325. Neurosyphilis Management in the Post-Procaine Penicillin Era

Abstract

BackgroundNeurosyphilis (NS) is an infection of the central nervous system caused by Treponema pallidum. Intramuscular (IM) penicillin (PCN) G procaine is a treatment option for those who cannot receive or decline intravenous (IV) therapy. Since August 24, 2016, it has been unavailable from the manufacturer, necessitating the use of IV PCN for NS. Our institutions organized a multidisciplinary, coordinated care system to expedite outpatient treatment of NS upon diagnosis. We report successful management of NS at an urban safety-net hospital in the post-procaine PCN era.MethodsWe identified patients with suspected NS from the King County Public Health STD and Harborview Infectious Disease clinics from October 2016 to February 2018. Demographics, clinical symptoms, diagnostics, treatment, and outcomes were collected by chart review. Successful NS treatment was defined as resolution of cerebrospinal fluid (CSF) pleocytosis or elevated protein, improvement in neurologic symptoms or appropriate decrease in serum rapid plasma reagin (RPR) or CSF Venereal Disease Research Laboratory (VDRL) titers.Table 1: Demographic and Socioeconomic CharacteristicsTotal = 43 n (%)GenderMale39 (91)RaceWhite29 (67)Black3 (7)Asian3 (7)Homeless5 (12)Insurance statusaPrivate15Medicaid20Medicare8Charity care11Substance use disorder15 (35)HIV Positive22 (51)Viral load suppressed (< 200 copies/mL)13 (59) aRepresents more than one payer per patient.ResultsWe identified 43 cases of suspected NS. The most common symptoms were blurred vision, headache, and tinnitus. All had a lumbar puncture (LP). Median days from LP to treatment initiation was 6—many starting on day of diagnosis. Fourteen patients (33%) required admission for treatment. Two patients declined therapy. IV PCN G was used in 93% of cases; one received IM ceftriaxone. Treatment was successful in 32 of 41 (78%) cases, with 23 of these (72%) managed as outpatients. Three cases were treatment failures for incomplete therapy adherence or equivocal response and uncertain diagnosis.ConclusionWithout available IM procaine PCN, neurosyphilis is challenging to manage in vulnerable populations or those wishing to avoid inpatient admission. Employing a multidisciplinary, coordinated care approach can lead to successful treatment of NS using IV PCN in the outpatient setting.Disclosures All authors: No reported disclosures.