The Price of Delay and the Uncoupling of Severity: A Penalized Multivariate Analysis of Treatment Adequacy Versus Timing as Determinants of Congenital Syphilis

Background: Despite global elimination targets, congenital syphilis (CS) remains a critical cause of preventable neonatal morbidity. While the importance of antenatal screening is established, the relative impact of treatment adequacy (dosage/adherence) versus timing on neonatal severity—specifically the uncoupling phenomenon where severe visceral damage occurs despite normal birth biometrics—remains under-characterized in resource-limited settings. Methods: A retrospective cross-sectional study analyzed 101 syphilis-exposed mother-infant pairs at a tertiary referral center in Indonesia (2021–2025). We evaluated maternal serologic testing time, treatment timing, and treatment adequacy (defined strictly per CDC guidelines; inadequate defined as