Sexually transmitted infection rates are increasing in the United States, with significant increases in the rates of syphilis among patients of reproductive age and, subsequently, congenital syphilis. Syphilis screening is recommended in sexually active patients 15 to 44 years of age in communities with high syphilis rates and in all pregnant patients at the time of diagnosis or prenatal intake, in the third trimester, and at delivery. Screening for chlamydia and gonorrhea is currently recommended in asymptomatic, sexually active patients younger than 25 years, as well as in older patients with risk factors. When clinicians are diagnosing active infections, patients with anogenital ulcerations should be tested for syphilis and herpes and treated empirically while awaiting test results. Treatment of syphilis depends on the disease stage; first-line regimens all involve penicillin G. Patients with vaginal discharge and dysuria should be tested for gonorrhea and chlamydia using nucleic acid amplification testing. Doxycycline should be used to treat chlamydia because it is more effective in rectal chlamydia, which often coexists with vaginal infection. Single-dose azithromycin is an alternative in populations at risk for poor medication adherence or confidentiality concerns. Ceftriaxone should be used to treat gonorrhea. Increasing drug resistance to gonorrhea is a growing public health threat, and clinicians must work with public health departments in cases of suspected treatment failure.
Case 2. RS is a 29-year-old gravida 3, para 2 (G3P2) patient who presents for prenatal care at 16 weeks’ gestation. A treponemal antibody screen is positive, and rapid plasma reagin (RPR) is 1: 32. She reports having syphilis when she was 22 years old. You contact the local health department. They confirm her history and treatment and report her last known RPR titer 4 years ago was 1: 2. She reports that the father of this child is different from the father of her last child.
Background
Sexually transmitted infections (STIs) commonly affect people of childbearing age, with implications for pregnancy and newborns.1 This review will focus on the leading causes of reportable bacterial STIs and common viral STIs causing symptomatic anogenital infection.
Epidemiology
The most recent national data from 2022 show an 80% increase in syphilis rates, an 11% increase in gonorrhea rates, and a 6% decrease in chlamydia rates since 2018.1 However, the COVID-19 pandemic led to less reliable surveillance data with interruptions in access to testing.2
SYPHILIS
Syphilis rates are highest in people 25 to 34 years of age (47 cases/100,000 individuals). Notably, the rate in those 55 years and older more than doubled between 2018 and 2022 (from 2.5-5.2/100,000), emphasizing the importance of taking a sexual history across the lifespan.1
Syphilis predominantly affects men who have sex with men, although data for recent years have shown marked increases in infections among women.3 Between 2018 and 2022, syphilis rates in women increased 193%, whereas the rate in men increased 48%.1 Increased syphilis rates were most pronounced with the onset of the COVID-19 pandemic, as resources from public health STI programs were diverted to COVID-19.4
As syphilis rates in women increased, so did cases of congenital syphilis.5 In 2022, there were 3,755 cases of congenital syphilis nationally, a 10-fold increase over the past decade.1 Missed opportunities to prevent congenital syphilis are common. Approximately 40% of cases in 2022 resulted from inadequate treatment of syphilis in the birthing parent despite timely testing.1
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