Syphilis referral pathway (Guidelines)

Basic information

Syphilis still remains uncommon, but the incidence of syphilis infection is the highest it has been since records began. Untreated syphilis is often asymptomatic, but can cause a wide array of symptoms and long term complications. Morbidity and prevention of transmission to sexual partners or vertical transmission during pregnancy can all be prevented by early testing and treatment. Syphilis is treated with a course of antibiotics under specialist care and follow up by a consultant in Sexual Health.

When to test for syphilis

Syphilis is easily diagnosed and treated and has public health implications. If struggling to find a cause, faced with unusual or unexplained symptoms or results, it is worth excluding syphilis and HIV.

• Routine screening is offered as part of a sexual health screen, for those attending for treatment or testing of sexually transmitted infections.
• Routine antenatal screening for infectious diseases (HIV, Hepatitis B and syphilis) should be offered to all pregnant women at an early stage in antenatal care because treatment of syphilis is beneficial to the mother and baby [ref: NICE guidance CG62 Antenatal care for uncomplicated pregnancies Section 1.8.10]. Those declining initial screening, or those with further risk, should be offered testing again at a later stage in pregnancy.
• Screening of all blood and organ donors
• Symptoms where syphilis testing may be indicated. Syphilis presents in many and varied ways:
  • Unexplained ulcer (oral, anal and genital are common, also pharyngeal, rectal, vaginal ulcers - often asymptomatic)
  • Rashes (especially if palms and soles involved). Syphilis rashes are varied and are often non-specific. A common characteristic is that it often affects the palms and soles, which rarely happens with other causes of rash, but the appearance of the rash on the palms and soles varies. Web search images for "syphilitic rash" to see examples.
  • Alopecia
  • Warty lesions (chondylomata lata)
  • Abnormal LFTs
  • Dementia
  • Lymphadenopathy
  • Uveitis
  • Optic neuritis
  • Unexplained neuropathies
  • Paraesthesia.

Tests for Syphilis

Serology blood test (brown blood tube, microbiology form) requesting syphilis screening.
If the patient has a past history of syphilis, this should be stated in the clinical details section of the request form.

Management

REFER URGENTLY to Highland Sexual Health for further management/advice. Do not wait for full serology (this can take a few weeks).

Positive syphilis screening will automatically trigger laboratory referral for full serological testing on the same sample.

It is good practice for the team who requested the initial test to inform the patient of the preliminary result and advise them that they are being referred to Highland sexual health for further advice and management.

A second confirmatory test is required, which can either be carried out by the referring team, or at the time of review by Highland Sexual Health.

Partner notification is part of the management of a confirmed syphilis infection and will be carried out by Highland Sexual health team.

Syphilis in pregnancy

All positive results of syphilis in pregnancy should be referred urgently to Highland Sexual Healthto determine whether-or-not this represents active infection, past treated infection, recurrent infection, or false positive result.

Management of confirmed syphilis infection in pregnancy should be through involvement of Sexual health with obstetrics, paediatrics, midwife and GP.

Referral to foetal medicine/paediatrics should be made for pregnant women who are treated for syphilis during the current pregnancy. If treatment for syphilis occurs less than 4 weeks before delivery, the neonate will require treatment.

Template birth plan: https://www.bashhguidelines.org/media/1196/syphillis-bp_print_2016_p3.pdf

All patients with positive syphilis tests should be referred urgently to Highland Sexual Health

For advice you can contact Highland sexual health via email nhshighland.healthadvisor@nhs.scot or clinical dialogue via SCI gateway 

Syphilis guidelines: https://www.bashhguidelines.org/current-guidelines/genital-ulceration/syphilis-2015/

Syphilis in pregnancy birth plan template: https://www.bashhguidelines.org/media/1196/syphillis-bp_print_2016_p3.pdf

Patient information to be given by referring team

Preliminary patient information should be given in a non-judgemental, sympathetic manner:

• Syphilis is an infection easily treated with antibiotics
• False positive results can occur, so a repeat test is required to determine whether this is a true result or not.
• It is (usually) passed on through sexual contact, so if you have a partner they will need to be tested as well, and we may need to test previous partners too.
• You are being referred to a specialist team who will be able to give you further advice, care and treatment if required.

Patient information leaflet link:  https://www.bashhguidelines.org/media/1037/sts_pil_non-pregnant_digital_2016.pdf

Leaflet for pregnant women:  https://www.bashhguidelines.org/media/1036/sts_pil_digital_2016.pdf