Diagnosis Culture:blood,stool,urine
Blood:40%(+)in1st week
UrineandStool:highly(+)afterthe1st
week
BoneMarrow:singlemostsensitivetest (+)in8590%
Lessinfluencedbypriorantimicrobialtherapy
Enzymeimmunoassay,latexagglutination,DNAprobesandmonoclonalantibodieshavebeendeveloped&areinuseinsome
laboratories
Treatment for Non-Typhoidal
Salmonella Infection AntibioticsNOT recommendedforuncomplicated
gastroenteritiscausedbyNontyphoidal species
prolongsdurationofcarriage
AntimicrobialTreatment
Inpatientswithincreasedriskofinvasivedisease:
infants/=3monafterinfection
~15%;Lowriskinchildren,highdoseIVAmpicillinororalAmoxicillin withProbenecid x46weeks
Foradultcarriers:Ciprofloxacin isdrugofchoice
Cholecystectomy: indicatedin
which
gallstones
provideanidus forresistancetomedicaltreatment
Steroids:
(+)delirium,obtundation,stupor,comaorshock
Dexamethasone:1mg/kq6hrx2days
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\\\\\\\\\
Relapse
Afterinitialclinicalresponseoccursin48%
nottreatedwithantibiotics
Fortreatedpatients,apparent~2wkafter
stoppingantibiotic;milderandshorter
duration;maybemultiple
Prevention:
Improvedsanitationandclean,runningwater
Personalhygiene,handwashing
Vaccination:
Oral,liveattenuatedty21astrain(Vivotif)
4enteric
coated
at
>/=6
yo q
5yrs;
6782%efficacy
Vicapsularpolysaccharidevaccine(Typhim Vi)
GivenIMq2yrsfor>/=2yo
Shigella Gramnegativebacilliwith>40serotypes
4speciesresponsibleforillness:
S.dysenteriae (Serogroup A)
S.flexneri (Serogroup B)
S.boydii (Serogroup C)
S.sonnei (Serogroup D)
Humansarethenaturalhost
Incubationperiod:17days
Transmission Fecaloralroute,ingestionofcontaminated
foodorwater,contactwithinanimateobject,
sexualcontact
Transmissionrequiresasfewas10to200
organismforinfectiontooccur
Carrierstateceaseswithin4weeksofonsetof
illness;chroniccarrierstateisrare
Clinical Manifestations
Primarilyinfectsthelargeintestine
Symptomsrangefromloosestoolswithminimalconstitutionalsymptomstomoreseveresymptomsfever,abdominalcramps,tenesmus,mucoid stoolswithorwithoutblood
Extraintestinal Manifestations
Neurologic ngsin40%hospitalizedchildren:convulsions,headache,lethargy,confusion,nuchal rigidity,hallucinationsbeforeorafterdiarrhea
NOT
findi
duetoShigatoxin
Complications:
Dehydration(mostcommon)
Bacteremia (uncommon)
Reitersyndrome(S.flexneri infection),
HUS(S.dysenteriae type1),
Toxic
megacolon and
perforation
Toxicencephalopathy(Ekiri syndrome)
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Diagnosis
StoolCulture
(+)fecalleukocytesonMethyleneBluestainedstoolsmear sensitivebutnotspecific
EnzymeimmunoassayforShigatoxin for
detectionof
S.
dysenteriae type
1in
stool
Bloodculture:inseverelyill,immunocompromised,malnourishedpatients
Othertests:fluorescentantibodytest,PCRassay,enzymelinkedDNAprobes
Treatment
Forsusceptiblestrains:Ampicillin and
Cotrimoxazole,Nalidixic acid
Forresistantstrains:Ciprofloxacin,Ceftriaxone
CurrentWHOrecommendation:
TreatforShigellosisinachildwithbloody
diarrhea DOC:Ciprofloxacin:15mg/kgbidx3days
AlternativeDrugs:
Ceftriaxone 50100mg/kg/dayIM/IVx25days
Azithromycin 610mg/kgODx35days
Vibrio cholerae Gram(),curved,motilebacillus
Serogroup O1havecaused
epidemics
2SerotypesofV.cholerae O1:
Inaba &Ogawa
2biotypes:ClassicalandEltorr
(predominant)
Serogroup 0139Bengal:epidemic
cholerainIndiansubcontinent&
southeastAsia
Otherserogroups &nontoxigenic
strainscausesporadic (not
epidemics)diarrhea
Vibrio cholerae ModeofInfection: ingestionofcontaminated
waterorfood(raworundercookedshellfish)
Humansnaturalhost
Directpersontopersonspread notdocumented
Peoplewithlowgastricacidity:increasedriskofinfection
Incubationperiod:13days(Range:fewhours 5days)
Clinical Manifestation Majorityofinfectedpatientsareasymptomatic
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Diagnosis
StoolCulture
Serology:4foldincreaseinvibriocidal
antibodytitersbetweenacute&convalescent
Clinical:suspectedinanychildwithsevere,
waterydiarrheaandahistoryofrecenttraveltoanendemicarea
Treatment
AntimicrobialTherapy
Shortensdurationofillness,reducesperiodofexcretion,decreasesfluidrequirements
DOC:OralDoxyclycline orTetracycline
AlternativeDrugs:Cotrimoxazole,Erythromycin, Furazolidone,Orciprofloxacin /Ofloxacin (>/=18yo)
DurationofTreatment:3days
Escherichia coli Associated with
Diarrhea Enterotoxigenic E.coli (ETEC)
Producesecretory enterotoxins
Majorcauseofinfantilediarrheaindeveloping
countries
Importantetiologicagentsoftravellers
diarrhea
Explosive,watery,nonmucoid,nonbloody
diarrhea,abdominalpain,nausea,vomiting&
littleor
no
fever
Enteroinvasive E
.coli
(EIEC)
UsuallywaterysimilartoETEC
Minority,dysenterylikeillnesswithbloody,
mucoid stoolsandfecalleucocyteswithfever,
systemictoxicity,abdominalcramps,
tenesmus
Enteropathogenic E.coli(EPEC)
Generallycauseacutediarrheabutsevere
casesleadtoprotracteddisease
Causechronicdiarrheaandmalnutritionin
infantsindevelopingcountries
Breastfeedingisprotective
ShigatoxinproducingE.coli(STEC)
Enterohemorrhagic E.coli(EHEC)
Abdominalpainandinitially,waterydiarrhea
bloodstreakedtobloody
Feverisuncommon
510%developsystemiccomplications:
o Hemolyticuremic syndrome
(renal
failure,
hemolytic
anemiaandthrombocytopenia)orthrombotic,
thrombocytopenicpurpura
Shigatoxin E.coli O157:H7 theprototype&most
virulentmemberoftheE.coli pathotype
Poorlycookedhamburgersacommoncauseoffood
borneoutbreaks
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Associatedwithpersistentdiarrhea(>14days)
indevelopingcountriesespeciallyin>12mos
old
Occasionally,bloody
Associatedwithgrowthretardationininfants
andmalnutrition
CauseAIDSassociatedchronicdiarrheaand
travelersdiarrhea
Enteroaggregative E.coli (EAggEC) Treatment Mainstay:fluid&electrolytetherapy
SpecificantimicrobialtherapyofdiarrheogenicE.coli isproblematicbecauseofdifficultyinmakingaccuratediagnosis&unpredictabilityofantibioticsusceptibility
TMP
SMZ:
appropriate
choice
for
ETEC,EPEC,EIEC EIECareusuallytreatedbeforecultureresults
becauseofsuspicionofshigellosis
AntibioticmayincreaseriskofHUSinSTECdiarrhea
Ciprofloxacin:forEAggEC travelersdiarrhea
E. coli and Other Gram Negative Bacilli
(Neonatal Sepsis and Meningitis )
E.colistrainswiththeK1capsularpolysaccharideantigen cause40%ofsepsisand80%ofcases
OtherGramnegativebacillicausingneonatalsepsis:nonK1strainsofE.coli,Klebsiella,Enterobacter,Proteus,Citrobacter,Salmonella,Pseudomonas,andSerratia sp.
Nontypable H.influenzae,andanaerobicgramnegativebacillirare
E. coli and Other Gram Negative Bacilli
(Septicemia and Meningitis in Neonates)
Difficultdifferentiateclinicallyneonatalsepticemiaor
meningitissecondarytoE.coli&othergramnegative
bacilli
SignsandSymptoms:fever,temperatureinstability,
heartrateabnormalities,gruntingrespirations,apnea,
cyanosis,lethargy,irritability,anorexia,vomiting,
jaundice
Meningitiscanoccurwithoutovertsigns
Citrobacter koseri,Enterobacter sakazakii &Serratia
marcesens maycausebrainabscessassociatedwith
meningitis
Source:maternalgenitaltract
Nosocomial,throughpersontopersontransmissionamongpersonnel&
environmentalsites
such
as
sinks,
solutions,
etc.
PredisposingFactors:
Intrapartum infection,
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Campylobacter Predominantsymptoms:diarrhea
(visibleoroccultbloodinthestool),
abdominalpain,malaise,fever
Milddiseaseresemblesviral
gastroenteritis
Severeinfectionmimicacute
inflammatorybowel
disease
Immunoreactive complications
occurduringconvalescence:GBS,
reactivearthritis,Reitersyndrome,
erythema nodosum
Tx:Erythromycin,Azithromycin,
Doxycycline orQuinolones
The End
Lord, thank you for everything,
I cant name them all but it all comes from You,everyday I am very grateful for everything!
Stage TreatmentandDosage AlternativesPrimary,secondary,or
earlylatent(1yr),
latentofunknown
duration,ortertiary
(gumma or
cardiovascularsyphilis)
PenicillinGbenzathine (2.4millionU
IM)weeklyfor3doses
Tetracycline(500 mgPOqid
for4wk)ordoxycycline
(100mgPObidfor4wk)
Neurosyphilis AqueouscrystallinepenicillinG(1224
millionU/24hrIVgivenas2.4million
Uevery4hr)for1014daysFor
children:Aqueouscrystallinepenicillin
G(200,000300,000U/kgeveryday
IV,givenevery46hr)for1014days
PenicillinGprocaine(2.4
millionU/dayIM)plus
probenicid (500 mgPOqid).
Bothfor1014days
Congenitalsyphilis AqueouscrystallinepenicillinG
(100,000150,000 U/kg/24hr,givenas
50,000U/kgIVevery12hrforthefirst
7daysandevery8hrthereafter)for
1014days
or
Procaine
penicillin
G
(50,000U/kgIMdailyinasingledose)
for1014days
Edited by: K.D. Espino, 2009