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Syphilis

Key sources
The following summarized guidelines for the evaluation and management of syphilis are prepared by our editorial team based on guidelines from the U.S. Preventive Services Task Force (USPSTF 2018; 2016), the International Union Against Sexually Transmitted Infections (IUSTI 2014), and the AIDSinfo Society (AIDSInfo 2009).
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Guidelines

1.Screening and diagnosis

Indications for screening, patients at increased risk: screen for syphilis infection in patients who are at increased risk for infection.
A
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  • Indications for screening (pregnant women)

2.Classification and risk stratification

Staging of active disease: diagnose primary syphilis in patients with serological evidence of syphilis infection presenting with an ulcer (chancre). The chancre of syphilis is primarily superficial, single, painless, and indurated with a clean base discharging clear serum, most often located in the anogenital region. However, lesions are often atypical in appearance and may be multiple, painful, deep, and indistinguishable from herpes.
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  • Classification of latent disease

3.Diagnostic investigations

Types of serological tests for syphilis
Treponemal tests detect IgG and/or IgM antibodies. These become positive around 6 weeks after infection and remain positive for life in most patients. These tests include the following:
treponemal enzyme immunoassay (EIA)
treponemal chemiluminescence immunoassay
treponema pallidum hemagglutination test
treponema pallidum passive particule agglutination test
treponema pallidum IgG immunoblot test
Non-treponemal tests detect a mixture of heterophile IgG and IgM antibodies. These become positive 6 weeks after infection, correlate grossly with disease activity, and are useful to monitor disease activity and the efficacy of treatment. These tests include the following:
venereal disease research laboratory
RPR
toluidine red unheated serum test

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  • Initial testing

  • Confirmatory testing

  • Evaluation for neurosyphilis

4.Medical management

Antibiotic therapy, early-stage disease, human immunodeficiency virus-negative
Use benzathine penicillin G (2.4 million units IM, for one dose) as preferred therapy for patients with early syphilis.
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Use procaine penicillin (600 000 units IM once daily, for 10-14 days) as alternative therapy for patients with early syphilis, if benzathine penicillin G is not available.
B

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  • Antibiotic therapy, early-stage disease (HIV-positive)

  • Antibiotic therapy, late-latent disease (HIV-negative)

  • Antibiotic therapy, late-latent disease (HIV-positive)

  • Antibiotic therapy, neurological, otic, or ocular disease (HIV-negative)

  • Antibiotic therapy, neurological, otic, or ocular disease (HIV-positive)

  • Prevention of Jarisch-Herxheimer reactions

5.Specific circumstances

Pregnant patients, human immunodeficiency virus-negative
Use benzathine penicillin G (2.4 million units IM, for one dose) as the preferred therapy in pregnant patients with early syphilis.
B
Consider using procaine penicillin (600,000 units IM once daily, for 10-14 days) as alternative therapy for pregnant patients with early syphilis, if benzathine penicillin G is not available.
C

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  • Pregnant patients (HIV-positive)

  • Patients with penicillin allergy (HIV-negative)

  • Patients with penicillin allergy (HIV-positive)

  • Patients with transplant-induced syphilis

6.Patient education

Counseling on treatment reactions: counsel patients regarding theJarisch-Herxheimer reaction, an acute febrile reaction accompanied by headache and myalgias that can occur within the first 24 hours after the initiation of treatment for syphilis. It occurs more frequently in patients with early syphilis, high non-treponemal antibody titers, and prior penicillin treatment. Inform patients that this reaction does not represent an allergic reaction to penicillin.

7.Follow-up and surveillance

Tracing of sexual contacts
Ensure sexual contact notification is performed in all patients with syphilis (notification by the patient: patient referral; by a health department: provider referral). Sexual contacts should include all those individuals who have had oral, vaginal or anal intercourse with infected individuals, whether or not barrier protection was used.
Notify sexual contacts within the past 3 months for patients with early syphilis, as the incubation period is up to 90 days. Partner notification may have to extend up to 2 years for patients in secondary syphilis with clinical relapse or in early latent syphilis. Longer periods may be required in those with late latent and late syphilis.

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  • Treatment of sexual contacts

  • Follow-up blood testing

  • Follow-up CSF testing