Hosts: Jake Lancaster MD, Chief Medical Information Officer and Amanda Comer DNP, System Director, Advanced Practice Providers Guest: Alex Yoby, Pharmacist CME Credit Info: Link to complete brief survey and claim CME credit: https://www.surveymonkey.com/r/C55LKSYCME credit is available for up to 3 years after the stated release date Contact CEOD@bmhcc.org if you have any questions about claiming credit. CDC’s Sexually Transmitted Infections (STI) Treatment Guidelines, 2021 Notable updates: These guidelines discuss 1) updated recommendations for treatment of Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis; 2) addition of metronidazole to the recommended treatment regimen for pelvic inflammatory disease; 3) alternative treatment options for bacterial vaginosis; 4) management of Mycoplasma genitalium; 5) human papillomavirus vaccine recommendations and counseling messages; 6) expanded risk factors for syphilis testing among pregnant women; 7) one-time testing for hepatitis C infection; 8) evaluation of men who have sex with men after sexual assault; and 9) two-step testing for serologic diagnosis of genital herpes simplex virus Syphilis Lore It is postulated that syphilis came to Europe in the 1490s when Columbus arrived in Italy from America. After Italy surrendered to the invading French in 1495, this new disease rapidly spread across Europe. The name "syphilis" comes from the work of Girolamo Fracastoro, a noted poet and physician in Verona, Italy. In 1530, he wrote about a shepherd named Syphilus who angered Apollo, causing the god to curse the entire population with the affliction that we now know as syphilis T. pallidum Syphilis is a systemic, bacterial infection caused by Treponema pallidum. Treponema are thin, Gram-negative, slowly metabolizing spirochetal bacterium, requiring an average of 30 hours to multiply. It is microaerophilic and cannot grow on standard culture media. Treponema pallidum’s outer membrane lacks lipopolysaccharides and has few surface-exposed unique proteins, making it difficult for the immune system to fight the infection. Because of this characteristic, T pallidum is labeled as a stealth pathogen. T. pallidum is the only Treponema species that causes sexually transmitted disease. Syphilis is characterized by a wide range of variable clinical symptoms that can resemble other diseases, which make it difficult to diagnose without a test, therefore, it is often referred to as “The Great Imitator”. The infection progresses through multiple stages (primary, secondary, latent, and tertiary) and can affect virtually every organ system in the body, even many years or even decades after the original infection. Infected people are contagious during the primary and secondary stages of syphilis. Stages of syphilis Primary syphilis: Primary syphilis classically presents as a single painless ulcer or chancre at the site of infection but can also present with multiple, atypical, or painful lesions. A chancre is defined as a firm, round, painless ulcer at the site of entry of an infecting organism. Chancres appear 10 to 90 days (median of 21 to 25 days) after exposure to the infecting organism. While the chancre represents the initial local reaction to the infection, the bacteria quickly become widely disseminated in the body, including the cerebrospinal fluid, even without any additional immediate symptoms. Up to 70% of early syphilis patients will demonstrate cerebrospinal fluid (CSF) changes consistent with neurosyphilis, and 30% will have direct evidence of T pallidum. Despite this occurrence, very few will develop clinical neurosyphilis. Secondary syphilis: A diffuse and extensive maculopapular rash that includes the palms of the hands and the soles of the feet, as well as oral lesions in the mouth, are the characteristic cutaneous manifestations of secondary syphilis. Symptoms typically appear 2 to 8 weeks after the disappearance of the primary chancre and have multiple systemic manifestations that can involve any system or body part. The T pallidum multiply and spread rapidly, causing fevers, myalgias, headaches, anorexia, sore throat, weight loss, joint pain, malaise, and particularly, the cutaneous manifestations characteristic of secondary syphilis. Enlarged lymph nodes are common in this stage and are usually described as firm, rubbery, and with only minimal tenderness. The lesions of secondary syphilis generally resolve within a few weeks, even without treatment, but will relapse in 25% of untreated patients, usually within 12 months. After that, without treatment, the disease enters the latent stage, and about 33% of patients will eventually develop tertiary syphilis. Tertiary syphilis: Late symptomatic disease that can manifest months, years, or even decades after the initial infection as cardiovascular syphilis (aortic aneurysm, aortic valvulopathy), neurosyphilis (meningitis, hemiplegia, stroke, aphasia, seizures, spinal neuroarthropathy, tabes dorsalis, syphilitic paresis), or gummatous syphilis (infiltration of any organ and its subsequent destruction). Latent syphilis: Latent syphilis is defined as syphilis characterized by seroreactivity without other evidence of primary, secondary, or tertiary disease. Latent infections (i.e., those lacking clinical manifestations) are detected by serologic testing. Latent syphilis acquired within the preceding year is referred to as early latent syphilis; all other cases of latent syphilis are classified as late latent syphilis or latent syphilis of unknown duration. Latent syphilis is not transmitted sexually Neurosyphilis: T. pallidum can infect the CNS, which can occur at any stage of syphilis and result in neurosyphilis. Early neurologic clinical manifestations or syphilitic meningitis (e.g., cranial nerve dysfunction, meningitis, meningovascular syphilis, stroke, and acute altered mental status) are usually present within the first few months or years of infection. Late neurologic manifestations (e.g., tabes dorsalis and general paresis) occur 10 to >30 years after infection. Congenital syphilis: Congenital syphilis results from transplacental transmission or contact with infectious lesions during birth and can be acquired at any stage, often causing stillbirth or neonatal congenital infections. Without treatment, up to 40% of women with syphilis will have stillborn births, and many more will have premature labor or low-birth-weight babies. Effective prevention and detection of congenital syphilis depends on identifying syphilis among pregnant women and, therefore, on the routine serologic screening of pregnant women during the first prenatal visit and at 28 weeks’ gestation and at delivery for women who live in communities with high rates of syphilis, women with HIV infection, or those who are at increased risk for syphilis acquisition. Certain states have recommended screening three times during pregnancy for all women; clinicians should screen according to their state’s guidelines. Epidemiology Per the CDC, a syphilis epidemic is occurring in the United States, with sustained increases in primary and secondary syphilis from 5,979 cases reported in 2000 to 133,945 cases reported in 2020, a 2,140% increase The rate of reported congenital syphilis in the United States has increased dramatically since 2012. About 53 percent of congenital syphilis is reported from southern states, according to data from the U.S. Centers for Disease Control and Prevention. 3,761 cases of congenital syphilis in the United States were reported to CDC in 2022. including 231(6%) stillbirths and 51(1%) infant deaths. 88% of cases of congenital syphilis in 2022 were directly impacted by the lack of timely testing and adequate treatment during pregnancy. · MISSISSIPPI: In 2022, Mississippi ranked 5th in reported rates of primary and secondary syphilis with a rate of 31.1 per 100,000 individuals (the rate was 28.1 per 100,000 individuals in 2021). Mississippi also ranked 6th in reported rates of congenital syphilis with a rate of 207.6 per 100,000 live births (the rate was 182.0 per 100,000 live births in 2021). · ARKANSAS: In 2017, only 27 pregnant women with reported...
