Health Alert Template for Congenital Syphilis

Instructions

The template health alert below can be adapted and used by a health department to notify local public health practitioners, clinicians, public health laboratories, and public information officers about an increase in congenital syphilis in their jurisdiction. It is customizable – you should use data from your jurisdiction to make it relevant to your community. You can customize this article further by including local screening recommendations and a point of contact for reporting confirmed, probable or suspected congenital syphilis cases.

Summary

 

  • As of [date], [number] cases of congenital syphilis have been diagnosed in [jurisdiction].

    Alternatively: As of [date], [number] cases of primary and secondary syphilis have been diagnosed in women under 40 years old, an increase of [percentage] since [date].

  • [Insert local screening recommendations or changes in screening recommendations here.] No infant should leave the hospital without the mother’s serological status having been documented at least once during pregnancy.
  • Treatment: Pregnant women with syphilis should be treated with one to three shots of benzathine penicillin G, 2.4 million units IM depending on the stage of syphilis (see CDC treatment guidelines – https://www.cdc.gov/std/tg2015/syphilis-pregnancy.htm). Penicillin G is the only known effective antimicrobial for preventing maternal transmission to the fetus and treating fetal infection. Pregnant women who have a history of penicillin allergy must be desensitized and treated with penicillin.
  • Congenital syphilis should be considered in all stillbirths after 20 weeks, and in infants of mothers with evidence of syphilis infection during pregnancy, especially if syphilis is newly acquired during pregnancy. Infected infants can be asymptomatic at birth, but can develop serious symptoms in the neonatal period or later in life.
  • Please report all information related to clinical and laboratory reports on suspected or probable congenital syphilis cases to [Name] at [phone] or [email].

 

Background

 

Congenital syphilis rates in the US started to increase in 2012 and continued to rise with an increase of almost 44% from 2016 to 2017. [NOTE: The jurisdiction can insert local epidemiology data here.]

Symptoms

Treponema pallidum causes syphilis and can present in several stages.  The chancre of primary syphilis is painless and may not be noted by infected persons as it resolves even without treatment.  Most patients who seek care do so with secondary syphilis whose symptoms include a rash that may involve the palms and soles, condyloma lata, and lymphadenopathy.  Left untreated, syphilis can cause cardiac system abnormalities and neurological symptoms in later stages.

A pregnant woman can transmit syphilis to her child during any stage of syphilis and any trimester of pregnancy. However, the risk of transmission is highest if the mother has been infected recently. Syphilis infection during pregnancy increases adverse pregnancy outcomes including preterm birth and stillbirth.  Up to 40% of babies born to mothers with untreated syphilis (if infected within four years prior to delivery) will be stillborn or die in infancy.  Congenital syphilis can lead to newborn and childhood illness including hydrops fetalis; hepatosplenomegaly; rashes; fevers; failure to thrive; deformity of the face, teeth, and bones; blindness; and deafness.

 

Actions for Providers/Recommendations:

 

Screening

  • All pregnant women residing in [jurisdiction] should be screened for syphilis [NOTE: Insert any specific local screening recommendations.]
  • Women who experience a stillbirth after 20 weeks of pregnancy should be tested for syphilis.
  • Infants should not be discharged from the hospital unless the mother has been tested for syphilis at least once during pregnancy and preferably again at delivery.

Diagnosis and Treatment

Syphilis during pregnancy

  • Two tests are required to diagnose syphilis, a non-treponemal assay (i.e., Venereal Disease Research Laboratory [VDRL] or Rapid Plasma Reagin [RPR]) and a confirmatory treponemal test (i.e., fluorescent treponemal antibody absorbed [FTA-ABS] tests, the pallidum passive particle agglutination [TP-PA] assay, etc). False positive non-treponemal tests are seen in pregnancy so confirmatory testing with a treponemal test is necessary to diagnose syphilis.
  • Adequate treatment of syphilis in pregnant women as soon as possible during pregnancy dramatically decreases the rate of congenital syphilis. Syphilis known to be acquired within the prior 12 months (primary, secondary, early non-primary non-secondary) should be treated with 4 million units of IM Benzathine penicillin G.  Syphilis acquired >12 months prior (late syphilis) or of unknown duration should be treated with Benzathine penicillin G 7.2 million units total, administered as 3 doses of 2.4 million units IM each at 1-week intervals. If doses are further apart than 7 days or missed, the treatment schedule must restart from the beginning.
  • Patients with penicillin allergies should be desensitized and treated with penicillin as it is the only known effective antimicrobial for preventing maternal transmission to the fetus and treating fetal infection.
  • Partners should (at a minimum) be presumptively treated (2.4 million units of IM Benzathine penicillin G) to prevent reinfection during pregnancy. Ideally, they should be evaluated for syphilis by a provider and staged and treated appropriately.

Congenital Syphilis in the infant

  • Infected infants can be asymptomatic.
  • Infants born to untreated mothers, or mothers with inadequate treatment (including those treated <30 days prior to delivery) should be evaluated and treated for congenital syphilis per CDC guidelines (https://www.cdc.gov/std/tg2015/congenital.htm).
  • All neonates born to women who have a reactive nontreponemal and treponemal tests should be evaluated with a quantitative nontreponemal serologic test (RPR or VDRL) and be examined thoroughly for evidence of congenital syphilis (see details in CDC treatment guidelines https://www.cdc.gov/std/tg2015/congenital.htm).
Caption for compliance.
Treatment population Stage Treatment
Syphilis during pregnancy

 

Primary   2.4 million units of IM Benzathine penicillin G1
Secondary
Early non-primary non-secondary
Unknown duration Benzathine penicillin G 7.2 million units total, administered as 3 doses of 2.4 million units IM each at 1-week intervals2
Late
Neuro and ocular syphilis Aqueous crystalline penicillin G 18-24 million units per day, administered as 3-4 million units IV every 4 hours or continuous infusion, for 10-14 days
Congenital syphilis in the infant3 Aqueous crystalline penicillin G 100,000-150,000 units/kg.day, administered as 50,000 units/kg/dose IV every 12 hours during the first 7 days of life and every 8 hours thereafter for a total of 10 days
OR
Procaine penicillin G 50,000 units/kg/dose IM in a single daily dose for 10 days
  1. Patients with penicillin allergies should be desensitized and treated with penicillin as it is the only known effective antimicrobial for preventing maternal transmission to the fetus and treating fetal infection.
  2. If doses are further apart than 7 days or missed, the treatment schedule must restart from the beginning.
  3. If more than 1 day of therapy is missed the entire course should be restarted.

Please report congenital syphilis cases to [name] at [health department contact info]

For questions please contact the [Jurisdiction] at [phone].

 

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