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According to The American Society for Reproductive Medicine (ASRM) some new data on the use of assisted reproductive technology (ART) in the USA have highlighted the importance of maternal age in determining success. The Centre for Disease Control and Prevention published its latest annual ART success rate report, using data for the newest data provided by 391 reporting fertility clinics. The newest data, 37 percent of ART procedures in women younger than 35 years led to live births. The report also shows that the number of ART procedures performed, and the number of live-birth deliveries, continue to increase year on year.
The revised guidelines present two major changes to existing guidelines: (A) there are now just 2 categories of pneumonia instead of 3 (a€?pneumoniaa€? which is treated at home with oral amoxicillin and a€?severe pneumoniaa€? which requires injectable antibiotics) and (B) oral amoxicillin replaces oral cotrimoxazole as first line treatment, preferably in 250mg dispersible tablet form, twice daily for five days which can be reduced to three days in low HIV settings.
The effect of early diagnosis and treatment on maternal and fetal outcomes in patients with HELLP syndrome? Background: HELLP syndrome, a severe form of preeclampsia clinically characterized by hemolysis, elevated liver enzymes, and low platelet count, was first described in 1982. Materials and Methods: To assess the impact of recognition of this syndrome on fetal and maternal outcomes, we conducted a retrospective study and reviewed the records of patients with preeclampsia treated at Mayo Clinic before and after 1982. Results: We did not observe a statistically significant difference in maternal demographics or diagnostic laboratory findings. Conclusions: These observations suggest that recognition of HELLP as a distinct clinical syndrome has led to improved outcomes of pregnancies, probably due to more timely diagnosis and earlier termination of pregnancy.
Studies of maternal outcomes in pregnancies complicated by HELLP syndrome have demonstrated increased risks for disseminated intravascular coagulation, placental abruption, acute renal failure, pulmonary edema, subcapsular liver hematoma, and retinal detachment (7,8).
The objectives of this study were i) to study the natural course of HELLP syndrome in patients who were treated for preeclampsia prior to 1982, before its recognition as a distinct syndrome, and who, in retrospect, met the diagnostic criteria, and ii) to study whether an increased awareness of HELLP syndrome after 1986 resulted in more timely diagnosis, earlier treatment, and hence improved maternal and fetal outcomes. The protocol was approved by the Institutional Review Board and all subjects had consented to the use of their records for research.
Based on the same set of criteria, the diagnosis of HELLP was verified in a randomly selected group of 24 women treated for HELLP syndrome between the years 1986-1994. The following data were collected: maternal age, gestational age, mode of delivery, maternal mortality, intrauterine fetal death, maternal complications (pulmonary edema, pleural effusion, pericardial effusion, intracerebral hemorrhage, seizures, abruptio placentae, hepatic rupture, and retinal detachment), time from diagnosis to delivery, seizure prophylaxis with MgSO4, and laboratory results. Descriptive statistics are reported for quantitative traits as medians and interquartile ranges, and for categorical traits as percentages. Prior to 1982, significantly more women with HELLP syndrome developed renal failure (63.6% vs. In addition to renal failure, we also calculated a “complication score” that was the sum of all other complications recorded in the medical record. Our study provides evidence that the definition of HELLP as a distinct clinical syndrome has led to improved outcomes of pregnancy, likely due to a more timely diagnosis, leading to an earlier termination of pregnancy.
Similar to previous studies (8), we report that women with HELLP syndrome are at risk for complications, such as pulmonary edema, pleural effusion, pericardial effusion, retinal detachment, hepatic necrosis, intracerebral bleeding and seizures, with women treated prior to 1982 being at a higher risk for these complications compared to those treated after 1982.
Despite a proactive approach and immediate delivery, women treated after 1982 still experienced significant complications, although at much lower rates than those treated more conservatively before 1982.
Some authors have suggested intravenous dexamethasone as treatment to raise platelet counts and improve liver function test abnormalities (17). The natural history of HELLP syndrome with respect to laboratory abnormalities during the peripartum period was studied by Martin et al. The reasons why some women with preeclampsia develop HELLP, while others do not, remain poorly understood (20).
In summary, we conclude that the recognition of HELLP syndrome as a deceptive and severe form of preeclampsia in 1982 has since resulted in improved maternal and fetal outcomes, mainly due to the widely accepted practice of immediate delivery. After giving birth, a mother suffering from postpartum hemorrhage (PPH) can die within two hours if she doesn’t receive proper treatment. To better address postpartum hemorrhage, the program incorporates several elements of prevention, early detection, treatment and community-awareness building, including the use of the non-pneumatic anti-shock garment (NASG) to resuscitate and stabilize women already in shock and facing death until comprehensive care for PPH can be obtained. Use of the non-pneumatic anti-shock garment was previously unknown in Burundi, so its introduction was not easy. The national referral hospital served as a starting point for rolling out training of service providers throughout Burundi. In the district hospital of Kayanza, one of the health facilities supported by the program, hospital staff had often complained of delays in pregnant women reaching the hospital when experiencing obstetric complications and shock due to post-partum hemorrhage.
The NASG has dramatically shown its importance as a lifesaving element in the approach to address PPH.Mrs.
Pathfinder International works to improve the sexual and reproductive health of women, men and young people in developing countries. This report shows a decline with increasing maternal age in the proportion of fresh, non-donor procedures leading to live births. This proportion fell to 31 percent among women aged 35-37 years, 21 percent among women aged 38-40 years, 11 percent among women aged 41-42 years, and 4 percent among women older than 42 years. It is caused by a mistaken immune response to the nicotinic acetylcholine receptors (AChR), which are found in junctions between muscles and the nervous system. We made a retrospective diagnosis of HELLP in 11 of 146 patients treated for preeclampsia prior to 1982. It affects approximately 5% of pregnancies and remains a leading cause of both maternal and fetal morbidity and mortality worldwide (1).
Consequently, the presence of HELLP syndrome since its initial description has been considered a major indication for immediate delivery.
Relevant clinical data were abstracted from the records of patients with preeclampsia treated at Mayo Clinic before and after 1982. The year 1986 was chosen as the lower range for the control group to allow several years for HELLP to become a universally recognized syndrome requiring urgent attention. Acute renal failure was defined as an increase in serum creatinine of 1.5 times, or a decrease in the glomerular filtration rate by more than 25%, compared to baseline (10). Statistical procedures included the Wilcoxon rank sum test for continuous variables, Fisher’s exact test for categorical variables, exact inference for ordered contingency tables, and the Kaplan-Meier method was utilized for time to event analysis.
In that group, 8 of 11 infants (73%) were either stillborn (N = 7), or died hours after birth (N = 1).
Complications included in this score are pulmonary edema, pleural effusion, pericardial effusion, retinal detachment, hepatic necrosis, intracerebral bleeding, and seizure. Most importantly, there was a significant decrease in the length of time between presentation and either live birth or delivery of a stillborn infant (14 days pre-1982 vs. Comparisons of practice differences (time to and mode of delivery, magnesium sulfate prophylaxis) between the two groups. In addition, women treated prior to 1982 had more serious renal involvement, both with respect to the incidence and severity of acute renal failure. These results extend previous reports of adverse maternal-perinatal outcomes in women with HELLP syndrome (3,13-16), and emphasize the need for further research in this field that may result in more effective diagnostic and treatment strategies.
Conceivably, for patients before 1982, laboratory parameters that facilitated the retrospective diagnosis of HELLP might have been available only for those who were very ill, thus preselecting for particularly bad pregnancy outcomes, and resulting in the high perinatal mortality that we report (73%).
This approach has resulted in a modest delay in delivery (c25 hours) and is not widely accepted. However, recent research has indicated that women with HELLP syndrome demonstrate elevated levels of a soluble transforming growth factor ? co-receptor, endoglin, (21) that may act in concert with soluble fms-like tyrosine kinase 1 (sFlt-1), which has been shown previously to be elevated in sera of patients with preeclampsia (22).
As it is manifested as a combination of laboratory abnormalities, including hemolysis, abnormal liver tests, and thrombocytopenia, the role of laboratory professionals in the diagnosis, serial monitoring, and therapy of these patients increasingly is recognized (9). Report of the National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy. Syndrome of hemolysis, elevated liver enzymes, and low platelet count: a severe consequence of hypertension in pregnancy. Maternal-perinatal outcome associated with the syndrome of hemolysis, elevated liver enzymes, and low platelets in severe preeclampsia-eclampsia.
The HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets): much ado about nothing? Maternal morbidity and mortality in 442 pregnancies with hemolysis, elevated liver enzymes, and low platelets (HELLP syndrome). Acute renal failure - definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Pregnancy complicated by preeclampsia-eclampsia with the syndrome of hemolysis, elevated liver enzymes, and low platelet count: how rapid is postpartum recovery?
Maternal deaths associated with hypertensive disorders of pregnancy: a population-based study. Risk factors for post-partum complications occurring after preeclampsia and HELLP syndrome. Antepartum corticosteroids: disease stabilization in patients with the syndrome of hemolysis, elevated liver enzymes, and low platelets (HELLP).

Clinical utility of strict diagnostic criteria for the HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome. In total, 23 health facilities (20 health centers and 3 district hospitals) benefited from training and 30 non-pneumatic anti-shock garments were provided. Government officials appreciate the overall strategy and its complement to the reinforcement of other aspects of emergency obstetric care and major causes of maternal death.
The body produces antibodies that attack these AChR receptors, preventing signals from reaching the muscles. However, understanding has been advanced by recent scientific reports such as those which delineate the complete sequence of the genome of the syphilis spirochaete, provide a more precise description of fetal and neonate infection by use of rabbit infectivity tests and describe the gestational age distribution of fetal death secondary to syphilis.
We compared pregnancy outcomes to a randomly selected group of 24 women with HELLP syndrome treated at Mayo Clinic between 1986 and 1994. The incidence and severity of acute renal failure and other cumulative maternal complications (including pulmonary edema, pleural effusion, pericardial effusion, intracerebral hemorrhage, seizure, hepatic necrosis, and retinal detachment) were significantly higher prior to 1982.
The etiology and pathogenesis of this disorder remain elusive, resulting in a failure to develop specific preventive and treatment options.
In contrast, women prior to 1982 were delivered a median of 14 days after conservative management.
The most striking difference was observed with respect to fetal outcomes: the majority of pregnancies (73%) before 1982 ended with either intrauterine fetal death or infant loss, while only one intrauterine fetal death was recorded after 1982.
However, this percentage is not significantly different from the upper range of perinatal mortality that has been reported as high as 60%, even since the recognition of HELLP in 1982 (4). In contrast to preeclampsia, which typically occurs during the first pregnancy, HELLP syndrome tends to occur in multiparous women. They reported that the platelet count tends to decrease 24-48 hours after delivery, while LD activity typically peaks during the same time period.
In cases of partial HELLP, when one or two, but not all three features of HELLP are present, the rate of severe complications does not appear to be as high as in cases where all criteria of HELLP are met. A cry for laboratory assistance: a comprehensive review of the HELLP syndrome highlighting the role of the laboratory. Lea was pleased to present the happy results of this woman’s experience and survival. It appears that fetal syphilitic involvement progresses in a rather predictable fashion, and although there is disagreement about the optimal prenatal treatment regimen, programmatic efforts to prevent fetal death must provide seropositive pregnant women with a recommended treatment early in pregnancy, and certainly before the third trimester. The clinical spectrum of this disease covers a wide range of presentations, from mild forms of hypertension and proteinuria, to severe forms such as eclampsia, the convulsive form, and HELLP syndrome. Perinatal mortality included deaths occurring during late pregnancy (at 22 completed weeks of gestation and over), during childbirth, and up to seven completed days of life. In addition, maternal demographics and diagnostic laboratory values were similar between the groups (Table 1). After 1982, there was a marginally significant trend towards more women being delivered by induction or Caesarian section versus spontaneous delivery (P = 0.08). In addition, our study suggests that prior to 1982, pregnancies in women who presented with laboratory abnormalities that, in retrospect, were diagnostic of HELLP syndrome, were associated with significant maternal morbidity, mortality, and perinatal death rate. More aggressive treatment after 1982 is evidenced further by a trend towards more pregnancies being promptly delivered either by labor induction or Cesarean section. In patients without complications, an upward trend in platelet count and downward trend in LD activity by the fourth post partum day signal recovery.
Therefore, appropriate and timely testing is not only important for the initial diagnosis, but also in determining overall prognosis. However, to date, urine and serum measurements of these factors have not provided clinically reliable screening tools with current techniques.
14 days), and patients were more likely to receive seizure prophylaxis with magnesium sulfate. The acronym HELLP (for Hemolysis, Elevated Liver enzymes, and Low Platelet count) was coined in 1982 (2), and refers to the specific laboratory abnormalities that are characteristic of this form of preeclampsia.
There was no difference in the maternal death rate between groups, with 1 of 11 mothers dying prior to 1982 and 1 of 24 dying after 1986 (P = 0.5), (Table 2).
More women were treated with magnesium therapy for seizure prophylaxis as well, although this may reflect practice changes over time independent of the recognition of HELLP as a syndrome (Table 4). Finally, more women after 1982 were treated with magnesium sulfate, based on the evidence that supported the use of magnesium sulfate for seizure prophylaxis (12).
It is likely a reflection of not only timely diagnosis and treatment of HELLP, but also the availability of advanced perinatal care in a tertiary care center. In up to 30% of patients, symptoms and signs of HELLP develop only in the postpartum period (4).
Therefore, serial measurements of LD activity and platelet count are the two best markers of the course of the disease. Babies who survive often have arthrogryposis multiplex congenita (nonprogressive congenital contractures) due to lack of fetal muscle movement before birth. There was a trend towards more Caesarian sections and labor induction in women treated after 1982.
It is noteworthy that hemolysis and low platelet count have been recognized as complications of severe hypertensive disease in pregnancy for more than 100 years.
As the diagnosis of HELLP is largely based on laboratory abnormalities, our study underscores the role of timely laboratory testing and the expertise of laboratory professionals in the diagnosis and subsequent monitoring of these patients.
Despite these limitations, our data clearly indicate improved maternal and fetal outcomes after 1982, when the clinical recognition of HELLP syndrome usually led to immediate delivery. Making a final diagnosis depends upon obtaining laboratory reports and looking for HELLP-defining characteristics by obtaining a complete blood count with peripheral smear, LD, AST and ALT. As a LD activity increase may reflect both hepatic damage and hemolysis, the analysis of LD isoenzymes may provide further information: the elevations of LD 1 and LD 2 reflect the severity of hemolysis, while liver damage contributes to elevations in LD 5. Once the diagnosis of HELLP is established, the course of the disease should be monitored by following hematocrit, platelet count, LD, AST and ALT activity every six hours. A rise in AST and ALT activity reflects liver damage and typically occurs before biliary obstruction develops, which is reflected by elevations in bilirubin and alkaline phosphatase. These problems are potentially preventable if the mother is effectively treated during pregnancy. In 70% of patients, HELLP syndrome develops antepartum, in the second or third trimester of pregnancy, and in up to 30% it develops postpartum.
The platelet count is important not only for diagnosis, but for assessing the severity of the disease as well (11). Additional tests that may help in diagnosis and monitoring of patients with HELLP syndrome include haptoglobin, magnesium, and glucose levels.
Of note, hepatic rupture, one of the most severe complications of the HELLP syndrome, typically occurs in patients with established thrombocytopenia and extremely elevated liver enzymes. In addition, all patients should undergo laboratory testing that is performed for patients with either suspected or confirmed preeclampsia, including urinalysis with either a random or 24-hour protein determination, urea, creatinine, and serum electrolytes. Finally, further testing of coagulation parameters such as fibrinogen, fibrin split products or D-dimer, and prothrombin and partial thromboplastin times, may facilitate the diagnosis of disseminated intravascular coagulation, a condition that occurs in 15-20% of HELLP pregnancies (8,19). However, several important new studies have furthered understanding and can help inform those involved in prevention. Some of the basic facts of congenital involvement A— such as Hutchinson's triad (1) and Kassowitz's observation in 1846 that the longer a woman has syphilis before pregnancy occurs, the less likely it is that her fetus will die in utero or be born with congenital syphilis (2) A— have been known for over 100 years. With the rapid expansion of biomedical technological capabilities, it might be expected that by now the mysteries of congenital syphilis would have been solved and the important questions answered. The diagnostic tools that are widely available remain rather primitive; there have been no important advances in the treatment of maternal syphilis in recent years, and the ability to monitor the efficacy of treatment in utero is suboptimal.
This should allow scientists in the near future to develop additional tools and insights concerning this organism and the conditions for which it is responsible. One of the principal problems confronting syphilis researchers is the inability to cultivate T. On this basis, Idsoe (9) suggested that effective treatment of early syphilis required maintenance of a minimal serum concentration for 7–10 days without interruption.
Since the early stage of syphilis is characterized by spirochaetaemia, the probability of transmission to the fetus is nearly 100% if the mother has early syphilis (10).
Following secondary syphilis, the probability of recurrence of spirochaetaemia diminishes over time; the probability of sexual transmission two years after acquisition of syphilis is low (5).
The main factors that determine the probability of fetal transmission are stage of maternal syphilis and duration of exposure in utero.
Therefore, in considering fetal transmission, the following are pertinent: if a woman with syphilis becomes pregnant, what is the stage of syphilis at conception?
As discussed below, these factors are also relevant with regard to manifestations of fetal involvement.

Early researchers believed that the Langhans' cell layer of the cytotrophoblast was an effective placental barrier; fetal involvement had not been identified at earlier stages of gestation (13). However, this theory had to be discounted once it was discovered that the Langhans' cell layer persisted throughout pregnancy (14).
Moreover, in 1974, Harter & Benirscheke examined fetal tissue from spontaneous abortions among women with syphilis. Some questions about early fetal infection remained because placental disruption, rather than actual transmission, could have been responsible for the presence of spirochaetes in the abortuses. However, definitive evidence demonstrating the ability of treponemes to cross the placenta early in pregnancy was recently provided by Nathan et al. They performed amniocenteses between 14 and 19 weeks (average 16.8 weeks) on 11 pregnant women who had untreated syphilis. Using rabbit infectivity testing, they identified living treponemes in the amniotic fluid of four of the 11 women tested. However, this study raised numerous questions that have not yet been answered; for example, how do the treponemes get into the amniotic fluid? Is it by direct passage through the placenta (perhaps permitting fetal infection by ingestion) or via the fetus? It is useful to review the manifestations of fetal involvement and to note that the microscopic appearance of syphilitic lesions is similar whether manifested in the fetus, adult or infant. Lesions are characterized by perivascular infiltration by lymphocytes, plasma cells and histiocytes, with endarteritis and extensive fibrosis (5). These typical lesions reflect an inflammatory response, and have suggested to some researchers an important role for cytokines in the pathophysiology of disease secondary to syphilis (17). The pathology suggests multi-organ involvement, with an extensive inflammatory response. The manifestations reflect, in part, the immunological maturity of the fetus A— an observation made by Silverstein 40 years ago (25). In general, it is not until the age of 22 weeks that the fetus is capable of consistently mounting an immune response to infection (5, 26). Levels of interleukins, interferons and of tumour necrosis factor are much lower in preterm infants than in those born at term A— an important finding given the central role that cytokines may play in the pathophysiology of congenital syphilis.
However, other components of the immune system A— such as T-cell function A— are also far from competent earlier in gestation (27). The authors confirmed infection in the fetuses of 16 of these women A— 14 women had fetuses with detectable T. The authors suggested that these findings indicate that abnormal liver function may represent an early manifestation of true infection, preceding liver enlargement. Placental enlargement became more likely as duration of maternal infection increased, followed by haematological abnormalities which also became more likely with longer duration of maternal infection. Antitreponemal IgM was detectable in only three fetuses, two of which had hepatomegaly with ascites A— suggesting an association with severity of infection.
Although in 1949 Platou suggested that 60% of infants with congenital syphilis had CSF involvement (29), it is only recently that conclusive evidence has become available. Among those infants who had not been exposed to antibiotics (n = 76), 22% had a positive result of the rabbit infectivity test on CSF. The evidence suggested that CSF involvement was more likely if maternal syphilis was categorized as secondary or early latent (29%) than with other classifications (11%). In addition, among those infants who were not exposed to antibiotics and who had conventional evidence of congenital syphilis, 41% had treponemes detected in their CSF, providing evidence for the prevalence of CSF involvement among infants with congenital syphilis.
Unfortunately, there are few data available from randomized clinical trials that directly compare the effectiveness of the various therapeutic regimens. The point was underlined in a recent review addressing the efficacy of penicillin for treating maternal syphilis; 26 studies met the criteria for detailed scrutiny but none met criteria that permitted comparison of treatment regimens and in none were treatments randomly allocated (35). This was an important observation, since other work had suggested that pregnant women with syphilis who receive more than two or three doses of benzathine penicillin have better pregnancy outcomes than women who receive only one such dose (39, 40). However, the women who received two or three doses generally presented to prenatal care and received treatment earlier in gestation than women who received only one injection, which could be an important source of bias (39). The authors demonstrated that screening and treatment for syphilis was at least as cost-effective as prevention of mother-to-child transmission of human immunodeficiency virus (HIV) (42).
Treatment of maternal syphilis may also be complicated by the Jarisch–Herxheimer reaction, an acute febrile reaction frequently accompanied by headache and myalgia that usually occurs within 24 hours after any therapy for syphilis. This can affect approximately 40% of pregnant women treated for syphilis and is associated with uterine contractions and variable decelerations in fetal heart rate, but usually resolves without incident (36). Women beyond 20 weeks of gestation should be evaluated if they experience fever, decreased fetal movement, or regular contractions within 24 hours of treament (36). It may be that improvements in outcome depend on the provision of treatment early in gestation, before significant fetal involvement has developed. Using surveillance case reports, the authors reviewed the mortality associated with congenital syphilis in the United States. From 1992 to 1998, there were 942 deaths among the 14 627 cases of congenital syphilis reported. Fifty-two per cent of the deaths occurred among infants at less than 30 weeks of gestation and few severely affected infants were delivered at term. Assuming that maternal treatment must be provided at least 28 days prior to delivery, the authors concluded that, to reduce perinatal mortality by 70%, all pregnant women with syphilis must be treated before 21 weeks of gestation. The application of the CDC guidelines, which do not offer any alternative to penicillin and advise desensitization, may be problematic in many settings where such care is not available. Although erythromycin has been recommended by some agencies (32), its effectiveness is questionable (46).
This is consistent with evidence that the transplacental passage of erythromycin is limited (47) and although there are no clinical outcome data evaluating the use of azithromycin during pregnancy, this antibiotic also has limited transplacental passage. Ceftriaxone has been suggested as an alternative treatment for syphilis in non-pregnant adults who are allergic to penicillin, and pharmacokinetic studies among pregnant women have indicated that serum levels of ceftriaxone can be treponemicidal; the levels in fetal serum and amniotic fluid may also be treponemicidal (36). Unfortunately there are few data describing the effectiveness of such treatment among pregnant women. Some authors have questioned the effectiveness of standard therapeutic regimens for syphilis among HIV-infected populations (48) and there have been anecdotal reports of treatment failure among co-infected pregnant women (41). However, no studies so far have demonstrated the superiority of alternative approaches for treatment of syphilis among patients with HIV co-infection (49); both the CDC and WHO (31, 32, 36) advise that syphilis treatment need not be changed because of HIV co-infection.
A better understanding of the processes involved may help to improve clinical management. However, current knowledge suggests that, regardless of the penicillin regimen used, efforts to prevent severe fetal involvement and death must focus on treating pregnant women with syphilis sufficiently early in pregnancy. Minimal infectious inoculum of Spirochaeta pallida (Nichols strain) and a consideration of its rate of multiplication in vivo. In: Holmes KK, Sparling PF, Mardh PA, Lemon SM, Stamm WE, Piot P, Wasserheit JN, editors. Dermal inflammation elicited by synthetic analogs of Treponema pallidum and Borrelia burgdorferi lipoproteins. Congenital syphilis in the newborn infant: clinical and pathological observations in recent cases. Daffos F, Forestier F, Grangeot-Keros L, Capella Pavlovsky M, Lebon P, Chartier M, et al.
Developmental immunology and role of host defenses in neonatal susceptibility to infection.
The effectiveness of antenatal syphilis screening and single-dose benzathine penicillin treatment for the prevention of adverse pregnancy outcomes. Apparent failure of one injection of benzathine penicillin G for syphilis during pregnancy in human immunodeficiency virus-seronegative African women.
Practical aspects of choosing an antibiotic for patients with a reported allergy to an antibiotic. The transplacental transfer of the macrolide antibiotics erythromycin, roxithromycin and azithromycin. A randomized trial of enhanced therapy for early syphilis in patients with and without human immunodeficiency virus infection.

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