Red flags

Consider urgent referral for patients with the following:

  • Confusion
  • Neurological involvement
  • Herxheimer reaction after initiating treatment

Features that may lead to more urgent categorisation

  • Features primary or secondary syphilis
  • Anaphyllactic sensitivity to penicillin

Syphilis has become much more common over the last 10-15 years. Syphilis infection can be categorised into:

  • Early (less than 2 years duration) include primary, secondary and early latent
  • Late (over 2 years duration)

Other important information for referring practitioners

Lifestyle changes

  • Obtain full sexual history and contact tracing or refer to sexual health for follow up of contacts
  • Advise re infectivity

Medical management

Most cases can be managed in primary care. Advice can be obtained by contacting Queensland Sexual Health Services at Biala Sexual Health and HIV Service, 270 Roma St, Ph: (07) 3837 5611.

  • Definitive diagnosis of syphilis requires the following:
    • Reactive non-treponemal test: Rapid plasma regain (RPR) – this is the most commonly used test – or venereal diseases reference laboratory (VDRL), and
      • At least 1 reactive specific treponemal test, such as:
        • Treponema pallidum agglutination/haemagglutination (TPPA/TPHA)
        • Fluorescent treponemal antibody-absorption (FTA-ABS) test
        • Enzyme immune assay (EIA)
    • Demonstrated seroconversion of specific treponemal test within 12 months of a negative test
    • Detection of T. pallidum by nucleic acid test (NAT) from a clinical specimen
  • Definitive diagnosis of re-infection requires:
    • Significant increase (4 fold) in non-treponemal test titre (most commonly RPR) in a previously infected individual
  • Treponemal specific tests tend to remain positive for life and once positive are of no value in determining response to treatment or reinfection
  • Atypical results may occur in HIV patients
  • Seroconversion after contact can take up to 3 months
  • Treatment should be offered to the following:
    • Symptomatic patients (with typical ulcer or secondary lesions) with:
      • Rising RPR titre (4 fold) before treatment
      • Reactive RPR & specific test with evidence of negative serology within the previous 2 years
    • Asymptomatic patients with:
      • Reactive treponemal test (EIA, TPPA, TPHA or FTA-ABS) and one of the following:
        • Negative serology within the last 2 years
        • 4-fold increase in RPR titre on subsequent testing
  • Treatment is Penicillin G for all stages
    • Early syphilis (primary , secondary and early latent)
      • Benzathine penicillin G 1.8gm imi (given as 0.9gm into each buttock) or
      • Procaine penicillin G 1.0gm imi daily for 10 days or
      • Doxycycline 100mg bd for 14 days if penicillin allergic and not pregnant
        • This treatment is inferior to penicillin
    • Late latent syphilis
      • Benzathine penicillin G 1.8gm imi 3 doses given 1 week apart
      • Procaine penicillin G 1.0gm imi daily for 15 days
      • Doxycycline 100mg bd for 28 days if penicillin allergic and not pregnant
        • This treatment is inferior to penicillin
  • Treatment of contacts should be with Benzathine Penicillin G 1.8gm imi without waiting for results of serology as this can be negative for up to 3 months
  • If there are concerns regarding neurological involvement the patient should be referred for consideration of lumbar puncture

Referral requirements

A referral may be rejected without the following information.

  • Presence of any red flags
  • Timeline of symptoms
    • Chancre
    • Rash, etc
  • Mode of infection
  • Sexual history
  • Travel history
  • Previous treatment history
  • Examination to include relevant feature e.g. primary lesion, features suggesting secondary stage, etc
  • Investigations
    • Syphilis serology (see below for interpretation of this)
    • FBC, E/LFT, HIV

Additional referral information (useful for processing the referral)

  • ECG if late latent syphilis suspected
  • CT brain if late latent syphilis is suspected

Out of catchment

Metro North Health is responsible for providing public health services to the people who reside within its boundaries. Special consideration is made for patients requiring tertiary care or services that are not provided by their local Hospital and Health Service. If your patient lives outside the Metro North Health area and you wish to refer them to one of our services, inclusion of information regarding their particular medical and social factors will assist with the triaging of your referral.

  • Impact on employment
  • Impact on education
  • Impact on home
  • Impact on activities of daily living
  • Impact on ability to care for others
  • Impact on personal frailty or safety
  • Identifies as Aboriginal and/or Torres Strait Islander
  • To establish a diagnosis
  • For treatment or intervention
  • For advice and management
  • For specialist to take over management
  • Reassurance for GP/second opinion
  • For a specified test/investigation the GP can’t order, or the patient can’t afford or access
  • Reassurance for the patient/family
  • For other reason (e.g. rapidly accelerating disease progression)
  • Clinical judgement indicates a referral for specialist review is necessary
  • Presenting symptoms (evolution and duration)
  • Physical findings
  • Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
  • Body mass index (BMI)
  • Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes), noting these must be stable and controlled prior to referral
  • Current medications and dosages
  • Drug allergies
  • Alcohol, tobacco and other drugs use
  • Full name (including aliases)
  • Date of birth
  • Residential and postal address
  • Telephone contact number/s – home, mobile and alternative
  • Medicare number (where eligible)
  • Name of the parent or caregiver (if appropriate)
  • Preferred language and interpreter requirements
  • Identifies as Aboriginal and/or Torres Strait Islander
  • Full name
  • Full address
  • Contact details – telephone, fax, email
  • Provider number
  • Date of referral
  • Signature
  • Willingness to have surgery (where surgery is a likely intervention)
  • Choice to be treated as a public or private patient
  • Compensable status (e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.)
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