Management of primary and secondary syphilis in a large London teaching hospital

Background: Acute syphilis is on the increase, especially in London, and prompt diagnosis and treatment is vitally important to prevent complications and onward transmission.  We audited all cases in our patient cohort to assess compliance with BASHH auditable outcomes.

Methods: We collected all patients who had been coded as primary or secondary syphilis (A1 or A2) between xx and xx for those attending Barts Healthcare NHS Trust.  We then performed a retrospective case note analysis looking at demographics, symptoms at presentation and subsequent management.

Results: 132 records were returned with 95% being male and of those 93% identifying as men who have sex with men (MSM). 73% of all patients were seen by a doctor at first visit. 55% were HIV positive, with 3 patients being newly diagnosed HIV positive at initial visit. 70% had symptoms of primary or secondary syphilis with an ulcer or rash accounting for the majority. 87% had a PCR for herpes simplex virus (HSV) which was positive in 7% of cases. Samples for dark ground microscopy were taken in 38% of cases and only one third were positive. 42% were treated for syphilis on their initial visit (14% if seen by a technician, 31% if seen by a nurse and 51% if seen by a medic, p=0.006). 34% of HIV negative patients were treated on the day compared to 50% of HIV positive individuals, but was not significant (p=0.06). Of those not treated on the initial visit, 90% had been treated by 2 weeks. 

Discussion: The majority of acute syphilis diagnoses were in MSM with the majority of these being seen by medical staff initially.  High rates of HIV positivity were seen in this cohort, and a significant number of new HIV diagnoses reinforcing the importance of routine HIV testing in this high risk group.  Most patients presented symptomatically with a surprisingly high co-infection of HSV for those presenting with ulcers.  Dark ground microscopy was performed in only a minority of cases and only a third of these were positive, possibly indicating a decreasing trend in the ability and skills to perform effective specimen taking and sample reading.  All patients with positive dark ground microscopy were treated at the initial visit.   Only 4 in 10 patients were treated at the first visit indicating a lack of awareness of symptoms of acute syphilis; this may also have led to higher rates on onward transmission and sequelae.  More education on recognising acute syphilis ad the treatment thereof is needed.