Heterosexual infectious syphilis notifications triple in Adelaide

15 November 2021

Notifications of infectious syphilis among people reporting sexual partners of a different sex have increased significantly across Adelaide. To 30 September 2021, there were 21 notifications among females, and 53 notifications among males reporting female partners. This is 3.3 and 2.7 times as high as the previous five-year average of 6.4 and 19.4 notifications per year, suggesting the epidemics among men-who-have-sex-with-men (MSM) and Aboriginal and Torres Strait Islander people are increasingly affecting heterosexual and non-Indigenous populations. Syphilis is a sexually transmissible infection (STI). Additionally, vertical transmission in pregnancy is a major concern as congenital syphilis can cause stillbirth, neonatal death, preterm delivery, low birth weight, and severe congenital and developmental abnormalities.

Doctors are advised to:

  1. Maintain a high clinical suspicion for syphilis in all population groups
    • Primary syphilis may present with one or more typically painless ulcers at the site of infection.
    • Secondary syphilis may present with a rash and constitutional symptoms such as fever or malaise.
    • Be alert to new visual complaints and consider syphilis in the differential diagnosis. Ocular and neurological symptoms may occur at any stage of syphilis.
    • Take a dry swab of any potentially syphilitic lesion or rash for syphilis PCR, in addition to bloods for syphilis serology. Herpes simplex (HSV) swabs are unsuitable for syphilis PCR.
  2. Consider syphilis screening in all sexually active patients
    • Offer syphilis screening to all asymptomatic patients as part of regular sexual health check-ups. This includes MBS item 715 health assessments for Aboriginal and Torres Strait Islander people.
  3. Request syphilis and HIV serology in patients with other STIs or risk factors for STIs, including STI contacts and persons who inject drugs
  • A diagnosis of chlamydia or gonorrhoea indicates that the patient is at risk of syphilis.
  • Test for syphilis and HIV in persons diagnosed with or a contact of a person with an STI.
  • Offer syphilis screening to persons with evidence of injecting drug use. Injecting drug use is emerging as a behavioural risk factor for syphilis acquisition.
  1. Order syphilis screening early in pregnancy and consider repeat testing
    • Ascertain the pregnancy status of all potentially pregnant persons tested for syphilis or other STIs.
    • Screen for syphilis at the first antenatal visit. Repeat screening is indicated if the pregnant person or their sexual partner(s) are considered at high risk of acquiring STIs, or the risk is uncertain.
    • Urgently recall all pregnant persons with reactive syphilis serology to assess the need for treatment.
  2. Facilitate prompt treatment of syphilis and ensure appropriate monitoring
    • Treat patients with infectious syphilis promptly with 1.8g/2.4 million units benzathine penicillin (Bicillin L-A) via intramuscular injection (IMI).
    • Treat patients with non-infectious syphilis (i.e. asymptomatic infection with no evidence of seroconversion or fourfold rise in reactive plasma regain (RPR) titre in the previous two years) with 1.8g/2.4 million units benzathine penicillin IMI weekly for 3 weeks.
    • Treat contacts of syphilis presumptively with 1.8g/2.4 million units benzathine penicillin IMI and collect syphilis serology concurrently.  
    • Consider ordering benzathine penicillin (Bicillin L-A) through the Emergency Drug Supply Schedule (Prescriber Bag), in order to minimise the risk of treatment delay (https://bit.ly/3jZsBWb).
    • Repeat RPR testing at 3, 6, and 12 months to monitor treatment response and exclude re-infection.
  3. Notify new syphilis cases & cases requiring treatment in pregnancy (even if previously notified)
  4. Seek advice and assistance from specialist services
  • Contact Adelaide Sexual Health Centre for clinical advice on (08) 7117 2800, or CDCB for public health management advice on 1300 232 272, including services through the SA Syphilis Register for Aboriginal and Torres Strait Islander patients.
  • See the Australian STI Management Guidelines available at http://www.sti.guidelines.org.au/.

See Health Pathways for localised information at: https://saproject.healthpathwayscommunity.org/

Dr Louise Flood – Director, Communicable Disease Control Branch