Clinical Guidelines Syphilis



SYPHILIS (TREPONEMA PALLIDUM)INTRODUCTION Syphilis is a systemic sexually transmitted disease caused by Treponema pallidum. The disease has been divided into a series of overlapping stages. Primary infectionSecondary infection Tertiary infection Latent infectionEarly latent- syphilis acquired within the preceding yearLate latent- > 1 year or unknown duration of diseaseSUBJECTIVE DATA History may include:History of SyphilisRecent change in sexual partnerPartner with symptoms of or infection with SyphilisLack of STD protection (condom use)Reports multiple sexual partners &/or partner has multiple partnersReports symptoms of Syphilis infection (i.e., chancre, rash)Commercial sex work or coerced sexIllicit drug useMSMHIV +Pregnant OBJECTIVE DATAAssessment may include:Physical exam findings: Primary-painless indurated ulcer or chancre at the infection siteSecondary- skin rash, mucocutaneous lesions, lymphadenopathy, neurologic infection, cranial nerve dysfunction, meningitis, stroke, acute or chronic altered mental status, loss of vibration sense, and auditory or ophthalmic abnormalitiesTertiary- findings dependent on location of granulomatous (gamma) lesions – in heart, brain, nerves, eyes, blood vessels, liver, bones.Latent –No physical evidence of disease, must be diagnosed with serologic testing.ASSESSMENTDiagnosis is confirmed by:Dark-field examination of exudates.Non-treponemal tests: VDRL and RPR Treponemal tests: FTA-ABS tests, TP-PA assay, various EIAs, and chemiluminescence immunoassay. The use of only one type of serologic test is insufficient for diagnosis, because each type of test has limitations, including the possibility of false-positive test results in persons without syphilis. False-positive nontreponemal test results can be associated with various medical conditions unrelated to syphilis, including autoimmune conditions, older age, and injection-drug use; therefore, persons with a reactive nontreponemal test should receive a treponemal test to confirm the diagnosis of syphilis.PLAN Treatment:(Family Planning Clinics are recommended to consult with the Medical Director and /or Communicable Disease Director to collaboratively diagnose, treat, and care for clients with syphilis.)Recommended Regimen for AdultsBenzathine penicillin G is the preferred drug for treating all stages of syphilis.See Current CDC Guidelines at CDC STD Treatment Guidelines PDFThe preparation used, the dosage, and the length of treatment depends on the stage and clinical manifestations of the disease.SPECIAL CONSIDERATIONSPenicillin Allergy: See CDC STD Treatment Guidelines 2015Pregnancy: Refer to their prenatal providerHIV-immuno suppressed clients: Refer to care coordinatorJarisch-Herxheimer Reaction: The Jarisch-Herxheimer reaction is an acute febrile reaction frequently accompanied by headache, myalgia, fever, and other symptoms that can occur within the first 24 hours after the initiation of any therapy for syphilis. Patients should be informed about this possible adverse reaction and how to manage it if it occurs. The Jarisch-Herxheimer reaction occurs most frequently among persons who have early syphilis, presumably because bacterial burdens are higher during these stages. Antipyretics can be used to manage symptoms, but they have not been proven to prevent this reaction. The Jarisch-Herxheimer reaction might induce early labor or cause fetal distress in pregnant women, but this should not prevent or delay therapy (see Syphilis During Pregnancy).MANAGEMENT OF SEX PARTNERSee CDC STD Treatment Guidelines 2015CLIENT EDUCATION Sexual partner and any sexual contacts in the last 90 days (preceding onset of symptoms or diagnosis) must be informed of possible infection and provided written materials about the importance of seeking evaluation for any symptoms suggestive of complications (i.e., skin rash, chancre, lymph adenopathy etc. Screening and treatment of sex partners is essential for decreasing the risk for re-infection. Provide Medication Information SheetProvide STD education and informationOffer other STD testingProvide current educational information on T. pallidum Provide contraceptive information, if indicated Encourage consistent and correct condom use to prevent STDs Educate partners, if possible, about symptoms and to encourage partners to seek clinical evaluation All persons diagnosed with primary and secondary syphilis should be tested for HIV.FOLLOW-UP (details see CDC STD Treatment Guidelines 2015)Clinical and serologic evaluation should be performed at 6 and 12 months after treatment.Clients who have symptoms that persist or recur after treatment should be evaluated and retested.HIV status should be evaluated.REFERRALPregnant clients – (refer to prenatal care)Referral must be made if treatment management is not provided in your clinic.REPORTINGSyphilis infection is a reportable disease in Michigan. Reports should be made to your local health department without delay.REFERENCESCDC: Sexually Transmitted Disease Treatment Guidelines, 2015Reportable Diseases in Michigan: A Guide for Physicians, Health Care Providers and Laboratories 2019Reviewed/Revised: 2020 ................
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