United States: Amidst the swift escalation of syphilis incidents throughout the United States and globally, medical practitioners face the formidable task of enhancing their proficiency in both identifying and treating this frequently disregarded ailment.
Surpassing 200,000 documented incidents in 2022 alone, marking the highest count since 1950 with a significant 17.3 percent surge compared to the preceding year, as disclosed by the Centers for Disease Control and Prevention (CDC), the prevalence of syphilis has been on a continual rise, nearly every year since its lowest point in 2001.
This upsurge is not limited to the United States; in the United Kingdom, for example, 2023 saw the highest infection rate in fifty years, according to David Mabey, BCh, DM, of the London School of Hygiene and Tropical Medicine. Furthermore, he emphasized that syphilis and other sexually transmitted infections present notable challenges in low- and middle-income nations, notwithstanding the scarcity of comprehensive data, as cited by Medspace.
In view of this, numerous contemporary healthcare professionals lack substantial exposure to the ailment, as observed by Ina Park, MD, an authority in sexually transmitted infections at the University of California, San Francisco. Reflecting on her own experience, Park asserted, “An entire cohort of medical practitioners, including myself, encountered no instances during our formative years of training. We find ourselves in a significant period of catch-up.”
An Ailment Encompassing Centuries
Delving into the intricacies associated with diagnosing this elusive ailment at the 2024 Annual Meeting of the Conference on Retroviruses and Opportunistic Infections (CROI) in Denver, Park distilled her guidance to a straightforward directive: “Test, test, test!”
Additionally, syphilis’s disguising attributes render it capable of mimicking various ailments, as well as entering a state of dormancy. This can lead even seasoned physicians to overlook syphilis or yield less precise findings, as per Medspace.
Ms. Jones’s emphasis on the updated FCD screening recommendations concerning syphilis screening cannot be overstated, she emphasized. Every sexually active individual aged 15 to 44 residing in urban areas with over 4.6 per 100000 prevalence of syphilis must undergo screening. Moreover, the physician reminded healthcare personnel to remain vigilant whenever there is the slightest suspicion of the ailment, even with lower incidence rates. In cases of sexually active patients, testing should be the initial step if the patient manifests new symptoms, as advised by the physician.
Navigating Complexities
The scarcity of familiarity with syphilis extends beyond diagnosis to treatment, particularly in complex cases, noted Khalil Ghanem, MD, PhD, from the Johns Hopkins University School of Medicine in Baltimore. He remarked, “When an ailment remains dormant for an extended period, one’s proficiency in managing it may wane.”
At the CROI, Ghanem proposed strategies for addressing challenging scenarios involving ocular syphilis, otic syphilis, and neurosyphilis, as well as interpreting perplexing test outcomes indicating erratic antigen levels.
In cases of suspected ocular or otic syphilis, Ghanem advocated for immediate referral to the emergency department, bypassing the customary consultation with specialists such as ophthalmologists, owing to the risk of irreversible complications such as permanent blindness or deafness. “Delay is inadvisable in such circumstances,” he cautioned, according to reports by Medspace.
Close monitoring of a patient’s rapid plasma regain, and venereal disease research laboratory antigen levels are indispensable for managing syphilis and evaluating treatment efficacy, Ghanem emphasized. Nevertheless, he acknowledged that interpreting these levels can pose challenges, with instances where they deviate unexpectedly post-treatment.
To decipher enigmatic test results, Ghanem stressed the importance of acquiring a comprehensive patient history to discern potential risks of reinfection, signs of neurosyphilis or other complications, pregnancy status, and other relevant factors. “Based on this information, one can devise the most prudent treatment approach,” he remarked.
Shortage Predicaments
Efforts to mitigate the spread of syphilis have been further complicated by supply shortages. Last summer, Pfizer announced the depletion of stocks of penicillin G benzathine (Bicillin), a long-acting injectable vital for syphilis treatment, particularly in pregnant individuals. Pediatric supplies were exhausted by June 2023, followed by adult stocks by September.
Given Pfizer’s monopoly on penicillin G benzathine production, interim solutions are scarce, prolonging the shortage until at least mid-2024. Consequently, the US Food and Drug Administration has temporarily authorized the use of benzylpenicillin benzathine (Extencilline), a French formulation not approved in the United States, until supplies stabilize.
This shortage underscores the critical need for alternative syphilis treatments during pregnancy, which is essential for mitigating the risk of congenital syphilis. Ghanem expressed hope that this predicament would spur the National Institutes of Health and other stakeholders to expedite research into alternative therapies suitable for pregnant individuals.