The preferred drugs for the treatment of
syphilis,
benzathine and
procaine penicillin, have not been available in Shanghai for many years, and currently, the incidence of
syphilis is increasing. Alternative
antibiotics for patients with
syphilis during the
benzathine and
procaine penicillin shortage include
macrolides. The failure of
macrolide treatment in
syphilis patients has been reported in Shanghai, but the reason for this treatment failure remains unclear. We used polymerase chain reaction technology to detect a
23S rRNA A2058G mutation in Treponema pallidum in 109 specimens from
syphilis patients. The use of
azithromycin/
erythromycin in the
syphilis patients and the physicians' prescription habits were also assessed based on two questionnaires regarding the use of
macrolides. A total of 104 specimens (95.4%) were positive for the A2058G mutation in both copies of the
23S rRNA gene, indicating
macrolide resistance. A questionnaire provided to 122 dermatologists showed that during the
penicillin shortage, they prescribed
erythromycin and
azithromycin for 8.24±13.95% and 3.21±6.37% of their patients, respectively, and in the case of
penicillin allergy,
erythromycin and
azithromycin were prescribed 15.24±22.89% and 7.23±16.60% of the time, respectively. A second questionnaire provided to the
syphilis patients showed that 150 (33.7%), 106 (23.8%) and 34 (7.6%) individuals had used
azithromycin,
erythromycin or both, respectively, although the majority did not use the drugs for
syphilis treatment. Our findings suggest that
macrolide resistance in Treponema pallidum is widespread in Shanghai. More than half of the
syphilis patients had a history of
macrolide use for other treatment purposes, which may have led to the high prevalence of
macrolide resistance. Physicians in China are advised to not use
azithromycin for early
syphilis.