When Systemic Therapy Is Delayed for Syphilitic Uveitis, Ceftazidime May Help

Intravitreal injections with the antibiotic ceftazidime can serve as an effective stop-gap therapy for syphilitic uveitis while patients await systemic therapy, a retrospective case series suggested.

From 2019-2024, 10 patients (14 eyes) were successfully treated with intravitreal ceftazidime as they awaited systemic penicillin therapy that was delayed, reported Akshay S. Thomas, MD, and Emily C. Davis, MPH, of Tennessee Retina in Nashville, in the American Journal of Ophthalmology.

“All patients had improvement in their ocular inflammation and almost complete disease control with local therapy,” Thomas told MedPage Today. “Eventually they got IV antibiotics and had complete resolution.” While there’s no substitute for IV penicillin therapy in the long run, the positive outcomes show that ceftazidime can tide patients over for short periods, he noted.

Syphilitic uveitis appears to be on the rise, with hospitalizations — which are commonly required for systemic treatment — increasing from nearly 400 admissions in 2010 to more than 700 in 2019, a cross-sectional study reported. Incidence rates per 100,000 population grew from 0.08 in 2011 to 0.23 in 2019.

It’s not uncommon for ophthalmologists to diagnose syphilitic uveitis, which is often the first sign that a patient has advanced syphilis, Thomas said, adding that it’s standard to test patients with uveitis for the disease, which means that a patient has neurosyphilis.

Penicillin is the preferred treatment. “If a patient has primary syphilis, you need a single shot and you’re done,” he explained. “If they have eye involvement — neurosyphilis — you need 10-14 days of IV antibiotics.”

But IV penicillin has been in short supply in recent years, and Thomas noted that there have been other obstacles to quick treatment with the drug.

Some patients are allergic to penicillin and may need to undergo desensitization. Others might delay IV treatment for personal reasons or due to lack of insurance. Furthermore, the COVID pandemic limited hospital access for IV therapy in some cases, he said.

According to the study, there’s been little research into penicillin alternatives. Thomas and Davis turned to ceftazidime, a commonly used intravitreal antibiotic. “We have easy access to it, and we know it’s safe in the eye,” he said. As for cost, Thomas said insurers have covered the treatment.

Ophthalmologist David Hinkle, MD, a retina and uveitis specialist at Tulane University in New Orleans, told MedPage Today that the ceftazidime strategy makes sense.

“If you can’t get the patient to an appropriate place to get treatment, this could potentially reduce the risk of the patient having permanent vision loss,” he said. However, “you really need to make sure the patient understands that this approach in no way is curative.”

The case series reported on 10 patients with syphilitic uveitis. They ranged in age from 41-64, 50% were female, 60% were white, and the rest were African American. In addition, 40% were HIV-positive, 20% were unhoused, 50% were uninsured, 20% were current IV drug users, and 30% were allergic to penicillin.

IV penicillin treatment was postponed from 1 week to 3 months due to penicillin allergy or shortage, noncompliance, lack of hospital bed availability, or a combination of factors.

The patients were given one or two weekly intravitreal injections of 2.25 mg/0.1 mL ceftazidime; those with panuveitis were also administered topical prednisolone.

At the visit following the final injection (mean time elapsed 8.5 days), all patients had improved inflammation. In nine eyes, vision improved by an average of 5.4 lines. Infection with Treponema pallidum, the syphilis bacterium that was detected in two eyes in two patients, resolved following treatment.

The case series highlighted three individual cases of syphilitic uveitis:

A 47-year-old white woman reported worsening vision. Best-corrected visual acuity in one eye was count fingers and hand motion in the other. She reported having an anaphylactic reaction to penicillin as a child, but due to the pandemic, hospitals couldn’t treat her with penicillin desensitization and IV therapy. Following two treatments with ceftazidime, her visual acuity improved from 20/25 in one eye and 20/40 in the other. At follow-up following penicillin desensitization and treatment, her visual acuity was 20/20 and 20/25, respectively.

A 59-year-old African-American man had persistent ocular symptoms (20/50 in the right eye) despite treatment with oral doxycycline given in lieu of penicillin due to a shortage. Following two ceftazidime treatments, visual acuity improved to 20/40. It further improved to 20/25 following penicillin therapy.

A 51-year-old white woman had visual acuity of counting fingers in one eye and refused hospitalization. Visual acuity improved to 20/60 after one ceftazidime injection and 20/50 after IV penicillin treatment.