A Randomized, Comparative Pilot Study of Azithromycin Versus
Benzathine Penicillin G for Treatment of Early Syphilis
EDWARD W. HOOK, III, MD,* DAVID H. MARTIN, MD, JOAN STEPHENS, RN, BARBARA S. SMITH, RNP, AND KIM
SMITH, MT (ASCP)*
Background: Penicillin is the only medication currently rec-
ommended for treatment of early syphilis in non-penicillin-
allergic patients. Preliminary data suggest that azithromycin
may be effective for syphilis therapy.
Study Design: This was a randomized, comparative pilot
study of intramuscular injections of benzathine penicillin G
and two oral azithromycin regimens for treatment of syphilis.
Methods: We randomly assigned patients with early syphilis
to treatment with either intramuscular injections of 2.4
million units of benzathine penicillin G or azithromycin
administered orally, either as a single 2.0-g dose or as two 2.0-
g doses given 1 week apart. Serological response to therapy
was evaluated at 3, 6, 9, and 12 months following therapy.
Participants whose rapid plasma reagin (RPR) test became
nonreactive or whose RPR titer decreased >2 dilutions were
classified as responding to therapy. When serological tests did
not show a response to therapy, the treatment was classified
as a failure if RPR titers increased >2 dilutions.
Nonresponders were those whose se-rologic titers remained
within 1 dilution of the initial RPR titer.
Results: Cumulative response rates were as follows: benza-
thine penicillin G, 86% (12 of 14); azithromycin, 2.0-g single
dose, 94% (16 of 17); and azithromycin, two 2.0-g doses given
1 week apart, 83% (24 of 29). Therapy failed for one patient
treated with benzathine penicillin and one patient treated
with
The authors thank Dr. Michael St. Louis and Mr. Jack Spencer of the
Centers for Disease Control and Prevention for their support and advice
in the initiation of the study; clinicians and disease intervention specialists
at the Jefferson County and New Orleans Health Departments for referral
of study participants; Laura H. Bachmann, MD, MPH, David Brown,
PHD, Charity M. Richey, MPH, and Marga Jones, MSHI, for data
management and statistical support; Dr. Raymond Johnson of Pfizer
Global Research and Development for assistance in obtaining
medications and review of the manuscript; Jane R. Schwebke, MD, for
advice in manuscript preparation; and Carol Laningham and Sharron
Hagy for assistance in manuscript preparation.
Supported by the Centers for Disease Control and Prevention through
grants to the Alabama and Louisiana State Health Departments and by
donations of medication by Pfizer, Inc., and Ortho-McNeil Pharmaceuti-
cals. Drs. Hook and Martin have each received research grant support and
honoraria from Pfizer.
Reprint requests: Edward W. Hook, III, MD, The University of Alabama
at Birmingham, 703 19th Street South, 242 Zeigler Research Building,
Birmingham, AL 35294-0007. E-mail: ehook@uab.edu
Received for publication August 28, 2001, revised November 16, 2001,
and accepted November 20, 2001.
From *The University of Alabama at Birmingham School of
Medicine and Jefferson County Department of Health,
Birmingham, Alabama; the Louisiana State University
Health Sciences Center, New Orleans; and Delgado
Clinic, New Orleans Health Department, New Orleans,
Louisiana
the two-dose azithromycin regimen, whereas in six patients
the clinical manifestations of infection resolved but there was
no serological response.
Conclusion: Oral therapy with 2.0 g of azithromycin as a
single dose or as two doses 1 week apart is a promising
alternative to therapy with benzathine penicillin G for
syphilis and should be studied further.
DESPITE A MORE THAN 80% DECREASE in cases
since 1990,1 in the United States early (primary, secondary,
and early latent) syphilis continues to be among the top 10
reportable infectious diseases and is more common than in
most other developed nations. In October 1999, the
Centers for Disease Control and Prevention (Atlanta, GA)
an-nounced a campaign to eliminate syphilis transmission
in the United States by the year 2005.2,3 Key elements of
this campaign include enhanced disease surveillance,
efforts to strengthen partnerships with involved
communities, rapid interventional responses to new and
continuing outbreaks, health promotion, and expanded
clinical and laboratory services.
New, easy to use, effective therapeutic agents could also assist
in syphilis control efforts. At present, only intramus-cular
injections of benzathine penicillin G or (for patients who are
allergic to penicillin) a 14-day course of oral doxycycline or
tetracycline is recommended for treatment of early syphilis. 4,5 used for the nearly 10% of patients who report penicillin
The recommended penicillin regimen has the advantage of allergy.6,7 For penicillin-aller-gic patients the doxycycline and
being single-dose therapy, but it re-quires injection of a tetracycline regimens may be less effective than penicillin,
relatively large volume (4 ml) of medication and may not be create concerns about com-

486
Vol. 29 No. 8 AZITHROMYCIN FOR SYPHILIS 487
pliance with the medication, and are not recommended for
treatment of pregnant patients.
Azithromycin is an azalide antimicrobial agent with a long
(68-hour) half-life that has been used as oral single-dose
therapy for sexually transmitted diseases (STDs) in-cluding
chlamydial infections,8 nongonococcal urethritis,9
chancroid,10 and gonorrhea.11 The drug has been shown to
be effective in multiple doses for treatment of experimental
syphilis in rabbits12 and in a small number of patients with
early syphilis.13 In addition, a pilot study suggests that a
single 1.0 g oral dose may be effective for syphilis preven-
tion in persons recently exposed to infected sex partners
(incubating syphilis).14
To begin to address the continuing need for alternatives to
currently recommended therapy, we performed a pilot study
evaluating 2.0 g of azithromycin, administered orally as
either a single dose or as two doses one week apart for
treatment of patients with early syphilis.
Methods
Patients with early syphilis at STD clinics in Birming-ham,
Alabama, and New Orleans, Louisiana, were referred to the
investigators for evaluation and possible enrollment in the
study. They were eligible for study participation if they had
early (primary, secondary, or early latent) syphilis.
For this study, primary syphilis was defined on the basis of
positive dark-field microscopy for Treponema pallidum on
lesion exudate. Secondary syphilis was defined as a
clinically typical or dark-field-positive cutaneous eruption
and rapid plasma reagin (RPR) titer 1:8, and a reactive
microhemagglutination T pallidum (MHA-TP)test or fluo-
rescent treponemal antibodyabsorption (FTA-ABS) test.
Early latent syphilis was defined as a reactive RPR test, a
reactive MHA-TP or FTA-ABS test, and either a clear
history of clinical manifestations typical of primary or sec-
ondary syphilis within the past year, health department
documentation of exposure to a known case of primary or
secondary syphilis diagnosed within the past year, or a
negative syphilis serological test within the past year.4 Ad-
ditional enrollment criteria included age of 18 years and
willingness to return for study-related follow-up visits for 1
year.
Exclusion criteria for the study were pregnancy; breast-
feeding; allergy to -lactam or macrolide antibiotics; his-tory of
intravenous drug abuse; history of use of antibiotics active
against T pallidum or use of an investigational drug in the 30
days preceding enrollment (use of quinolone, sulfon-amide,
trimethoprim, metronidazole, and spectinomycin an-tibiotics
was allowed); known or suspected coexistent STDs requiring
treatment with drugs effective against T pallidum; advanced
HIV infection manifested by a history of oppor-tunistic
infection; known severe liver or renal disease; and
unreliability (as considered likely by the investigators) for
participating in the study procedures and prompt follow-up.
This study was reviewed and approved by the institu-tional
review boards of the University of Alabama at Bir-
mingham and Louisiana State University.
Treatment and Follow-Up
Following provision of written informed consent, partic-
ipants were randomly allocated by means of a computer-
generated randomization code to receive one of three treat-
ment regimens: azithromycin, 2.0 g administered as a
single oral dose; two 2.0-g oral doses of azithromycin,
adminis-tered 6 to 8 days apart; or benzathine penicillin G,
admin-istered as either 2.4 million units intramuscularly
once in Birmingham or twice, 7 days apart, in New Orleans
(the latter was the standard treatment for early syphilis in
the New Orleans Health Department STD clinics at the
time of this study).
Participants were seen at 7 and 14 days after initiation of
treatment and then 1, 3, 6, 9, and 12 months after initiation
of therapy. At each visit patients provided an interval his-
tory of sexual exposure, were clinically evaluated for per-
sistent or recurrent syphilis, and had a serum specimen
obtained for syphilis serological testing. Consenting pa-
tients who were initially HIV-seronegative were retested for
HIV at 6 and 12 months. Urine pregnancy tests were per-
formed for all women at the initial visit.
After therapy, individual participants underwent locally
performed serological testing for syphilis, which provided
results soon after each visit. For study-related evaluation of
therapeutic response, sera were stored frozen and shipped to
Birmingham, where all sera for each patient were tested at the
same time by a technician masked to all clinical data in order
to minimize any potential effect of day-to-day varia-tion in
serological test performance. Participants received payment at
the time of each study visit to reimburse them for their efforts
related to study participation.
Analysis
For evaluation of response to therapy, aliquots of sera were
stored, and all serum specimens obtained from each patient
over the duration of the study were tested at a single time
using RPR (Macro-Vue; Becton Dickinson, Cock-eysville,
MD) and FTA-ABS tests according to standard
procedures.15 The highest titer measured on day 0, 7, or 14
was used as the baseline titer for evaluation of response to
therapy. Response to therapy was determined with use of
RPR titer data from the visits in month 3, 6, 9, and 12.
Therapeutic response was defined as follows. Cure was
resolution of all signs and symptoms of syphilis, including
all suspicious lesions present at baseline, and either a neg-
ative RPR titer or a 4-fold decrease in RPR titer. Clinical
response/serological nonresponse (serofast status) was res-
488
HOOK ET AL

Sexually Transmitted Diseases August 2002

TABLE 1. Characteristics of the Patients at Enrollment

Benzathine Penicillin G
Azithromycin 2.0 g
Azithromycin 4.0 g
Characteristic
(n 21)
(n 21)
(n 32)

Median age (Range), years

29
(1846)
33
(1856)
28
(1849)
Male, no. (%)
12
(57)
13
(62)
16
(50)
Race, no. (%)

Black
21
(100)
18
(86)
30
(94)
White

3
(14)
2
(6)
Stage of syphilis, no. (%)

Primary
11
(52)
8
(38)
11
(34)
Secondary
6
(29)
9
(43)
9
(28)
Early latent
4
(19)
4
(19)
12
(38)

values were cal-culated for these analyses. For all

olution of signs and symptoms of syphilis present at base-
line and either no change in RPR titer or a twofold (one-
dilution) decrease or increase in RPR titer. Failure was the
appearance of new diagnostic (i.e., dark-field-positive) le-
sions or a greater than fourfold (two-dilution) increase in
RPR titer, without a definite history of interval exposure to
an infected sexual partner.
Data were analyzed using SAS (version 8; SAS Institute,
Cary, NC), and dichotomous variables were compared
using Fisher exact test. For evaluation of differences in the
dis-tribution of baseline characteristics or side effects
between groups, P values were computed as two-tailed. For
evalua-tion of response to therapy, participants in each
treatment group were dichotomously classified as
response/nonre-sponse, and relative risks and 95% CIs
were reported as measures of association, with evaluation
of the difference between treatment regimens. One-sided P
calculations, P values 0.05 were considered significant.
Results
From October 1995 through December 1997, 74 patients
with early syphilis were enrolled in the study (Table 1). The
average age of participants was 30 years (range, 18 56).
Forty-one participants (55%) were male and 69 (93%) were
black. At enrollment, 30 patients (41%) had primary syph-
ilis, 24 (32%) had secondary-stage syphilis, and 20 (27%)
had early latent syphilis. Seventy-three (97%) of 74 partic-
ipants had reactive RPR and FTA-ABS tests; a single pa-
tient whose RPR/FTA-ABS tests were nonreactive and who
was positive for primary syphilis by dark-field microscopy
was enrolled. There were no significant differences among
the patients in each of the three treatment groups in terms
of age, sex, race/ethnicity, and stage of syphilis. Only three
study participants (4%) were HIV-seropositive, two of
whom received benzathine penicillin G therapy and one of
whom received two 2.0-g doses of azithromycin 1 week
apart.
Sixty patients (81%) were followed up for 3 months and
could be evaluated for response to therapy (benzathine
penicillin, 14; azithromycin, single dose, 17; azithromycin,
two doses, 29). Seven (33%) of 21 patients treated with
benzathine penicillin were nonevaluable because they did
not return for follow-up (4 patients) or because of intercur-
rent use of antibiotics between the time of enrollment and
the 3-month follow-up visit (3 patients). Seven (13%) of 53
patients treated with one of the azithromycin regimens were
withdrawn from the study before the 3-month follow-up
visit: 4 (19%) of 21 in the single-dose azithromycin group
and 3 (9%) of 32 in the two-dose azithromycin group. Of
these seven azithromycin recipients who were dropped be-
fore the 3-month follow-up visit, six were dropped because
of failure to keep scheduled follow-up appointments and
one was dropped because the tentative diagnosis of early
latent syphilis at enrollment could not be verified.
In general, both therapeutic agents were well tolerated.
JarischHerxheimer reactions were reported by five (24%)
of the penicillin-treated participants and nine (17%) of the
azithromycin-treated participants (P 0.52). Gastrointesti-nal
adverse events were more common in the azithromycin
treatment groups. Among participants who returned for at
least one follow-up visit, 1 vomited about 45 minutes after
his single-dose treatment with azithromycin (this patient
remained in the study and was followed for 3 months after
therapy, responding with a 5-dilution decrease in RPR
titer), and nausea was reported by 7 (13%) of 52 patients
who returned for 1- or 2-week follow-up visits; self-limited
diarrhea was reported by 5 (10%) of these 52 patients. In
contrast, only 1 (5%) of 19 participants who were treated
with penicillin and returned for 1- or 2-week follow-up
visits reported a gastrointestinal adverse event (nausea).
Although patients receiving azithromycin were nearly five
times more likely than penicillin recipients to report gastro-
intestinal side effects, the differences were not significant
(relative risk [RR] 4.75; 95% CI, 0.6733.9; P 0.09). In all
instances, these adverse events were classified by
participants as mild to moderate in severity.
All patients with clinical manifestations of syphilis such as
chancres, rashes, or condylomata lata demonstrated clear
improvement of lesions at the first follow-up visit, 1 week
after therapy. No participant experienced the onset of new
Vol. 29 No. 8 AZITHROMYCIN FOR SYPHILIS 489
TABLE 2. Serological Response to Therapy at 3, 6, 9, and 12 Months Following Therapy With Benzathine Penicillin G or Azithromycin

Percentage (proportion) with 2-Dilution Decrease in RPR Titer, per Interval Since Initiation of

Treatment*

Treatment Drug
3 mo
6 mo
9 mo
12 mo

Benzathine penicillin G
86 (12/14)
83 (10/12)
100
(9/9)
100
(10/10)
Azithromycin, 2.0 g
88 (15/17)
94 (16/17)
100
(14/14)
100
(14/14)
Azithromycin, 4.0 g
71 (20/28)
76 (20/26)
79
(19/24)
86
(19/22)
*Some participants did not return for all follow-up visits or had follow-up visits that occurred outside the defined time window.
or recurrent syphilitic lesions or rashes after therapy. No
seroconversions to HIV-1 were noted.
The proportion of patients with serological response to
therapy was similar in all three treatment groups. Serolog-
ical response rates for evaluable participants at each speci-
fied follow-up visit are shown in Table 2. When overall
response rates for the three groups were tabulated, using
the last evaluable date to define response, serological
responses were also similar; the majority of patients who
did not respond to therapy were classified in the clinical
response/ serological nonresponse category. Thus, using the
last evaluable clinic visits, the overall response rate among
benzathine penicillintreated patients was 86% (12 of 14).
One patient dropped from the study after 3 months of
follow-up had not achieved a serological response at the
time he was dropped, and another patient had a two-
dilution increase in RPR titer at the 6-month follow-up visit
and was classified as a treatment failure.
Of the participants treated with azithromycin (2.0 g) on a
single occasion, 94% (16 of 17) were found to have
attained a serological response to therapy at the time of
their last follow-up, a rate not significantly different from
the cure rate for the benzathine penicillin treatment group
(RR 0.97; 95% CI, 0.74 1.27; P 0.75). One participant
evalu-able through 6 months of therapy did not have a
serological response to therapy. Among participants treated
with two 2.0-g doses of azithromycin separated by a 1-
week interval, 83% (24 of 29) had serologically responded
to therapy at the time of their last study follow-up visit (RR
for cumulative cure rate in comparison with that for
benzathine penicillin: 0.88; 95% CI, 0.721.08; P 0.95).
Of the five participants who did not respond serologically to
treatment, four (whose last study visits were in months 3, 6,
and 12 [two patients] after initiation of therapy) were
classified in the serological nonresponse category, and the fifth
was classified in the treatment failure category on the basis of
a two-dilution increase in the RPR titer. Both patients
classified as treatment failures were retreated with benzathine
penicillin G when the serological treatment failure was noted.
Discussion
Penicillin has been the therapy of choice for syphilis since
its introduction, and for 30 years the administration
of long-acting benzathine penicillin has been the preferred
therapy for early syphilis.5 Single administrations of benza-
thine penicillin G overcome potential problems related to
poor adherence with multiple-dose therapy. In addition, the
drug is readily affordable, and it can be utilized for treat-
ment of pregnant women. The discomfort associated with
the relatively large-volume, deep intramuscular injection
and the relatively high prevalence of self-reported
penicillin allergy6,7 may compromise its use in some
settings. The tetracycline and doxycycline regimens
recommended for penicillin-allergic patients are somewhat
less effective.4 There is no recommended alternative to
penicillin for treat-ment of syphilis in pregnant women.4
This pilot study suggests that single-dose oral treatment with
2.0 g of azithromycin may be as effective as benzathine
penicillin injections for treatment of early syphilis. In rela-
tively few patients, the outcome of treatment with a single 2.0-
g dose of azithromycin or two 2.0-g doses given 1 week apart
was not significantly different from the outcome of treatment
with benzathine penicillin G in a comparable group of
patients. In addition, the serological responses seen in this
study were similar to those in a large multicenter syphilis
treatment trial in which the same dose of benzathine penicillin
was used.16 Furthermore, there was no significant difference in
response rates between patients treated with single doses of
azithromycin and those who received two doses of medication
a week apart.
Our treatment results are also consistent with those in
previous animal studies,12 in a small study of multiple-dose
azithromycin therapy for early syphilis,13 and in a small
randomized trial of azithromycin versus benzathine penicil-
lin for prevention of syphilis in exposed patients.14 Taken in
combination, these results suggest that further evaluation of
single doses of azithromycin for syphilis treatment is
warranted.
In this study azithromycin therapy was also relatively well
tolerated: although 13% of participants noted nausea and
10% reported loose bowel movements following ther-apy,
these difficulties were classified by patients as mild to
moderate in severity. Furthermore, none of the 32 partici-
pants randomized to receive two 2.0-g doses of azithromy-
cin was hesitant to take the second dose of medication
because of previously experienced side effects. Given an-
490 HOOK ET AL Sexually Transmitted Diseases August 2002
ecdotal reports that the gastrointestinal side effects associ-ated
with azithromycin vary with the formulation of drug ingested
(i.e., greater side effects with the sachet formula-tion than with
capsules, which in turn are less-well-tolerated than the
currently available tablet formulation), both the rate of
gastrointestinal side effects and formulation of drug utilized
should be further evaluated in future studies.
Although our results are encouraging, a number of limi-
tations of this pilot study should be acknowledged and
considered in future studies. In a study utilizing a rabbit
model of early syphilis,12 similar cure rates were noted for
penicillin- and azithromycin-treated rabbits, but experimen-
tal syphilitic chancres resolved somewhat more slowly in
the azithromycin-treated rabbits. Lesion-resolution rates
were only subjectively evaluated in this study and appeared
comparable. Nonetheless, careful measurement of lesion
resolution should be included in future studies. In addition,
although syphilis is associated with increased HIV sero-
prevalence in the United States, only 3 (4%) of 74 partici-
pants in this trial were known to be HIV-coinfected. Thus,
further evaluation of azithromycin for treatment of syphilis
in patients with HIV infection is also warranted.
It might also be argued that the patients receiving treat-
ment with the different benzathine penicillin regimens used
in Birmingham and New Orleans during the time the study
was conducted should be considered two comparison
groups rather than one. Because no significant differences
in penicillin response rates were noted between the two
cities (data not shown), we chose to combine the results to
in-crease the size of the comparison group.
Finally, definition of cure is difficult in any study of the
treatment of syphilis in humans because of imprecise mon-
itoring of serological response to therapy. Overall, 40
(87%) of the 46 patients in this trial treated with
azithromycin had a two-dilution decrease in the syphilis
serological test (RPR) titer, the level utilized by the CDC to
define thera-peutic response.4 This response rate is
comparable to that noted by Rolfs et al.16 in the only large
evaluation of benzathine penicillin as therapy for syphilis
in the past 30 years.
That approximately 15% of treated patients do not have
meaningful changes in serological test titers for up to 1 year
after treatment is troublesome to clinicians. In addition, this
relatively high nonresponse rate suggests the need for larger
sample sizes in studies designed to have sufficient power to
demonstrate that therapeutic regimens are comparable. Al-
though rising serological test titers likely indicate treatment
failure, the clinical significance of serological test titers that
neither rise nor fall but remain unchanged is unclear and is
worthy of further study.
In summary, in this pilot study the response to treatment of
early syphilis with azithromycin, 2.0 g, given by mouth as
either a single dose or two doses 1 week apart, appeared
similar to response rates with recommended doses of ben-
zathine penicillin G. If its efficacy is verified by further
study, azithromycin may be the first new agent effective for
single-dose treatment of syphilis in 30 years. As such, it has
the potential to contribute to the ongoing efforts to
eliminate endemic syphilis within the United States.
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