Treponema pallidum, subspecies pallidum.
Clinically the disease has 3 stages however about 50% of people will have no symptoms and will only be diagnosed by serological testing. (See latent syphilis below).
|Early Latent (<2 years) syphilis:
Late latent (>2 years) syphilis:
See STI Atlas for images.
- Diagnosis is by a combination of serology, history and clinical assessment.
- If serology is negative, repeat testing after 2 weeks if clinical suspicion of syphilis.
||Blood specimens are usually screened with an EIA, (although some labs still screen with TPPA or TPHA). If reactive, RPR and TPHA (or TPPA) performed as confirmatory testing.|
||Swab of ulcer
Diagnosis may be confirmed by direct identification of T. pallidum from an ulcer.
NAAT testing may be positive prior to seroconversion in very early cases.
EIA – Enzyme immunoassay
- In patients with prior treated syphilis, since the EIA and TPPA tests are usually positive for life, only an RPR test is required to detect reinfection or treatment success.
- Seek specialist advice for assistance in interpreting serology results if unsure.
- For men who have sex with men (MSM): at least annually, up to 4 times a year.
- For HIV positive MSM, up to 4 times per year or at least on each occasion of CD4/viral load monitoring
- Routine antenatal testing (repeat in late pregnancy if at risk of infection or reinfection e.g. Aboriginal women in context of current outbreak).
- Routine immigration testing
- A sexual contact of a person with syphilis
- Routine sexual health check
- Presence of any signs and symptoms of infectious syphilis.
Clinical indicators for testing
- Early referral or discussion with a sexual health specialist or service is strongly recommended
- Patients being treated for primary and secondary syphilis should have rapid plasma regain (RPR) repeated on the day treatment is commenced to provide an accurate baseline for monitoring treatment.
|Principal Treatment Options|
|Infectious syphilis (primary, secondary, early latent)||Benzathine penicillin 1.8g IMI, stat||Procaine penicillin 1.5g IMI, for 10 days|
|Non-infectious syphilis (late latent)||Benzathine penicillin 1.8g IMI, weekly for 3 weeks||Procaine penicillin 1.5g IMI, for 15 days|
Intramuscular penicillin formulation used should be long acting, as short acting formulations (e.g. benzyl penicillin) are ineffective.
- Jarisch-Herxheimer reaction is a common reaction to treatment in patients with primary and secondary syphilis. It occurs 6-12 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.
- Procaine reaction is a rare reaction to procaine penicillin. It is characterised by a sensation of impending doom with hallucinations. The reaction is self-limiting and lasts about 30 minutes. The patient needs to be reassured and given general supportive measures.
Other immediate management
- Advise no sexual contact for 7 days after treatment is administered
- Advise no sex with partners from the last 3 months (primary syphilis) and 6 months (secondary syphilis) until the partners have been tested and treated if necessary.
- Contact tracing
- Provide patient with factsheet
- Notify the state/territory health department.
Special treatment situations
- Early referral or discussion with a sexual health specialist or service is strongly recommended.
|Complicated||Refer those with acute neurological, ophthalmic or suspected tertiary disease to local sexual health or infectious diseases clinic|
||Seek specialist advice. Treat as for non-pregnant according to stage. Only penicillin has been shown to be effective, so those allergic should be desensitised and treated with penicillin.|
|Allergy to principal treatment choice
Non-penicillin regimens have less evidence than penicillin but have shown to be effective.
Infectious Syphilis: Doxycycline 100mg PO, BD for 14 days
Non-infectious Syphilis: Doxycycline 100mg PO, BD for 28 days
|HIV co-infection||Discuss with sexual health specialist|
According to sexual history and clinical stage of infection:
- Primary syphilis: 3 months plus duration of symptoms
- Secondary syphilis: 6 months plus duration of symptoms
- Late latent syphilis: long term partners only
- Presumptively treat all sexual contacts of patients with primary or secondary syphilis regardless of serology with benzathine penicillin 1.8g IMI, stat.
See Australasian Contract Tracing Manual - Syphilis for more information.
If confirmed STI, follow up provides an opportunity to:
- Confirm patient adherence with treatment
- Repeat serology to assess response to treatment - seek specialist advice
- Confirm contact tracing has been undertaken or offer more contact tracing support.
- Provide further sexual health education and prevention counselling.
Test of Cure (TOC)
Review all patients clinically and with repeat reactive plasma regain (RPR) testing at 3 months, then at 6 months and (if necessary) at 12 months after completing treatment.
Consider testing for HIV and other STIs at 3 month visit, if not undertaken at first presentation, or retesting post the window period.
100% have had follow up serology tests by 6 months.