BASHH National Audit Group
Case Note Audit on the Management of Late Syphilis
(Excluding congenital syphilis)
BASHH Clinical Effectiveness Group Auditable Outcome Measures (2008):
 Performing VDRL/RPR titre at commencement of therapy
 Response to treatment:
o Resolution of clinical lesions
o A two dilution (four-fold) or greater titre decrease in the VDRL/RPR within three to six months
after treatment
o For neurosyphilis, the CSF cell count should have decreased by six months and the CSF should
be entirely normal by two years except for persistent positive specific tests
 At least 60% of contactable partners should attend for screening and/or treatment (although, while this
standard may be achievable in some settings, it may not be in all)
Five essential questions are: Qs 5, 7, 9, 12, 22 highlighted in yellow
Name of Clinic:
Case ID:
Audit Form No:
Q.1: Age (years):
Q.2: Gender
 Male
 Female*
Q.3: Sexuality
 Heterosexual  Homosexual
*  √ if pregnant
 Bisexual
 Unknown
Q.4: Ethnicity
Ethnic category
White
British
Irish
Any other White background
Asian or Asian British
Indian
Pakistani
Bangladeshi
Any other Asian background



Mixed
White and Black Caribbean
White and Black African
White and Asian
Any other mixed background








Black or Black British
Caribbean
African
Any other Black background



Other Ethnic Groups
Chinese
Any other ethnic group
Not stated



Q.5a: Which of the following screening tests were done initially to diagnose syphilis, and
what was/were the result of the(se) test(s). Please tick all that apply:
Done?
Test
Negative

Enzyme immunoassay (EIA) that detected both antitreponemal IgG and IgM antibody

EIA that detected anti-treponemal IgG only
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
Positive

BASHH National Audit Group

Treponema pallidum particle agglutination assay (TPPA)



Treponema pallidum haemagglutination assay (TPHA)



Venereal Diseases Research Laboratory (VDRL)



Rapid plasma regain test (RPR)



Other, please specify:


Q.5b: Which of the following test were done to confirm the diagnosis of syphilis, and what
was/were the result of the(se) test(s). Please tick all that apply:
Done?
Test
Negative
Positive

Repeating testing on a second blood sample



Treponema pallidum particle agglutination assay (TPPA)



Treponema pallidum haemagglutination assay (TPHA)



Venereal Diseases Research Laboratory (VDRL)



Rapid plasma regain test (RPR)



Antitreponemal IgM antibody



Treponemal IgG immunoblot using recombinant antigen



Fluorescent treponemal antibody absorption test (FTA)



Direct fluorescent antibody (DFA)



Other, please specify:


Q.5c: Which of the following additional tests were done to support a diagnosis of late
syphilis, and what was/were the result of the(se) test(s)? Please tick all that apply:
Done?
Test
Negative
Positive

Tissue biopsy



Other, please specify:


Q.6: Please state any presenting clinical features
 Symptomatic. Please state which symptoms were present:
 Asymptomatic
 Clinical signs of syphilis found. Please state which clinical signs of syphilis (including any
neurological or cardiovascular system signs attributed to syphilis) were found:




No clinical signs of syphilis found
Past history of treatment for syphilis
Obstetric history of miscarriages or stillbirths
Other, please state:
Q.7a: Which of the following were offered and provided to this patient?
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Please tick all that apply:
Offered
Provided
Mouth examination


Skin examination


Perianal skin examination


Lymph node location examination


Cardiovascular system examination


Neurological examination


Optic fundus examination


Lumbar puncture and CSF examination


Electrocardiogram


Chest X-Ray




Other, please specify:
Q.7b: If CSF examination was carried out, please state the findings here:
Q.8: What stage of syphilis infection did this patient have?
 Late latent syphilis
 Cardiovascular syphilis
 Gummatous syphilis
 Other, please specify:
 Neurosyphilis
Q.9: Was the patient offered an HIV test during this episode? Please tick all that apply:
 Known HIV positive
 Offered HIV test, result positive
 Offered HIV test, result negative
 Not offered HIV test
 Offered HIV test, declined
 A plan for repeat HIV testing was documented
 Other, please specify:
Q.10: Was the patient offered screening tests for other sexually transmitted infections (STIs)
during this episode?
 Offered, declined
 Not offered
 Offered, result(s) negative
 Offered, result(s) positive. Please state diagnostic codes of infections detected:
 Other, please specify:
Q.11a: If female, was a pregnancy test offered?
 Yes
 No
 Not documented/known
 Not applicable
Q.11b: If Yes, please state the result of the pregnancy test:
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Q12a: Please specify which of the following drug treatments was given for late syphilis.
Please tick all that apply (if more than one treatment was given, please explain the circumstances
under Other):
 Benzathine penicillin 2.4 MU intramuscularly weekly for two weeks (three doses)
 Procaine penicillin 600,000 units intramuscularly once daily for seventeen days
 Procaine penicillin 1.8–2.4 MU i.m. once daily plus probenecid 500 mg orally four times daily for
seventeen days
 Doxycycline 100 mg orally twice daily for twenty-eight days
 Doxycycline 200 mg orally twice daily for twenty-eight days
 Amoxycillin 2 grams orally three times daily plus probenecid 500 mg four times daily, both for
twenty-eight days
 Benzylpenicillin 18–24 MU daily, given as 3–4 MU intravenously every four hours for seventeen
days
 Long acting Biclinocillin IM 2 MU (containing benethamine penicillin 1.2 MU
 Long-acting procaine penicillin G in aluminium stearate (Jencillin O) 2 MU
 Other, please specify:
Q12b: Was the treatment given under direct observation by clinic staff?
 Yes
 No
 Not documented/known
Q.13: If the patient was penicillin-allergic, was penicillin desensitization offered?
 Yes, declined
 Yes, accepted
 Not offered
 Not penicillin-allergic
 Other, please state:
Q.14: Was a discussion with the patient about possible adverse reactions to treatment
documented?
 Yes
 No
 Not documented/known
Q.15a: Did the patient have any adverse reaction to treatment for syphilis?
 Yes
 No
 Not documented/known
Q.15b: If Yes, please give details of the reaction and the treatment given:
Q.16a: Was a corticosteroid course prescribed?
 Yes
 No
Q.16b: If Yes, please state why this was prescribed:
Q.17a: Was the patient offered specific follow up for syphilis treatment? Please tick all that apply:
 No follow up was offered
 Offered follow up, but declined
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



Offered follow up, accepted
Option of review left to patient choice
A follow up plan was documented
Other, please specify:
Q.17b: If a follow up plan was documented, please specify the follow-up intervals
documented, beginning from treatment completion. Please tick all that apply:
 3 monthly until serofast*
 Other, please state below:
*serofast means there was no change in the VDRL/RPR titer with repeated testing during follow up.
Q.18a: On how many occasions did the patient attend a genitourinary medicine clinic for
follow up after completion of treatment for syphilis? Please state the number of follow visits:
 The patient did not attend for any follow up visits at this clinic
 The patient was followed up at another genitourinary medicine clinic
Q.18b: If the patient did not attend any planned follow up visit at your clinic, was recall of the
patient attempted on at least one occasion?
 Yes
 No
 Not documented/known
Q.19: Did the patient complete the full course of treatment?
 Yes
 No
 Not documented/known
Q.20a: Did any symptoms attributed to syphilis resolve?
 Yes
 No
 Not applicable
 Not documented/known
Q.20b: If No, please state which symptoms remained:
Q.20c: Did any clinical signs of syphilis resolve?
 Yes
 No
 Not applicable
 Not documented/known
Q.20d: If No, please state which clinical signs remained:
Q.21: Was the patient given a letter documenting his/her treatment?
 Yes
 No
 Not documented/known
Q.22a: What was the serological outcome for this patient following treatment for syphilis?
Please tick all that apply:
 Negative pre-treatment VDRL/RPR which was also negative 3 months after treatment completed
 VDRL/RPR titre decreased by at least two dilution steps (fourfold) within the 3-6 months from
treatment completion
 VDRL/RPR serofast between two tests taken three months apart
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 VDRL/RPR titre remained at greater than 1:8 with repeated follow up testing
 VDRL/RPR titre initially decreased by at least two dilution steps, but later increased by at least
two dilution steps
 Other, please specify:
Q.22b: What further diagnoses and/or action(s) followed this patient’s (initial) treatment for
syphilis. Please tick all that apply:







Reinfected diagnosed
Treatment failure diagnosed
Reactivation of syphilis diagnosed
Patient retreated for syphilis
Patient discharged from further follow up for this syphilis episode
Annual follow up recommended for life
Regular VDRL/RPR testing recommended beyond any follow up plan for syphilis for as long as
at continued risk syphilis reinfection
 (Repeat) CSF examination carried out. Please state the reason for this and the findings:
 Other outcome, please specify:
Q.23a: Was it documented that the patient was offered written information on syphilis?
 Yes
 No
Q.23b: If Yes, did this include information on possible adverse reactions to treatment for
syphilis?
 Yes
 No
Q.24: Please provide any additional comments about the management of this patient in your
clinic here:
For case note questions on partner notification, please see the Case Notes Audit on
Partner Notification Questionnaire: www.bashh.org/groups/national_audit_group
Last modified 17 October 2012 Hugo McClean/Anatole Menon-Johansson
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