325. Neurosyphilis Management in the Post-Procaine Penicillin Era
Session: Poster Abstract Session: CNS Infections
Thursday, October 4, 2018
Room: S Poster Hall
  • NS Post-Procaine IDWEEK Poster 9-19 revision FINAL.pdf (1.9 MB)
  • Background: Neurosyphilis (NS) is an infection of the central nervous system caused by Treponema pallidum. Intramuscular (IM) penicillin (PCN) G procaine is a treatment option for those who cannot receive or decline intravenous (IV) therapy. Since 8/24/2016, it has been unavailable from the manufacturer, necessitating use of IV PCN for NS. Our institutions organized a multidisciplinary, coordinated care system to expedite outpatient treatment of NS upon diagnosis. We report successful management of NS at an urban safety-net hospital in the post-procaine PCN era.

    Methods: We identified patients with suspected NS from the King County Public Health STD and Harborview Infectious Disease clinics from 10/2016 to 2/2018. Demographics, clinical symptoms, diagnostics, treatment and outcomes were collected by chart review. Successful NS treatment was defined as resolution of cerebrospinal fluid (CSF) pleocytosis or elevated protein, improvement in neurologic symptoms or appropriate decrease in serum rapid plasma reagin (RPR) or CSF Venereal Disease Research Laboratory (VDRL) titers.
    Table 1: Demographic and socioeconomic characteristics
    Total = 43
    n (%)
    Male 39 (91)
    White 29 (67)
    Black 3 (7)
    Asian 3 (7)
    Homeless 5 (12)
    Insurance status
    Private 15
    Medicaid 20
    Medicare 8
    Charity care 11
    Substance use disorder 15 (35)
    HIV Positive 22 (51)
    Viral load suppressed (< 200 copies/mL) 13 (59)
    ❖ Represents > 1 payer per patient

    Results: We identified 43 cases of suspected NS. The most common symptoms were blurred vision, headache and tinnitus. All had a lumbar puncture (LP). Median days from LP to treatment initiation was 6 - many starting on day of diagnosis. Fourteen patients (33%) required admission for treatment. Two patients declined therapy. IV PCN G was used in 93% of cases; 1 received IM ceftriaxone. Treatment was successful in 32 of 41 (78%) cases, with 23 of these (72%) managed as outpatients. Three cases were treatment failures for incomplete therapy adherence or equivocal response and uncertain diagnosis.

    Conclusion: Without available IM procaine PCN, neurosyphilis is challenging to manage in vulnerable populations or those wishing to avoid inpatient admission. Employing a multidisciplinary, coordinated care approach can lead to successful treatment of NS using IV PCN in the outpatient setting.

    Chase Cannon, MD, Allergy & Infectious Diseases, University of Washington, Seattle, WA, Alison Beieler, PA-C, MS, Harborview Medical Center, Seattle, WA, Meena Ramchandani, MD, MPH, King County Public Health STD Clinic / University of Washington, Seattle, WA, Roxanne Kerani, PhD, King County Public Health / University of Washington, Seattle, WA and Shireesha Dhanireddy, MD, Medicine, University of Washington, Seattle, WA


    C. Cannon, None

    A. Beieler, None

    M. Ramchandani, None

    R. Kerani, None

    S. Dhanireddy, None

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