The Rising Tide of Syphilis: Coming To A Patient Near You

Gail Bolan, MD


July 14, 2017

Editorial Collaboration

Medscape &

During my days as a medical student at Dartmouth, a professor loosely quoted Sir William Osler—"He who knows syphilis knows medicine"—but then added that it would be unlikely for me to see many cases of syphilis. And yet I've been fighting it in the clinic in one way or another for almost my entire career. Why am I telling you this? Because at that time, and even up until about a decade ago, we believed that we had syphilis on the ropes.

Gail Bolan, MD, Director, Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention

Fast-forward to 2017. The Centers for Disease Control and Prevention's (CDC's) most recent data[1] find that reported rates of primary and secondary syphilis, the most infectious stages of the disease, are the highest that they have been in more than 20 years. In fact, rates have increased in every region, in a majority of age groups, and across almost every race/ethnicity. If recent news reports[2] of outbreaks in states around the country are any indication, the situation may get worse before it gets better.

Despite increases across many communities, everyone is not affected equally. Gay, bisexual, and other men who have sex with men (MSM) continue to face both the highest and the highest-rising rates of syphilis. Now, for the first time in many years, women, who not long ago experienced historically low rates, have begun to see increases as well. This newer trend has led to a surge in congenital syphilis.[1] CDC has also seen an increase in reports of ocular syphilis.[3]

So now what? To get to the point of the matter, CDC is concerned—and rightly so. Untreated syphilis can be very dangerous, leading to visual impairment, hearing loss, stroke, and other neurologic problems in adults. In pregnant women, it can cause stillbirths and significant health consequences among newborns.

At the same time, because syphilis rates remained so low for so long, it's likely that many of you have had limited, if any, experience with diagnosing and treating it. The issue is further compounded by a deteriorating public health infrastructure that features fewer health department clinics for the treatment of sexually transmitted infections, the very places that traditionally provided same-day testing and onsite treatment with injectable Benzathine penicillin G. Add to that the fact that many of the clinics that do remain open are experiencing reduced hours, staff, and testing. Suddenly our growing syphilis problem looks a little grim.

It's not all bad news: We know how to prevent syphilis and we know how to treat it (and, unlike with gonorrhea, antibiotic resistance has not become a serious concern). However, we cannot rely on the situation to right itself.

What we need is a path forward. In late April, we released the CDC Call to Action: Let's Work Together to Stem the Tide of Rising Syphilis in the United States. That's where you come in. You can help make a difference by taking the following actions.

To Reduce Congenital Syphilis

Complete a sexual history for your patients. Support a welcoming environment and have honest and open talks with your patients about their sexual history. STD counseling should be provided to those at risk for STDs, and contraceptive counseling should be provided to those at risk for unintended pregnancy.

Test all pregnant women for syphilis. This should occur at the first prenatal visit or at the time that pregnancy is confirmed. Repeat screening for pregnant women at high risk and in areas of high prevalence at the beginning of the third trimester and at delivery.

Treat infected women immediately. If a woman has syphilis or suspected syphilis, treat her immediately with long-acting penicillin G, especially if she is pregnant, according to CDC's STD Treatment Guidelines.[4] Benzathine penicillin G is the only recommended treatment for pregnant women with syphilis. Test and treat the infected woman's sex partner(s) to avoid reinfection. If you have challenges obtaining penicillin G, contact your state or local health department.

Confirm syphilis testing at delivery. Before discharging the mother or infant from the hospital, make sure that the mother has been tested for syphilis at least once during pregnancy or at delivery if there was no prenatal care. If she tests positive, manage the infant appropriately. All women who deliver a stillborn infant should be tested for syphilis at delivery.

Quickly report all cases of syphilis and congenital syphilis. Report cases of syphilis by stage to the local or state health department right away. Congenital syphilis cases, along with infectious syphilis cases, should be reported within 24 hours.