Kinetics of RPR Decline in Pregnant Persons Treated for Syphilis in Pregnancy and Their Infants.

Congenital syphilis is a re-emerging infectious threat in areas of North America. The purpose of this study was to quantitatively describe the rate of decline of nontreponemal (rapid plasma reagin, RPR) titers in pregnant persons with syphilis and their infants. In a retrospective review, we included 120 pregnant persons with 563 reactive RPR measurements (median 5, range 2 to 11 per person) and 35 infants with 81 RPR measurements (median 2, range 2 to 6 per infant). First-order decay, second-order decay, and a mathematical model representing functional FcRn-mediated antibody recycling were fitted to individual patient RPR trajectories. The RPR titers decreased with a median half-life of 39 days (IQR 28-59) and 27 days (IQR 17-41) in birthing parents and infants, respectively. The half-life varied with the initial RPR titer, suggesting that the kinetics of RPR decline was not first-order. A mathematical model accounting for saturable antibody recycling explained the longevity of RPR reactivity, predicted the observed non-linear kinetics, and fit the empiric data well. In summary, RPR titers decline with a half-life of roughly one month; however, the elimination does not follow first-order kinetics. Saturable antibody recycling may explain the prolonged and non-linear elimination of nontreponemal antibodies.