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I allow myself to get too bogged down by logistical things which has definitely hindered the growth in a part of my traveling spirit. Damn Type A personality has me thinking about organization and routine too frequently. You can do it if you want to, you just have to give up some material goods.

Also, we own a house, and house upkeep costs a lot of money. We tend to put our money towards vacation though, and as a result, we have an unfinished backyard. Chris, My wife introduced me to your website and manifesto. Gotta say, it feels good to live life on the edge. I lucked out and got a job that allows me to travel the world working in new countries and cities for extended periods.

As for the logistics of traveling the world, it is difficult and requires devotion and planning. Also being DINKs makes it easier. Heading to Hong Kong tomorrow. Then flying back home to NY next week. Staying for a few days and heading to Brazil until May sometime. I graduated from university, and work full time at a big company in my city. It has always been my dream to travel extensively. I am a teacher and have two full months off every summer.

This year I am going to finally take advantage of this perk and will be traveling to Southeast Asia. It all seems daunting — but I am determined. Just need a little sound advice…. Hi, great article chris. I am in my mid thirties and have recently become single. I have always wanted to travel but have put it off for a lot of the reasons you mention. Have you expanded on this post with some advice on how best to go about it. Excellent read. Need more writings like this to motivate people to get out there and see the world.

Thats usually that worst part. Excellent article! Loved it, so true. I, like stephb, literally typed in quitting your job and traveling. I was very fortunate to grow up overseas in Holland for 8 years because of the military. Too young to remember. My spirits are low and I just need to do something. I make a similar argument to travel within the constraints of our busy lives. What if instead of travelling for 5 years non-stop you could take one or two months every year, for the rest of your life.

Amazing post and really inspiring… I stumbled upon this article because I was looking for answers… Thanks for this. That was very inspiring. I am 25, and I just quit grad school after three totally depressing years. I wonder if I could work for a few years and then do this, but then I still wonder, how will I find a job after that? I echo the sentiments of some others, though. My plan, if I go ahead with the travel, is to have enough people in my network that I can find work later. For all those that want to travel but are worried about working and money, it is possible to do both.

Many companies are in need of people willing to travel the majority of the year. My wife and I are doing it. Great read — there must be thousands of people who would like to travel around the world. I took a year out 9 years ago and met my wife. The trip changed my life for sure and quiet a few of the people I met still keep in contact.

I travelled alone and would say its the best way to go. Chris, Great article! Jesse, you mentioned the loss of opportunity to progress in your career and your loss of k savings as a result of travelling. I say think about this; the time spent abroad would only help your professional development by giving you exposure to a whole new world. At most it will throw you a year or 2 off track. Whereas, if you were to wait until you retire to travel the world you may have more physical constraints to your mobility. Thanks for the nice article which inspire someones dreams, ambition and other life pursuit.

As i grew with my uncommon behavior of resisting to be board, to day i make my career through travel, Eastern and southern Africa Traveler Guide also i plan to write about something in travel or. Before my wife and I split, we traveled for 7 months and it was wonderful. But I also have two older parents who in the past year have moved to where I live. Neither is ill, but my dad just turned Chris — do you have older parents? Do you miss them when you travel?

Do they wish they saw more of you and were home more frequently? How do you balance spending time with your family when you are far away for long periods of time? Chris, I stubbled on your website and thrilled to see so many looking to change from the meat grinder slave to your job mentality to enjoy life and see the world. At 47 I quit my SVP fortune corporate job in July to allow my wife and I to invest into rentals and laundry business absentee owners so that we could replace our income and travel.

From Mexico, India, to Japan to Africa in the last several months, there is just so much to do and see. I would recommend to anyone, if you can invest your savings to generate cash flow or have the savings, dump the job and enjoy life. I did, even in this state of economic crisis and have no regrets.

What is the worst to happen to me, I go back to work someday , take the shot, you will be glad you did. And what do you know, her bag gets stolen from the back of the chair in the cafe! Great article! If more people followed what they loved the world could be such a different place. I stopped in Seattle for 5 days and I met so many interesting people, but I missed you! Last year I finished school. I was doing my travels while nobody else was travelling and tried to escape from the mass and multitudes everywhere I went. My friends where asking me the same: where do you have that money saved??

I felt myselft when I was reading you telling them: I prefer cooking at home and everyone come home that going to a restaurant, I always travel by cheap, use ridesharing… these words are fulling me with more energy. I spent all the money I had saved during my study abroad in the uS and my 4 monhts travels around the south and west coast of the us and mexico and belize just a little bit of these countries.

I need to learn a little bit from work too. We need to learn from a lot of things in life, travel is one and i can tell u the most important one, but adaptation in a country, spending more time with people, working in a company….. I believe in change, and change of people because of the small experiences in life everywhere. These experiences you are talking about. And action is the answer to everything!!! Everything you said Chris is what I have been thinking.

I just want to see everything this world has. It has been a huge dream of mine to travel the world, but I have had similar thoughts as the ones you described especially the one about money. You hit a nerve with me as well. I look forward to all your advice to get me on my way. Thank you. Or… one may simply not enjoy traveling…?

Is that so wrong? It changed my life completely, and I saw a few people commenting that their children keep them home- take them with you! I learned more from that year off than I have from any other year in school. I recently started a job that is a tremendously good fit for me and is allowing me a lot of professional development and connections in a field that I am excited about…However, working day in and day out in an office job is incredibly draining to me.

More and more, I really crave travel and meeting fascinating people and seeing the world. Obviously there is just not enough time and flexibility to explore the world in traditional job settings like this…So now what? I want to explore with my partner, but how could we possibly both leave our jobs?

How could we get jobs when we came back given that so many people especially in his industry have been out of work for months and months? What would we do about our home and our cat? All of these pragmatic questions are ever-present and seem to keep us from doing anything drastic and even from getting into the meat of the conversations we try to have about work, travel, and what we want out of our lives. I find that we just complain and complain about the daily grind and the culture we live in that demands constant productivity and career improvement, but we never come to any conclusions about what to do.

I worry that I will just feel more and more trapped and never figure out a way to live the life I really want that could actually work, pragmatically. Thanks for provoking the discussion. Do you have to be young, 20 to 35 to do this? Vietnam, Asia has been my latest adventure. If anyone wants to join me, contact me. Looking at beginning of Check out my bio, and travel galleries at website above.

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I agree that if you have the desire to quit your job and hit the road, then you should definitely do it. But I do think that money IS still a very crucial setback for some people. I love traveling more than anything in the world and have been fortunate enough to visit more than 40 countries on six continents. However, aside from a brief period of time when I went backpacking for four months, I have been unable to ever take a year-long trip around the world my big dream , or to move to a foreign country for a year and learn another language, and have had to satisfy myself with a lot of shorter vacations.

As a teenager I bought into the idea that education is the best investment and took out massive amounts of student loans not uncommon for Americans to pay for two degrees from two very prestigious universities. Little did I expect that a decade later, I would still be plowing through this debt. So, while I agree that some people who choose not to quit their jobs and travel do it because they prefer to be able to afford luxuries in life, sometimes the situation can be a bit more complicated.

Wow i love your blog; this post is really inspiring. I just need to summon the courage, i think, to take the risk. Kelly, you already know what you need and want to do. I encourage you to do so. Take advantage of your mobility now. In my experience, family and friends will only look at it from their own perspective, and they will bring you down. I sincerely hope you follow your dream.

Dave I hear you and back up your comments to Kelly. I have had the same experiences though my children are now self sufficient. At 43 I am at the crossroads. Stay in my comfortable six figure job or quit and go back packing for 12 months or more. Unfortunately my marriage is no longer and I have decided that life is what you make it.

I am not going to wait till retirement age and wake up one day and realise its all too late. I graduated college in , I immediately got a job and became a prisoner of that biweekly paycheck. I will begin my adventures in Colombia on July 30th. I will stay in Colombia for 5 weeks, then Spain, then who knows… It is very liberating to actually do what one has always wanted to do! For those of you who are worried about how to finance your trip abroad, one of the best and easiest ways is to teach English.

I will be finished on July 23rd. This inexpensive certification will make me marketable abroad. Just do it! When I was at my younger yers, I grabbed any opportunities to travel, but believe it or not, I am tired from traveling now, the idea of visiting the wonders of the world or where the sun never sets does not strike an interest anymore, the only place I probably look forward to travel is some secluded beach resort and buried myself inside the face of the earth.

But I agreed all of you out there should do a bit of traveling to see the world before any commitment or any dependencies, money is not an issue when you are young, you can work and travel, the only thing that will hold you back is laziness and fear. So I find it hard to describe how truly wonderful it is to read all these comments and find so many others feel the same. My boyfriend and I have been living and working in a foreign country for the past two years taking weekend trips and vacation here and there, but are about to give up very well paid jobs and take the next six months off to travel before we move on to a new country and resume our careers again.

I totally agree that it all comes down to what your priorities are, but also I would encourage everyone to follow what brings them joy. For some people, this is not travel, and I absolutely respect that. Hi there chris. I am 17 and attend a great school and I have lots of friends but I cannot help but think that I am different to everybody else in the dreams that I have. New Zealand has brought me up well but I wish to travel around the world and go really far in life and go to many places around the world.

I have, unlike you, got into a UK gap programme in a school in London. I am looking forward to it and really hope to meet you one day in an exotic location around the world. Great blog…This is for the young, seeing Paris at 20 years of age is alot different than seeing it at Now I just want to relax in Key West or the Caribbean, and live a lifestlye of less.

Hobo up! My husband and I are planning something just like this! Why wait until you retire? It might never happen. This will happen within one year. Great blog. I work in healthcare and have many co-workers who have never ventured out of the US even Canada! I tell them not to wait until retirement before traveling as it might be too late.

They also tell me that they are tied down because of all the debts and mortgage. Any suggestions? Your article is very encouraging. You know, as far as year that I want to do what you have suggested. I have lots of plans before to quit my job and engage in business. This is still true today. Right now. However, it seems I have very less initiative to do that. I have many fears. What will happen to my three 3 college students? Where will we get the financies for their studies? You know I am active in our church Catholic community and I feel guilty if my current passion for these activities will be stopped in the event I will devote my time to business and travel abroad.

Since my last travel to Cremona, Monza, Italy and Seoul, South Korea on company expense back in and respectively, I really miss those opportunities to see and talk to other nationalities. I also miss the excitement of going to church when we feel we are the underdog; going to church in Cremona with Italians which are tall and we are midgets.

However, your article encourage me again to pursue my long time plans. You see this coming October 1, , I will be exactly 10 years in sevice for the company I am working now. I am now qualified to apply for an early retirement 10 years in service and 50 years old. Right now I am drawing my plans to make it happen at least this year. I can definitely relate to the message of this website.

I started working full-time in just after I finished university. For one and a half years, I got stuck in a typical desk job where you have neverending paperwork and clients to meet. Somewhere along I realised that a lot of office work is routine and boring. Just how fun is it to photocopy and staple sheets of paper several times a day? How exciting is it to stare at your PC monitor eight hours a day, five times a week? And yet I met a lot of people who have been in the company for as long as I have lived! What a waste of energy. Which is how I stumbled into this website.

Well, I am also wondering whether I can travel to Mexico by myself…. Great article Chris. Sometimes you just have to take your dreams seriously. Thanks again. I do have debt, unfortunately. After that, I hope to do some traveling. And prioritizing debt repayment over travel. Thanks a lot for this. Sick of my job and need to see the world. We packed everything in in Europe and came to live in semi-rural India where my wife got a job at a vineyard.

And the kids? The Czech Rep. I like staying home. Not shy, an introvert. They are two different things. I find that I get overstimulated, which exhausts me. If I spend enough days exhausted, I get sick. Hospital sick…pneumonia sick. So I go, get sick, come home determined to not get roped into another long grueling trip. But being adventurous and curious, remember introversion does not equal wallflower I always do. Hello, the post is a good inspiration, the comments are good to, but, what about the money? Been there doing that. I would say we were doing fine with our house and vehicles.

Unfortunately, we were about 12k in debt not including the house. We got our act together cleaned up our debt sold our vehicles and are now renting our house out. Last week we saw Kyoto Japan, and Beiing China. Our lives are actually richer now than they were with our desk jobs in the states. Life is too short, pay off your debt, quit your job, and travel. I do value traveling around the world more than I value what I currently spend my money on. I have debts that already exist, and I can not escape.

If I quit my job, it will be very difficult for me to get a new one if and when I return. Also, I own a lot of things. Many of them I can get rid of, but I will have to pay to store the rest while I am away. I have plenty of close friends and relatives, but none of them will quit their jobs and travel the world with me.

I need someone to travel with before I get up and go. The most practical way for me to travel around the world is to wait for now. I need to save money, eliminate debt, and find someone to travel with. Great stuff Chris. West coast USa really appeals to me, I am based in london. I am very interested in hearing about ways to pursue the ravel with two small kids in tow.

Any advice on schooling on road etc, legal requirements etc feel a little tied to the primary school if you catch my drift! This is wonderful article! After 5 years of working as a lawyer, I have just recently resigned to travel through South America a dream I have had for a few years. I am both excited and nervous too. But I already know the journey will be lifechanging. Keep writing and keep travelling — your site and your vision are fantastic. I love that you are spreading the word that most everyone can travel the world, if they so choose. I used to be one who only dreamed of it.

Then a wonderful thing happened, my first husband left me and I was despondent. I finally took 4 months, alone, to travel the world to get over my grief. The funny thing is, we do this every year! Instead of getting a new car, we take a long vacation overseas. I have just stumbled on to your website a few weeks ago and I glad I did.

I am planing on going over to Europe in Jan Your tips on traveling hacks are going to be quite helpful. My friend and I are planning on the places that we are going to visit. We want to avoid the Touristy places and find the little traveled spots. It was somewhat of a risk at the time, but it has always been one of my fondest memories, and it changed my life. Travel, making music, snowboarding, painting, family, whatever. Then you ruthlessly eliminate and ignore the rest. I live 20mins from Boston, Massachusetts.

I have always wanted more out of life. I realize I am working for a living; instead of having the life of travel I want. I have been dreaming about change and travel for so long! Time for me to stop planning and start doing! Thanks for this post. Hi Chris- Thanks for the article. The truth is I quit my job because I feel I am not growing anymore and life seems boring.

Chris, it is just so amazing how many people who posted here really want to leave their desk jobs and travel. I read in one of the comments that getting a TEFL degree and teaching English abroad is a good way to earn money and travel. Right now my friend and I are making plans on how to avoid the dreaded job. Chris thank you for being such an inspiration to so many people! I will let you know how my adventures go. I just returned from 7 months europe trip. My dream since high school and on to college but finally at 50 years old, i did it.

Lots of dream and focus on my priority of my passion of travel and have found some email friends and kept in touch all this years and when i visit they invited me to stay each place i stay at least two weeks. I fly to europe on standby ticket, slept at the airport if the flight full but en route to and from Europe i got business class and it was nice!

Anyway, i spent everything and now need to be looking for a job and start saving again. I traveled alone as i am single but met some nice people along the way and we form the comeraderies and gotogether and it was fun. Traveling is something that I have always wanted to do. I live in the US and have traveled throughout the country but have never been outside the US. My company is paying for it so I would have to commit a year with them after I graduate which would be I really hope that people can give me some helpful hints, motivation, or anything.

My main worry is my school debt because it is so huge. Then I worry about what I will do when I come back. Thanks for the blog I am definitely subscribing. I have lived in several countries while growing up, and while I missed home terribly as a child, I looked forward to leaving home also.

I thought of it as an adventure, and that made me want to get on the plane and spend the next few months away from home. The biggest lesson I learnt is that people everywhere are the same. They have the same dreams, aspirations and fears. Once you realized that, making friends is easy! The world is both larger and smaller than you think. It is sometimes hard to answer when my friends ask me what people in England is like. We watch the same movies, listen to the same hit songs, drink the same beer, even laugh at the same jokes.

How are we different? To Felicia, who was asking for help with her yearning to travel, but certain things hold her back:. See if you can take a smaller trip, first. People are friendly, the public transportation system is excellent, and you can stay in cheap hostels no matter how old you are and meet people who are traveling just like you. Ask your company to give you 6 weeks off. Tell them you need it. I did this with my co years ago — they gave me 4 months off. Sell your house, pay down your loan, get rid of all your stuff….

Go, Nomer! I love your article. I have just booked up to go travelling around Asia for 3 months and your article has just reinforced all my reasons for doing it! As someone who packed up their life a year ago to go traveling, I really enjoyed reading this piece. All very true. I have never been out of Ireland more than two weeks at a time.

Once this is done I plan to tell my family. I have only told two close friends about my plans. I know that when I tell everyone else family, workmates they will think I am insane giving up a well paid job. I have a substantial amount of money saved even though I became a mortgage slave 4 years ago.

I just think now is the right time to do this before I end up meeting someone and getting married and having kids. It does scare me about what I will do when the year is up as jobs are thin on the ground.

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But I always come back to this blog and others like it to reassure myself that everything will be ok and not too wuss out of this journey. Just reading peoples comments make me feel so positive that travelling the world is the way forward! I too am in a huge dilemma though, travel or progress with my career.

The experience money and future career prospects are extremely fantastic for someone my age but the huge problem is whether to say or go. During my placement I saved enough money to have my first experience of travelling and was lucky enough to spend 2 months in South America. The experience has changed me and views on life completely, making me so determined to see more of the world. Just stumbled upon your great site.

I agree with your way of seeing life and priorities and what truly drives the human spirit. I am now in Europe and looking to move to Germany and starting fresh again. I am a Nomad and I love it. I am changing my life and trusting my inner wisdom and intuition and letting synchronicity takes place so I can gain the most out of my travels. I am looking to go to the Himalyas for a year and am trusting that the financing for the trip will come.

Travel is the best education that one can give to oneself and YES priorities are important. My priorities are to live life the fullest and learn and share with others and of course supporting sustainable ways of living and sharing my professional expertise with others while learning to further ground on the Earth plane. Looking forward to reading your future articles. Good comments here. Chris, it was eery reading this article. It sounded like I wrote it. I have been traveling for many years myself, and I hear the exact same questions you have.

I have to agree! It has absolutely nothing to do with money. I live in a 3rd world country and bet I make maybe a fraction of the poorest person posting on this blog. However, despite my lack of finance or money, I bet other than Chris I am the richest person here. You cannot put a price on the experiences and memories that one acquires through travel and adventure. And the people that you meet and the relationships that follow, are priceless! Kudos to you Chris, keep up the good work!

You were an inspiration to me. I really appreciate how open you are and how much you share with the rest of the world. Thanks keep the goodness coming! Travel, for me, is icing on the cake, not the cake itself. Coming back to this article again! This is my goal. Been repeating this to myself over and over again and will continue to repeat it.

It looks like some of the written text in your content are running off the screen. Can somebody else please provide feedback and let me know if this is happening to them as well? Love the article. I think most people are held back by their own fears and their inability to grasp that all is possible with a little creativity. I quit my job 9 months ago and am currently FUNemployed. I will be traveling to Bali, Brazil and Africa. Life is awesome and to wait for some future date to live out your dreams is assuming that you will make it to that future date. I believe that our purpose in life is to live out our joy without delay.

The Universe does not profit from you sitting in a cube miserable. You were created to be joyous, creative and abundant- get out there and live the life of your dreams. My story and more on my website- I even started a GoFundMe page to help finance my crazy mad dream! You really make it appear so easy along with your presentation however I find this topic to be really something which I think I might by no means understand.

It kind of feels too complex and very large for me. I am having a look ahead for your next post, I will attempt to get the hold of it! Have you been turned down by so many banks? Do you need finance to establish your business? Do you need finance for the expansion of you business? Or do you need a personal loan? My loan ranges from personal to business loan. My interest rate is very affordable and our loan process is very fast as well.

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At my university we finished our classes at , but we should at 4 and there was no person who said that he want to stay more becouse he likes do it so much. So how is possible that some of them will be learn afetr university? Personally, I appreciate people who do something different than the others becouse I think then that he must think in some way to do exactly that. I truly am glad for those of you who found a way to live out your travel and adventure goals past age I guess I front end loaded. By 23 I had done what I thought was my bucket list.

Some published writing and a few years as a professional and collegiate athlete. Then Law School. I even married a medical doctor I love with everything I have. I would love to travel. Before my children were diagnosed my plan was to spin the globe, find a place, and go there to run a marathon; a different place every year. It is fortunate I love my work, but as I try to learn another language using the Rosetta Stone program, I am reminded that it is unlikely I will ever need to speak another language. Things could be worse. Godspeed to those of you following your dreams.

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Travelling with a husband and three children is expensive, so I am hoping to see the World a little bit at a time, as and when we can afford it. I love how inspiring this post is though. One day…. Our loans are well insured for maximum security is our priority. Are you losing sleep at nights worrying how to get a legitimate loan lender? Are you biting your fingernails to the quick? Instead of hitting you, contact Mark Moel Home Loan Loan Services now, the specialists who help stop the bad credit history loans, to find a solution that victory is our mission.

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If you need his help you can reach him on his email address: worldwidesupremetemple gmail. As you know, one need not travel physically to become inspiring or remarkable. There are many individuals who have never traveled whose thoughts, unlike their bodies, will nevertheless travel the globe in perpetuity. My great thanks, to my well-wishers and friends, who think so kindly of me as to undertake my welfare, but at the same time a most humble request to protect me in my current condition from any disturbance. However, just one of his thoughts Please excuse my paraphrasing , which is that one should act as though his every act were to become a universal principle of morality, is worthy of a seasoned traveler.

May the wind always be at your back. If you would like to travel around the world, consider Vietnam. Bc Family Homestay are always welcome you to Vietnam. Hello every one, here is an easy way without any delay to get your travelling passport and visa,incase you want to travel to any part of the country in the word and it will be deliverd to you at your door step. I love this. We only have one life to live. Priorities, priorities, priorities! So many people place their priorities in crazy places.

When I realized I wanted to travel the world, I got my priorities in check. Every penny that I could save time I went into an account, and when I was ready to pull the trigger, I sold and donated everything. Hello everybody, My name is Selina. I am happy given this testimony on this forum on how Dr Iyare helped me to restored my son on drug addiction and getting my husband back to me. Hi told me what i needed to do and i did it, to my own surprise. Today we are living happily together as a happy family now.

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Great post! Im currently in the process of leaving the nine to five in pursuit of more fulfilling work I can do from anywhere. All best. Though the book has a copyright date of , here I am 6 years later and just now reading it! I am better for having read your book! It has spawned several ideas! Point 2 has always been a big one for me. I had the means to work and travel for about 2 years before I actually pulled the pin and did it. This is my first time pay a visit at here and i am in fact pleassant to read all at one place.

Absolutely wonderful blog post about breaking out and seeing the world. Living with the regret of lost opportunity is probably the biggest motivator for me to flip my hermit habit and start traveling. I am 52 with no kids, have worked all my life travelled round the world : for 6 months when I was I think there is a bit of a nomad in me,. I have some equity in my house, I have brains and I can do a lot of things to a decent standard. Here are some of the excuses: I will miss my close friends, brothers, nieces, nephews, great nieces, nephews.

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Episodic or suppressive therapy with oral antiviral agents is often beneficial. Acyclovir mg orally three times a day for days, OR Acyclovir mg five times a day for days, OR Famciclovir mg orally twice a day for days, OR Valacyclovir 1. Acyclovir mg orally twice to three times a day, OR Famciclovir mg orally twice a day, OR Valacyclovir mg orally twice a day.

In the doses recommended for treatment of genital herpes, acyclovir, valacyclovir, and famciclovir are safe for use in immunocompromised patients. If lesions persist or recur in a patient receiving antiviral treatment, HSV resistance should be suspected and a viral isolate obtained for sensitivity testing. Such patients should be managed in consultation with a specialist, and alternate therapy should be administered. All acyclovir-resistant strains are resistant to valacyclovir and most are resistant to famciclovir. This preparation is not commercially available and must be compounded at a pharmacy.

Most mothers of infants who acquire neonatal herpes lack histories of clinically evident genital herpes. However, because recurrent genital herpes is much more common than initial HSV infection during pregnancy, the proportion of neonatal HSV infections acquired from mothers with recurrent herpes remains high. Prevention of neonatal herpes depends both on preventing acquisition of genital HSV infection during late pregnancy and avoiding exposure of the infant to herpetic lesions during delivery.

Women without known genital herpes should be counseled to avoid intercourse during the third trimester with partners known or suspected of having genital herpes. In addition, pregnant women without known orolabial herpes should be advised to avoid cunnilingus during the third trimester with partners known or suspected to have orolabial herpes. Some specialists believe type-specific serologic tests are useful to identify pregnant women at risk for HSV infection and to guide counseling with regard to the risk of acquiring genital herpes during pregnancy.

Such testing and counseling may be especially important when a woman's sex partner has HSV infection. All pregnant women should be asked whether they have a history of genital herpes. At the onset of labor, all women should be questioned carefully about symptoms of genital herpes, including prodrome, and all women should be examined carefully for herpetic lesions.

Women without symptoms or signs of genital herpes or its prodrome can deliver vaginally. Most specialists recommend that women with recurrent genital herpetic lesions at the onset of labor deliver by cesarean section to prevent neonatal herpes. However, abdominal delivery does not completely eliminate the risk for HSV transmission to the infant. The results of viral cultures during pregnancy in women with or without visible herpetic lesions do not predict viral shedding at the time of delivery, and therefore routine viral cultures of pregnant women with recurrent genital herpes are not recommended.

The safety of systemic acyclovir, valacyclovir, and famciclovir therapy in pregnant women has not been established. Available data do not indicate an increased risk for major birth defects compared with the general population in women treated with acyclovir during the first trimester These findings provide some assurance to women who have had prenatal exposure to acyclovir.

However, available data are insufficient to reach definitive conclusions regarding the risks to the newborn associated with acyclovir treatment during pregnancy. The experience with prenatal exposure to valacyclovir and famciclovir is too limited to provide useful information on pregnancy outcomes. Acyclovir may be administered orally to pregnant women with first episode genital herpes or severe recurrent herpes and should be administered IV to pregnant women with severe HSV infection. Preliminary data suggest that acyclovir treatment late in pregnancy might reduce the frequency of cesarean sections among women who have recurrent genital herpes by diminishing the frequency of recurrences at term 44,45 , and some specialists recommend such treatment.

The risk for herpes is high in infants of women who acquire genital HSV in late pregnancy; such women should be managed in consultation with an HSV specialist. Some specialists recommend acyclovir therapy in this circumstance, some recommend routine cesarean section to reduce the risk for neonatal herpes, and others recommend both. Infants exposed to HSV during birth, as documented by virologic testing or presumed by observation of lesions, should be followed carefully in consultation with a specialist.

Some specialists recommend that such infants undergo surveillance cultures of mucosal surfaces to detect HSV infection before development of clinical signs of neonatal herpes. Some specialists recommend the use of acyclovir for infants born to women who acquired HSV near term, because the risk for neonatal herpes is high for these infants. All infants who have evidence of neonatal herpes should be promptly evaluated and treated with systemic acyclovir. Granuloma Inguinale Donovanosis Granuloma inguinale is a genital ulcerative disease caused by the intracellular Gram-negative bacterium Calymmatobacterium granulomatis.

The disease occurs rarely in the United States, although it is endemic in certain tropical and developing areas, including India; Papua, New Guinea; central Australia; and southern Africa. Clinically, the disease commonly presents as painless, progressive ulcerative lesions without regional lymphadenopathy. The lesions are highly vascular "beefy red appearance" and bleed easily on contact. However, the clinical presentation can also include hypertrophic, necrotic, or sclerotic variants. The causative organism is difficult to culture, and diagnosis requires visualization of dark-staining Donovan bodies on tissue crush preparation or biopsy.

The lesions may develop secondary bacterial infection or may be coinfected with another sexually transmitted pathogen. Treatment halts progression of lesions, although prolonged therapy may be required to permit granulation and reepithelialization of the ulcers. Relapse can occur months after apparently effective therapy. Several antimicrobial regimens have been effective, but few controlled trials have been published.

Ciprofloxacin mg orally twice a day for at least 3 weeks, OR Erythromycin base mg orally four times a day for at least 3 weeks, OR Azithromycin 1 g orally once per week for at least 3 weeks. Therapy should be continued at least 3 weeks or until all lesions have completely healed. Some specialists recommend addition of an aminoglycoside e.

Persons who have had sexual contact with a patient who has granuloma inguinale within the 60 days before onset of the patient's symptoms should be examined and offered therapy. However, the value of empiric therapy in the absence of clinical signs and symptoms has not been established. Pregnancy is a relative contraindication to the use of sulfonamides. Pregnant and lactating women should be treated with the erythromycin regimen, and consideration should be given to the addition of a parenteral aminoglycoside e.

Azithromycin may prove useful for treating granuloma inguinale in pregnancy, but published data are lacking. Doxycycline and ciprofloxacin are contraindicated in pregnant women. Persons with both granuloma inguinale and HIV infection should receive the same regimens as those who are HIV negative. Consideration should be given to the addition of a parenteral aminoglycoside e. The disease occurs rarely in the United States. Women and homosexually active men may have proctocolitis or inflammatory involvement of perirectal or perianal lymphatic tissues resulting in fistulas and strictures.

A self-limited genital ulcer sometimes occurs at the site of inoculation. However, by the time patients seek care, the ulcer usually has disappeared. The diagnosis of LGV is usually made serologically and by exclusion of other causes of inguinal lymphadenopathy or genital ulcers.

The diagnostic utility of serologic methods other than complement fixation is unknown. Treatment cures infection and prevents ongoing tissue damage, although tissue reaction can result in scarring. Doxycycline is the preferred treatment. Some STD specialists believe azithromycin 1. Persons who have had sexual contact with a patient who has LGV within the 30 days before onset of the patient's symptoms should be examined, tested for urethral or cervical chlamydial infection, and treated. Pregnant and lactating women should be treated with erythromycin.

Azithromycin may prove useful for treatment of LGV in pregnancy, but no published data are available regarding its safety and efficacy. Doxycycline is contraindicated in pregnant women. Prolonged therapy may be required, and delay in resolution of symptoms may occur. Syphilis General Principles. Syphilis is a systemic disease caused by T.

Patients who have syphilis may seek treatment for signs or symptoms of primary infection i. Latent infections i. Latent syphilis acquired within the preceding year is referred to as early latent syphilis; all other cases of latent syphilis are either late latent syphilis or latent syphilis of unknown duration. Treatment for both late latent syphilis and tertiary syphilis theoretically may require a longer duration of therapy because organisms are dividing more slowly; however, the validity of this concept has not been assessed.

Darkfield examinations and direct fluorescent antibody tests of lesion exudate or tissue are the definitive methods for diagnosing early syphilis. A presumptive diagnosis is possible with the use of two types of serologic tests for syphilis: a nontreponemal tests e. The use of only one type of serologic test is insufficient for diagnosis, because false-positive nontreponemal test results may occur secondary to various medical conditions.

Nontreponemal test antibody titers usually correlate with disease activity, and results should be reported quantitatively. A fourfold change in titer, equivalent to a change of two dilutions e. Sequential serologic tests in individual patients should be performed by using the same testing method e. Nontreponemal tests usually become nonreactive with time after treatment; however, in some patients, nontreponemal antibodies can persist at a low titer for a long period of time, sometimes for the life of the patient.

This response is referred to as the "serofast reaction. Most patients who have reactive treponemal tests will have reactive tests for the remainder of their lives, regardless of treatment or disease activity. Treponemal test antibody titers correlate poorly with disease activity and should not be used to assess treatment response.

Some HIV-infected patients can have atypical serologic test results i. For such patients, when serologic tests and clinical syndromes suggestive of early syphilis do not correspond with one another, use of other tests e. However, for most HIV-infected patients, serologic tests are accurate and reliable for the diagnosis of syphilis and for following the response to treatment. No test can be used alone to diagnose neurosyphilis. Most other tests are both insensitive and nonspecific and must be interpreted in relation to other test results and the clinical assessment. Therefore, the diagnosis of neurosyphilis usually depends on various combinations of reactive serologic test results, abnormalities of cerebrospinal fluid CSF cell count or protein, or a reactive VDRL-CSF with or without clinical manifestations.

Penicillin G, administered parenterally, is the preferred drug for treatment of all stages of syphilis. The preparation s used i. However, neither combinations of benzathine penicillin and procaine penicillin nor oral penicillin preparations are considered appropriate for the treatment of syphilis. The efficacy of penicillin for the treatment of syphilis was well established through clinical experience before the value of randomized controlled clinical trials was recognized.

Therefore, almost all the recommendations for the treatment of syphilis are based on the opinions of persons knowledgeable about STDs and are reinforced by case series, clinical trials, and 50 years of clinical experience. Parenteral penicillin G is the only therapy with documented efficacy for syphilis during pregnancy. Pregnant women with syphilis in any stage who report penicillin allergy should be desensitized and treated with penicillin. Skin testing for penicillin allergy may be useful in pregnant women; such testing also is useful in other patients see Management of Patients Who Have a History of Penicillin Allergy.

The Jarisch-Herxheimer reaction is an acute febrile reaction frequently accompanied by headache, myalgia, and other symptoms that usually occurs within the first 24 hours after any therapy for syphilis. Patients should be informed about this possible adverse reaction. The Jarisch-Herxheimer reaction occurs most often among patients who have early syphilis. Antipyretics may be used, but they have not been proven to prevent this reaction. The Jarisch-Herxheimer reaction may induce early labor or cause fetal distress in pregnant women.

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This concern should not prevent or delay therapy see Syphilis During Pregnancy. Sexual transmission of T. However, persons exposed sexually to a patient who has syphilis in any stage should be evaluated clinically and serologically according to the following recommendations. For identification of at-risk partners, the time periods before treatment are a 3 months plus duration of symptoms for primary syphilis, b 6 months plus duration of symptoms for secondary syphilis, and c 1 year for early latent syphilis.

Parenteral penicillin G has been used effectively for more than 50 years to achieve clinical resolution i.

However, no comparative trials have been adequately conducted to guide the selection of an optimal penicillin regimen i. Substantially fewer data are available for nonpenicillin regimens. After the newborn period, children with syphilis should have a CSF examination to detect asymptomatic neurosyphilis, and birth and maternal medical records should be reviewed to assess whether such children have congenital or acquired syphilis see Congenital Syphilis.

Children with acquired primary or secondary syphilis should be evaluated e. All patients who have syphilis should be tested for HIV infection. In geographic areas in which the prevalence of HIV is high, patients who have primary syphilis should be retested for HIV after 3 months if the first HIV test result was negative.

Patients who have syphilis and who also have symptoms or signs suggesting neurologic disease e. Treatment should be guided by the results of this evaluation. Invasion of CSF by T. However, neurosyphilis develops in only a limited number of patients after treatment with the penicillin regimens recommended for primary and secondary syphilis.

Therefore, unless clinical signs or symptoms of neurologic or ophthalmic involvement are present, CSF analysis is not recommended for routine evaluation of patients who have primary or secondary syphilis. Treatment failure can occur with any regimen. However, assessing response to treatment often is difficult, and definitive criteria for cure or failure have not been established. Nontreponemal test titers may decline more slowly for patients who previously had syphilis. Patients should be reexamined clinically and serologically 6 months and 12 months following treatment; more frequent evaluation may be prudent if follow-up is uncertain.

Patients who have signs or symptoms that persist or recur or who have a sustained fourfold increase in nontreponemal test titer i. These patients should be re-treated and reevaluated for HIV infection. Because treatment failure usually cannot be reliably distinguished from reinfection with T. Failure of nontreponemal test titers to decline fourfold within 6 months after therapy for primary or secondary syphilis is indicative of probable treatment failure. Persons for whom titers remain serofast should be reevaluated for HIV infection. Optimal management of such patients is unclear. At a minimum, these patients should have additional clinical and serologic follow-up.

HIV-infected patients should be evaluated more frequently i. If additional follow-up cannot be ensured, re-treatment is recommended. Because treatment failure may be the result of unrecognized CNS infection, some specialists recommend CSF examination in such situations. When patients are re-treated, most STD specialists recommend administering weekly injections of benzathine penicillin G 2. In rare instances, serologic titers do not decline despite a negative CSF examination and a repeated course of therapy. Additional therapy or repeated CSF examinations are not warranted in these circumstances.

Penicillin Allergy. Data to support the use of alternatives to penicillin in the treatment of early syphilis are limited. However, several therapies might be considered effective in nonpregnant, penicillin-allergic patients who have primary or secondary syphilis. Doxycycline mg orally twice daily for 14 days and tetracycline mg four times daily for 14 days are regimens that have been used for many years.

Compliance is likely to be better with doxycycline than tetracycline, because tetracycline can cause gastrointestinal side effects. Although limited clinical studies, along with biologic and pharmacologic evidence, suggest that ceftriaxone is effective for treating early syphilis, the optimal dose and duration of ceftriaxone therapy have not been defined. However, some specialists recommend 1 gram daily either IM or IV for days. Preliminary data suggest that azithromycin may be effective as a single oral dose of 2 grams. Because the efficacy of these therapies is not well documented, close follow-up of persons receiving these therapies is essential.

The use of any of these therapies in HIV-infected persons has not been studied; the use of doxycycline, ceftriaxone, and azithromycin among such persons must be undertaken with caution. Patients with penicillin allergy whose compliance with therapy or follow-up cannot be ensured should be desensitized and treated with benzathine penicillin. Skin testing for penicillin allergy may be useful in some circumstances in which the reagents and expertise are available to perform the test adequately see Management of Patients Who Have a History of Penicillin Allergy.

Pregnant patients who are allergic to penicillin should be desensitized and treated with penicillin see Management of Patients Who Have a History of Penicillin Allergy and Syphilis During Pregnancy. HIV Infection. Latent syphilis is defined as syphilis characterized by seroreactivity without other evidence of disease.

Patients who have latent syphilis and who acquired syphilis within the preceding year are classified as having early latent syphilis. Patients who have latent syphilis of unknown duration should be managed as if they have late latent syphilis. Nontreponemal serologic titers usually are higher during early latent syphilis than late latent syphilis. However, early latent syphilis cannot be reliably distinguished from late latent syphilis solely on the basis of nontreponemal titers.

All patients with latent syphilis should have careful examination of all accessible mucosal surfaces i. Treatment of latent syphilis usually does not affect transmission and is intended to prevent occurrence or progression of late complications. Although clinical experience supports the effectiveness of penicillin in achieving these goals, limited evidence is available for guidance in choosing specific regimens. The following regimens are recommended for nonallergic patients who have normal CSF examinations if performed. Benzathine penicillin G 7. After the newborn period, children with syphilis should have a CSF examination to exclude neurosyphilis.

In addition, birth and maternal medical records should be reviewed to assess whether children have congenital or acquired syphilis see Congenital Syphilis. Older children with acquired latent syphilis should be evaluated as described for adults and treated using the following pediatric regimens see Sexual Assault or Abuse of Children. These regimens are for non-allergic children who have acquired syphilis and who have normal CSF examination results. All patients who have latent syphilis should be evaluated clinically for evidence of tertiary disease e.

Patients who have syphilis and who demonstrate any of the following criteria should have a prompt CSF examination:. If dictated by circumstances and patient preferences, a CSF examination may be performed for patients who do not meet these criteria. The risk of neurosyphilis in this circumstance is unknown. If a CSF examination is performed and the results indicate abnormalities consistent with neurosyphilis, the patient should be treated for neurosyphilis see Neurosyphilis. If a patient misses a dose of penicillin in the course of weekly therapy for late syphilis, the appropriate course of action is unclear.

Pharmacologic considerations suggest that an interval of days between doses of benzathine penicillin for late syphilis or latent syphilis of unknown duration might be acceptable before restarting the sequence of injections. Missed doses should not be considered acceptable for pregnant patients receiving therapy for late latent syphilis; pregnant women who miss any dose of therapy must repeat the full course of therapy.

Quantitative nontreponemal serologic tests should be repeated at 6, 12, and 24 months. In rare instances, despite a negative CSF examination and a repeated course of therapy, serologic titers may still not decline. In these circumstances, the need for additional therapy or repeated CSF examinations is unclear. Management of Sex Partners. The effectiveness of alternatives to penicillin in the treatment of latent syphilis has not been well documented.

Nonpregnant patients allergic to penicillin who have clearly defined early latent syphilis should respond to therapies recommended as alternatives to penicillin for the treatment of primary and secondary syphilis see Treatment of Primary and Secondary Syphilis. The only acceptable alternatives for the treatment of late latent syphilis or latent syphilis of unknown duration are doxycycline mg orally twice daily or tetracycline mg orally four times daily both for 28 days. These therapies should be used only in conjunction with close serologic and clinical follow-up. The efficacy of these alternative regimens in HIV-infected persons has not been studied, and thus must be considered with caution.

Tertiary syphilis refers to gumma and cardiovascular syphilis, but not to all neurosyphilis. Patients who are not allergic to penicillin and have no evidence of neurosyphilis should be treated with the following regimen. Patients who have symptomatic late syphilis should be given a CSF examination before therapy is initiated. Some providers treat all patients who have cardiovascular syphilis with a neurosyphilis regimen. The complete management of patients who have cardiovascular or gummatous syphilis is beyond the scope of these guidelines.

These patients should be managed in consultation with an infectious diseases specialist. Limited information is available concerning clinical response and follow-up of patients who have tertiary syphilis. Patients allergic to penicillin should be treated according to treatment regimens recommended for late latent syphilis. Pregnant patients who are allergic to penicillin should be desensitized, if necessary, and treated with penicillin see Management of Patients Who Have a History of Penicillin Allergy and Syphilis During Pregnancy.

CNS disease can occur during any stage of syphilis. A patient who has clinical evidence of neurologic involvement with syphilis e. Syphilitic uveitis or other ocular manifestations frequently are associated with neurosyphilis; patients with these symptoms should be treated according to the recommendations for patients with neurosyphilis. A CSF examination should be performed for all such patients to identify those with abnormalities who should have follow-up CSF examinations to assess treatment response.

Patients who have neurosyphilis or syphilitic eye disease e. Aqueous crystalline penicillin G million units per day, administered as million units IV every 4 hours or continuous infusion, for days. If compliance with therapy can be ensured, patients may be treated with the following alternative regimen. Procaine penicillin 2. The durations of the recommended and alternative regimens for neurosyphilis are shorter than that of the regimen used for late syphilis in the absence of neurosyphilis.

Therefore, some specialists administer benzathine penicillin, 2. If CSF pleocytosis was present initially, a CSF examination should be repeated every 6 months until the cell count is normal. If the cell count has not decreased after 6 months, or if the CSF is not normal after 2 years, re-treatment should be considered.

Ceftriaxone can be used as an alternative treatment for patients with neurosyphilis, although the possibility of cross-reactivity between this agent and penicillin exists. Some specialists recommend ceftriaxone 2 grams daily either IM or IV for days. Other regimens have not been adequately evaluated for treatment of neurosyphilis. Therefore, if concern exists regarding the safety of ceftriaxone for a patient with neurosyphilis, the patient should obtain skin testing to confirm penicillin allergy and, if necessary, be desensitized and managed in consultation with a specialist.

Pregnant patients who are allergic to penicillin should be desensitized, if necessary, and treated with penicillin see Syphilis During Pregnancy. Unusual serologic responses have been observed among HIV-infected persons who have syphilis. Most reports have involved serologic titers that were higher than expected, but false-negative serologic test results and delayed appearance of seroreactivity also have been reported. However, aberrant serologic responses are uncommon, and most specialists believe that both treponemal and non-treponemal serologic tests for syphilis can be interpreted in the usual manner for most patients who are coinfected with T.

When clinical findings are suggestive of syphilis, but serologic tests are nonreactive or the interpretation is unclear, alternative tests e. Neurosyphilis should be considered in the differential diagnosis of neurologic disease in HIV-infected persons. Compared with HIV-negative patients, HIV-positive patients who have early syphilis may be at increased risk for neurologic complications and may have higher rates of treatment failure with currently recommended regimens.

The magnitude of these risks, although not defined precisely, is likely minimal. No treatment regimens for syphilis have been demonstrated to be more effective in preventing neurosyphilis in HIV-infected patients than the syphilis regimens recommended for HIV-negative patients. Careful follow-up after therapy is essential. Treatment with benzathine penicillin G, 2.

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Some specialists recommend additional treatments e. Because CSF abnormalities e. Although most HIV-infected persons respond appropriately to standard benzathine penicillin therapy, some specialists recommend intensified therapy when CNS syphilis is suspected in these persons. Therefore, some specialists recommend CSF examination before treatment of HIV-infected persons with early syphilis, with follow-up CSF examination following treatment in persons with initial abnormalities.

HIV-infected patients should be evaluated clinically and serologically for treatment failure at 3, 6, 9, 12, and 24 months after therapy. Although of unproven benefit, some specialists recommend a CSF examination 6 months after therapy. HIV-infected patients who meet the criteria for treatment failure should be managed in the same manner as HIV-negative patients i. CSF examination and re-treatment also should be strongly considered for patients whose nontreponemal test titers do not decrease fourfold within months of therapy. Most specialists would re-treat patients with benzathine penicillin G administered as three doses of 2.

Penicillin-allergic patients who have primary or secondary syphilis and HIV infection should be managed according to the recommendations for penicillin-allergic, HIV-negative patients. The use of alternatives to penicillin has not been well studied in HIV-infected patients. HIV-infected patients who have early latent syphilis should be managed and treated according to the recommendations for HIV-negative patients who have primary and secondary syphilis. HIV-infected patients who have either late latent syphilis or syphilis of unknown duration should have a CSF examination before treatment.

Patients with late latent syphilis or syphilis of unknown duration and a normal CSF examination can be treated with benzathine penicillin G, at weekly doses of 2. Patients who have CSF consistent with neurosyphilis should be treated and managed as patients who have neurosyphilis see Neurosyphilis. Patients should be evaluated clinically and serologically at 6, 12, 18, and 24 months after therapy.

If, at any time, clinical symptoms develop or nontreponemal titers rise fourfold, a repeat CSF examination should be performed and treatment administered accordingly. If in months the nontreponemal titer does not decline fourfold, the CSF examination should be repeated and treatment administered accordingly. Patients with penicillin allergy whose compliance with therapy or follow-up cannot be ensured should be desensitized and treated with penicillin see Management of Patients Who Have a History of Penicillin Allergy.

The efficacy of alternative non-penicillin regimens in HIV-infected persons has not been studied. All women should be screened serologically for syphilis at the first prenatal visit. In populations in which prenatal care is not optimal, RPR-card test screening and treatment if the RPR-card test is reactive should be performed at the time a pregnancy is confirmed.

For communities and populations in which the prevalence of syphilis is high or for patients at high risk, serologic testing should be performed twice during the third trimester, at 28 weeks' gestation, and at delivery in addition to routine early screening. Some states mandate screening at delivery for all women. Any woman who delivers a stillborn infant after 20 weeks' gestation should be tested for syphilis.

No infant should leave the hospital if maternal serologic status has not been determined at least once during pregnancy and preferably again at delivery. Seropositive pregnant women should be considered infected unless an adequate treatment history is documented in the medical records and sequential serologic antibody titers have declined. Penicillin is effective for preventing maternal transmission to the fetus and for treating fetal infection.

Evidence is insufficient to determine whether the specific, recommended penicillin regimens are optimal. Treatment during pregnancy should consist of the penicillin regimen appropriate for the stage of syphilis. Some specialists recommend additional therapy in some patients. A second dose of benzathine penicillin 2.

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In the second half of pregnancy, management and counseling may be facilitated by a sonographic fetal evaluation for congenital syphilis, but this should not delay therapy. Sonographic signs of fetal syphilis i. Evidence is insufficient to recommend specific regimens for these situations. These women should be advised to seek obstetric attention after treatment if they notice any contractions or decrease in fetal movements.

Although stillbirth is a rare complication of treatment, concern about this complication should not delay necessary treatment. All patients who have syphilis should be offered testing for HIV infection. Coordinated prenatal care, treatment follow-up, and syphilis case management are important in the management of pregnant women with syphilis. Serologic titers should be repeated in the third trimester and at delivery. Serologic titers may be checked monthly in women at high risk for reinfection or in geographic areas in which the prevalence of syphilis is high.

The clinical and antibody response should be appropriate for the stage of disease. Most women will deliver before their serologic response to treatment can be assessed definitively. No alternatives to penicillin have been proved effective for treatment of syphilis during pregnancy. Pregnant women who have a history of penicillin allergy should be desensitized and treated with penicillin.

Tetracycline and doxycycline should not used during pregnancy. Erythromycin should not be used, because it does not reliably cure an infected fetus. Data are insufficient to recommend azithromycin or ceftriaxone. Congenital Syphilis Effective prevention and detection of congenital syphilis depends on the identification of syphilis in pregnant women and, therefore, on the routine serologic screening of pregnant women during the first prenatal visit.

Serologic testing and a sexual history also should be obtained at 28 weeks of gestation and at delivery in communities and populations in which the risk for congenital syphilis is high. Moreover, as part of the management of pregnant women who have syphilis, information concerning treatment of sex partners should be obtained to assess the risk for reinfection.

All pregnant women who have syphilis should be tested for HIV infection. Routine screening of newborn sera or umbilical cord blood is not recommended. Serologic testing of the mother's serum is preferred over testing infant serum, because the serologic tests performed on infant serum can be nonreactive if the mother's serologic test result is of low titer or if the mother was infected late in pregnancy.

No infant or mother should leave the hospital unless the maternal serologic status has been documented at least once during pregnancy and preferably again at delivery. Evaluation and Treatment of Infants in the First Month of Life The diagnosis of congenital syphilis is complicated by the transplacental transfer of maternal nontreponemal and treponemal immunoglobulin G IgG antibodies to the fetus. This transfer of antibodies makes the interpretation of reactive serologic tests for syphilis in infants difficult. Treatment decisions often must be made on the basis of a identification of syphilis in the mother; b adequacy of maternal treatment; c presence of clinical, laboratory, or radiographic evidence of syphilis in the infant; and d comparison of maternal at delivery and infant nontreponemal serologic titers utilizing the same test and preferably the same laboratory.

All infants born to mothers who have reactive nontreponemal and treponemal test results should be evaluated with a quantitative nontreponemal serologic test RPR or VDRL performed on infant serum, because umbilical cord blood can become contaminated with maternal blood and could yield a false-positive result. Conducting a treponemal test i. Currently, no commercially available IgM test can be recommended. All infants born to women who have reactive serologic tests for syphilis should be examined thoroughly for evidence of congenital syphilis e.

Pathologic examination of the placenta or umbilical cord using specific fluorescent antitreponemal antibody staining is suggested. Darkfield microscopic examination or direct fluorescent antibody staining of suspicious lesions or body fluids e. The following scenarios describe the evaluation and treatment of infants for congenital syphilis. If more than 1 day of therapy is missed, the entire course should be restarted. Data are insufficient regarding the use of other antimicrobial agents e. When possible, a full day course of penicillin is preferred, even if ampicillin was initially provided for possible sepsis.

In all other situations, the maternal history of infection with T. Scenario 2. Infants who have a normal physical examination and a serum quantitative nontreponemal serologic titer the same or less than fourfold the maternal titer and the. A complete evaluation is not necessary if 10 days of parenteral therapy is administered. However, such evaluation may be useful; a lumbar puncture may document CSF abnormalities that would prompt close follow-up. Other tests e. If a single dose of benzathine penicillin G is used, then the infant must be fully evaluated i.

If any part of the infant's evaluation is abnormal or not performed, or if the CSF analysis is rendered uninterpretable because of contamination with blood, then a day course of penicillin is required. NOTE: Some specialists prefer the 10 days of parenteral therapy if the mother has untreated early syphilis at delivery. Scenario 3. Scenario 4. Evaluation and Treatment of Older Infants and Children Children who are identified as having reactive serologic tests for syphilis after the neonatal period i. Any child at risk for congenital syphilis should receive a full evaluation and testing for HIV infection.

Any child who is suspected of having congenital syphilis or who has neurologic involvement should be treated with aqueous penicillin G. Follow-Up All seroreactive infants or infants whose mothers were seroreactive at delivery should receive careful follow-up examinations and serologic testing i. Nontreponemal antibody titers should decline by 3 months of age and should be nonreactive by 6 months of age if the infant was not infected i. The serologic response after therapy may be slower for infants treated after the neonatal period.

If these titers are stable or increase after months of age, the child should be evaluated e. Treponemal tests should not be used to evaluate treatment response because the results for an infected child can remain positive despite effective therapy. Passively transferred maternal treponemal antibodies can be present in an infant until age 15 months. A reactive treponemal test after age 18 months is diagnostic of congenital syphilis. If the nontreponemal test is nonreactive at this time, no further evaluation or treatment is necessary.

If the nontreponemal test is reactive at age 18 months, the infant should be fully re evaluated and treated for congenital syphilis. Infants whose initial CSF evaluations are abnormal should undergo a repeat lumbar puncture approximately every 6 months until the results are normal. Follow-up of children treated for congenital syphilis after the newborn period should be conducted as is recommended for neonates. Special Considerations Penicillin Allergy. Infants and children who require treatment for syphilis but who have a history of penicillin allergy or develop an allergic reaction presumed secondary to penicillin should be desensitized, if necessary, and then treated with penicillin see Management of Patients With a History of Penicillin Allergy.

Data are insufficient regarding whether infants who have congenital syphilis and whose mothers are coinfected with HIV require different evaluation, therapy, or follow-up for syphilis than is recommended for all infants. Management of Patients Who Have a History of Penicillin Allergy No proven alternatives to penicillin are available for treating neurosyphilis, congenital syphilis, or syphilis in pregnant women.

Penicillin is also recommended for use, whenever possible, in HIV-infected patients. Of the adult U. Re-administration of penicillin to these patients can cause severe, immediate reactions. Because anaphylactic reactions to penicillin can be fatal, every effort should be made to avoid administering penicillin to penicillin-allergic patients, unless they undergo acute desensitization to eliminate anaphylactic sensitivity.

With the passage of time after an allergic reaction to penicillin, most persons who have had a severe reaction stop expressing penicillin-specific immunoglobulin E IgE. These persons can be treated safely with penicillin. The results of many investigations indicate that skin testing with the major and minor determinants can reliably identify persons at high risk for penicillin reactions.

Recommendations If the full battery of skin-test reagents is available, including the major and minor determinants see Penicillin Allergy Skin Testing , patients who report a history of penicillin reaction and are skin-test negative can receive conventional penicillin therapy. Skin-test-positive patients should be desensitized. If the full battery of skin-test reagents, including the minor determinants, is not available, the patient should be skin tested using benzylpenicilloyl poly-L-lysine i.

Patients who have positive test results should be desensitized. Some specialists suggest that persons who have negative test results should be regarded as probably allergic and should be desensitized. Others suggest that those with negative skin-test results can be test-dosed gradually with oral penicillin in a monitored setting in which treatment for anaphylactic reaction can be provided. Penicillin Allergy Skin Testing Patients at high risk for anaphylaxis, including those who a have a history of penicillin-related anaphylaxis, asthma, or other diseases that would make anaphylaxis more dangerous and b are being treated with beta-adrenergic blocking agents, should be tested with fold dilutions of the full-strength skin-test reagents before being tested with full-strength reagents.

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In these situations, patients should be tested in a monitored setting in which treatment for an anaphylactic reaction is available. If possible, the patient should not have taken antihistamines recently e. Dilute the antigens either a fold for preliminary testing if the patient has had a life-threatening reaction to penicillin or b fold if the patient has had another type of immediate, generalized reaction to penicillin within the preceding year.

Duplicate drops of skin-test reagent are placed on the volar surface of the forearm. The underlying epidermis is pierced with a gauge needle without drawing blood. An epicutaneous test is positive if the average wheal diameter after 15 minutes is 4 mm larger than that of negative controls; otherwise, the test is negative.

The histamine controls should be positive to ensure that results are not falsely negative because of the effect of antihistaminic drugs. If epicutaneous tests are negative, duplicate 0. The crossed diameters of the wheals induced by the injections should be recorded. Otherwise, the tests are negative. Patients who have a positive skin test to one of the penicillin determinants can be desensitized Table 1. This is a straightforward, relatively safe procedure that can be done orally or IV.

Although the two approaches have not been compared, oral desensitization is regarded as safer to use and easier to perform. Patients should be desensitized in a hospital setting because serious IgE-mediated allergic reactions rarely can occur. Desensitization usually can be completed in approximately 4 hours, after which the first dose of penicillin is administered.

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After desensitization, patients must be maintained on penicillin continuously for the duration of the course of therapy. Diseases Characterized by Urethritis and Cervicitis Management of Male Patients Who Have Urethritis Urethritis is caused by an infection characterized by urethral discharge of mucopurulent or purulent material and sometimes by dysuria or urethral pruritis.

Asymptomatic infections are common. The principal bacterial pathogens of proven clinical importance in men who have urethritis are N. Testing to determine the specific etiology is recommended because both chlamydia and gonorrhea are conditions that are reportable to state health departments, and a specific diagnosis may enhance partner notification and improve compliance with treatment, especially in the exposed partner.

If diagnostic tools e. The additional antibiotic exposure and expense of treating a person who has nongonococcal urethritis NGU for both infections also should encourage the health-care provider to make a specific diagnosis. Nucleic acid amplification tests enable detection of N. These tests are more sensitive than traditional culture techniques for C. Etiology NGU is diagnosed if Gram-negative intracellular diplococci cannot be identified on urethral smears. The proportion of NGU cases caused by chlamydia has been declining gradually.

Complications of NGU among men infected with C. Documentation of chlamydia infection is important because of the need for partner referral for evaluation and treatment. The etiology of most cases of nonchlamydial NGU is unknown. Ureaplasma urealyticum and Mycoplasma genitalium have been implicated as causes of NGU in some studies. Specific diagnostic tests for these organisms are not indicated, because the detection of these organisms is often difficult and would not alter therapy.

Diagnostic and treatment procedures for these organisms are reserved for situations in which these infections are suspected e. Confirmed Urethritis Clinicians should document that urethritis is present. Urethritis can be documented on the basis of any of the following signs.

If none of these criteria is present, then treatment should be deferred, and the patient should be tested for N. If the results demonstrate infection with either N. Empiric treatment of symptoms without documentation of urethritis is recommended only for patients at high risk for infection who are unlikely to return for a follow-up evaluation.

Such patients should be treated for gonorrhea and chlamydia. Partners of patients treated empirically should be evaluated and treated. All patients who have urethritis should be evaluated for the presence of gonococcal and chlamydial infection. Testing for chlamydia is strongly recommended because of the increased utility and availability of highly sensitive and specific testing methods, and because a specific diagnosis may enhance partner notification and improve compliance with treatment, especially in the exposed partner.

Treatment should be initiated as soon as possible after diagnosis. Single-dose regimens have the advantage of improved compliance and of DOT. To improve compliance, the medication should be provided in the clinic or health-care provider's office. Azithromycin 1 g orally in a single dose OR Doxycycline mg orally twice a day for 7 days.

Erythromycin base mg orally four times a day for 7 days, OR Erythromycin ethylsuccinate mg orally four times a day for 7 days, OR Ofloxacin mg twice a day for 7 days, OR Levofloxacin mg once daily for 7 days. Patients should be instructed to return for evaluation if symptoms persist or recur after completion of therapy. Symptoms alone, without documentation of signs or laboratory evidence of urethral inflammation, are not a sufficient basis for re-treatment.

Patients should be instructed to abstain from sexual intercourse until 7 days after therapy is initiated. Patients should refer for evaluation and treatment all sex partners within the preceding 60 days. Because a specific diagnosis may facilitate partner referral, testing for gonorrhea and chlamydia is encouraged. Objective signs of urethritis should be present before initiation of antimicrobial therapy.

Effective regimens have not been identified for treating patients who do not have objective signs of urethritis but who have persistent symptoms after treatment.