Syphilis

Outbreak Training Website


Testing and Management


Detailed protocols regarding syphilis testing and clinical management are available from:


Why Testing for Syphilis is Important


Prompt and appropriate testing and management of syphilis is essential to:

  • Prevent the ongoing transmission to sexual partners
  • Prevent the transmission from mother to baby and subsequent poor outcomes such as miscarriage, stillbirth and congenital syphilis
  • Reduce transmission of HIV and other STIs and blood-borne viruses (BBVs), which increase in the presence of genital sores or inflammation of the mucous membranes.


Who and When to Test for Syphilis



In the context of the current syphilis outbreak, practitioners should maintain a low threshold for testing and treating people presenting with any signs or symptoms that could be due to syphilis or other STIs and BBVs. In addition, the frequency of screening should increase among those at highest risk. Refer to the Syphilis Series of National Guidelines (SoNG) for Public Health Units for a list of high risk groups and the STI/HIV Testing Guidelines for MSM (STIGMA) for additional information.

  • Testing for syphilis should always be included when conducting a thorough check up for STIs and BBVs and when any other STI or BBV has been detected as co-infections are common.

Age groups and high risk populations

Men who have sex with men (MSM)

See STI/HIV Testing Guidelines for MSM

At risk population defined by age, sexual orientation or location

  • During an outbreak situation screen at least 6 monthly e.g. remote areas, all young Indigenous people aged 15–40 years (exact age groups and frequency depends on the jurisdiction and local guidelines should be used)

HIV positive people

  • Tested up to 4 times a year for syphilis
  • Routine CD4 and viral load testing should be done at the same time if clinically appropriate

People who have previously been treated for syphilis

  • Once reactive, the syphilis antibody screening test will remain positive for life, but this does not protect against re-infection of syphilis. Syphilis serology should continue to be tested as per sexual risk factors and local epidemiology and guidelines

People who are pregnant

Asymptomatic screening

Asymptomatic screening for syphilis should be done routinely in the following circumstances:

  • 15- 40 year olds (exact age groups and frequency depends on the jurisdiction and local guidelines should be used)
  • New or change of partner/multiple partners
  • At follow up when any STI or BBV is detected, if not tested at the initial presentation
  • A contact of a person with any STI or BBV
  • The client requests a sexual health check up
  • During adult health check
  • Opportunistically – eg. during cervical screen or contraception consultation.
  • During Pregnancy - as per the updated Syphilis Chapter of the National Pregnancy Care Guidelines:
    • Routinely recommend syphilis testing at the first antenatal contact.
    • In areas affected by an ongoing syphilis outbreak, recommend testing at the first antenatal visit, at 28 and 36 weeks, at the time of birth and 6 weeks after the birth*. The frequency depends on the jurisdiction and local guidelines should be used.

*This provides the minimum time points for testing females at high risk of infection or reinfection. The testing schedule may be expanded based on local needs. Monitoring changes in risk is also important for females at high risk of infection or reinfection.

Symptoms

Test for syphilis when someone of any age presents with any signs and symptoms possibly due to syphilis or other STIs and BBVs such as:

  • Genital chancres, ulcers, sores or lumps
  • Rashes/lesions in ano-genital areas
  • Unexplained rashes anywhere on the body and rashes involving palms and soles
  • Patchy hair loss in the scalp or eyebrows
  • Unexplained headache, fevers, muscle aches pains or lymphadenopathy
  • When any STI or BBV is detected


    Other STI and HIV testing


    As STIs and BBVs are often acquired together, it is important to check these when testing for syphilis. The tests required will depend on your patient’s gender, symptoms and whether there are any abnormal findings on physical examination. Refer to your local guidelines (listed at the beginning of this module) for more information.



    Clinical Management Recommendations during an outbreak


    With regard to improving the clinical management of infectious syphilis, the Syphilis SoNG emphasises the importance of prompt and appropriate management of cases and contacts which support the existing state and national STI management guidelines and include the following recommendations:

    • Treatment should be given at the time of presentation to people presenting with signs or symptoms of primary or secondary syphilis.
    • Treatment of infectious syphilis identified on serology should be given as soon as possible and ideally within 2 days.
    • A serum specimen for syphilis serology RPR should be taken to give a baseline on the day of treatment, even though the patient may have been tested in the previous few days or weeks because the RPR could have risen between the previous test and day of treatment. The RPR on the day of treatment is necessary to show the RPR falling at 3-6 months and 12 months (or in accordance with local guidelines) following treatment. Ideally the follow-up RPRs should be done by the same laboratory as the RPR done on the day of treatment. The more frequent follow-up in an outbreak situation is helpful to look for re-infection where contact tracing has not been possible by the patient not disclosing their partners, or re-infection in a much higher prevalence situation.
    • Jarisch-Herxheimer reaction is a common reaction to treatment in patients with primary and secondary syphilis. It occurs six to 12 hours after commencing treatment, and is an unpleasant reaction of varying severity with fever, headache, malaise, rigors and joint pains, and lasts for several hours. Symptoms are controlled with analgesics and rest. Patients should be alerted to the possibility of this reaction and reassured accordingly.

    During pregnancy

    • Infectious syphilis in a pregnant woman requires an urgent response and treatment and follow up commenced as soon as possible and within 24 hours.
    • Seek advice from an expert in sexual health or infectious diseases regarding the care of females who test positive and their partners.
    • In areas affected by an outbreak, treat females as soon as possible without waiting for confirmatory testing, particularly if there is a risk of loss to follow-up.
    • For females with newly confirmed infectious syphilis, recommend an intramuscular dose of 2, 400, 000 units (given as two 1, 200, 000 units injections) benzathine penicillin as soon as possible, ensuring that females receive treatment at least 30 days before the estimated date of birth to ensure adequate treatment before the birth.
    • Ensure contact tracing (including offering testing and treatment to identified contacts) is carried out.  Involve an expert in contact tracing if required or seek advice from a sexual health or other relevant expert.

    WA clinicians please note

    Structured Administration and Supply Arrangement’s (SASA’s)

    The Structured Administration and Supply Arrangement’s (SASA’s) for Treatment of Syphilis Infection by Registered Nurses and Aboriginal Health Practitioners enable the administration of antibiotics for treatment of syphilis in WA. The SASA’s, and associated Conditions for administering treatment, were developed in consultation with public health physicians from WA Department of Health, WA Country Health Service and Aboriginal Community Controlled Health Organisations, and consultant sexual health physicians.

    Please click on the links below to read the relevant SASA:

    SASA - Treatment of Syphilis Infection by Aboriginal Health Practitioners

    SASA - Treatment of Syphilis Infection by Registered Nurses


    Follow up


    • Follow up serology to check for response to treatment should be done at 3, 6 and 12 months. A two titre (four fold) drop indicates an adequate response to treatment at 6 months. Local guidelines should be used to ensure frequency is correct according to the jurisdiction.

    • Once reactive, the syphilis antibody screening test will remain positive for life, but this does not protect against re-infection of syphilis. Syphilis serology should continue to be tested as per sexual risk factors and local epidemiology and guidelines.