Syphilis: Far from Ancient History

 

Am Fam Physician. 2020 Jul 15;102(2):91-98.

  Patient information: A handout on this topic is available at https://familydoctor.org/condition/syphilis.

Related editorial: Closing Primary and Prenatal Care Gaps to Prevent Congenital Syphilis

Author disclosure: No relevant financial affiliations.

Rates of primary, secondary, and congenital syphilis are increasing in the United States, and reversing this trend requires renewed vigilance on the part of family physicians to assist public health agencies in the early detection of outbreaks. Prompt diagnosis of syphilis can be challenging, and not all infected patients have common manifestations, such as a genital chancre or exanthem. The U.S. Preventive Services Task Force recommends screening for syphilis in all patients at increased risk, particularly those who reside in high-prevalence areas, sexually active people with HIV infection, and men who have sex with men. Other groups at increased risk include males 29 years or younger and people with a history of incarceration or sex work. All pregnant women should be screened for syphilis at the first prenatal visit, and those at increased risk should be screened throughout the pregnancy. The Centers for Disease Control and Prevention recommends the traditional screening algorithm for most U.S. populations. Penicillin is the preferred treatment across all stages of syphilis, although limited research suggests a possible role for other antibiotics in penicillin-allergic patients with primary or secondary syphilis. Pregnant women with syphilis who are allergic to penicillin should undergo penicillin desensitization before treatment.

Syphilis is a chronic bacterial infection caused by the spirochete Treponema pallidum. This disease has been known for hundreds of years, and its predictable clinical stages and well-established treatments made it a candidate for global eradication at several points during the 20th century. However, the incidence in the United States is currently increasing.1,2 Control efforts have been hindered by clinicians' lack of familiarity with clinical presentations, diagnosis, and treatment options. Additionally, the stigma associated with syphilis makes timely diagnosis and partner notification a challenge.

WHAT'S NEW ON THIS TOPIC

In the United States, rates of primary and secondary syphilis have increased nearly every year since 2001, with the 35,063 cases reported in 2018 representing a 71% increase from 2014.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Physicians should screen for syphilis in asymptomatic, nonpregnant adults and adolescents who are at increased risk.21

A

U.S. Preventive Services Task Force recommendation based on a systematic review of high-quality patient-oriented evidence

People at highest risk of syphilis should be screened multiple times per year.20,21

C

Expert opinion

All pregnant women should be screened for syphilis at the first prenatal visit.22

A

U.S. Preventive Services Task Force recommendation based on a systematic review of high-quality patient-oriented evidence

The traditional syphilis screening algorithm should be used instead of the reverse-screening approach to screen people in low-prevalence populations.10,20,28

C

Consensus guidelines in the absence of high-quality evidence from studies in low-prevalence populations

Penicillin should be administered as the first-line treatment for all stages of syphilis.10

C

Expert opinion and consensus guidelines in the absence of high-quality patient-oriented evidence

Patients with confirmed syphilis should be tested for HIV infection.10

C

Consensus guidelines in the absence of clinical trials


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Physicians should screen for syphilis in asymptomatic, nonpregnant adults and adolescents who are at increased risk.21

A

U.S. Preventive Services Task Force recommendation based on a systematic review of high-quality patient-oriented evidence

People at highest risk of syphilis should be screened multiple times per year.20,21

C

Expert opinion

All pregnant women should be screened for syphilis at the first prenatal visit.22

A

U.S. Preventive Services Task Force recommendation based on a systematic review of high-quality patient-oriented evidence

The traditional syphilis screening algorithm should be used instead of the reverse-screening approach to screen people in low-prevalence populations.10,20,28

C

Consensus guidelines in the absence of high-quality evidence from studies in low-prevalence populations

Penicillin should be administered as the first-line treatment for all stages of syphilis.10

C

Expert opinion and consensus guidelines in the absence of high-quality patient-oriented evidence

Patients with confirmed syphilis should be tested for HIV infection.10

C

Consensus guidelines in the absence of clinical trials


A = consistent, good-quality

The Authors

show all author info

JASON RICCO, MD, MPH, is a faculty physician at the University of Minnesota North Memorial Family Medicine Residency Program and an assistant professor in the Department of Family Medicine and Community Health at the University of Minnesota Medical School, Minneapolis....

ANDREA WESTBY, MD, FAAFP, is a core faculty physician at the University of Minnesota North Memorial Family Medicine Residency Program and an assistant professor in the Department of Family Medicine and Community Health at the University of Minnesota Medical School.

Address correspondence to Jason Ricco, MD, MPH, University of Minnesota Medical School, 1020 W. Broadway Ave., Minneapolis, MN 55411 (email: ricco004@umn.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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show all references

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