COLUMBUS COUNTY HEALTH DEPARTMENTS
SYPHILIS and CONTACTS TO SYPHILIS POLICY
Policy Title:
Syphilis and Contacts to Syphilis
Program Area:
STD Clinic
Policy Identifier:
(optional)
Effective Date:
10/2002
Approval Date:
Revision
Date(s):
10/2002
4/30/2013
Approved by:
Kim Smith RN, BSN, MSHCA, Health Director
Approved by:
Hilda Memory RN, BS, MSHA, Director of Nursing
Purpose:
The Columbus County Health Department STD clinic is to identify and treat client’s positive for
Syphilis and their contacts thus prevent the spread of disease.
Definitions:
Columbus County Health Department will provide STD screening and treatment
for clients with Syphilis and their contacts. Staff will provide risk reduction education to clients.
Responsibilities:
STD Clinic staff
Procedures:
A. Each client requesting STD services will be screened and examined according to the STD
Exam Policy.
B. If the patient has signs and symptoms of primary or secondary syphilis collect a stat RPR.
1. Collect one tube of serum separator.
Clinical Manifestations
Syphilis is an acute and chronic infectious venereal disease characterized by lesions
which may involve any organ or tissue. It is transmitted by direct contact
between humans, contact with freshly contaminated material, transfusion of infected
blood or plasma, or in utero by passage of organism from mother to fetus. The organism may
enter through any broken place in skin or mucous membrane.
1. Primary stage- Initial lesion (chancre) appear 2 to 4 weeks after
inoculation changing from a small red papule to a small ulcer hard
chancre, Usually painless and forms upon prepuce or vulva. Lymph nodes
enlarge about two weeks after appearance of lesion.
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COLUMBUS COUNTY HEALTH DEPARTMENTS
SYPHILIS and CONTACTS TO SYPHILIS POLICY
2. Secondary stage-Symptoms appear about 6 weeks after appearance of primary
lesion, principally in the form of lesions of the skin and mucus membranes.
Systemic symptoms such as headaches, fever, and malaise are common but may
be absent. Eruptions of skin, masulae syphilide, reddish brown coppery spots
continuing for a week or two and possible recurring later.
3. Tertiary "latent" stage- The heart and blood vessels (cardiovascular syphilis and
the central nervous system (neurosyphilis) are frequently involved. General
paralysis and various types of psychoses may result.
-
Medically Indicated
A. Typical lesion(s) (chancre)
B. Reactive non-treponemal test and no history of syphilis
C. A fourfold or greater increase in titer on a quantitative non-treponemal test compared with the
most recent test for persons with a history of syphilis.
D. Contacts to syphilis
Treatment
A. Primary, Secondary and Early Latent (duration less than one year) Syphilis:
1. Benzathine Penicillin (Bicillin L-A), 2.4 million units, IM (1.2 mu in each buttock).
2. If allergic to penicillin and not pregnant:
 Administer Doxycycline 100 mg PO BID X 14 days. (If possible, give one
dose daily as directly observed therapy).
3. If allergic to penicillin and pregnant:
Consult with medical director, physician or midlevel practitioner
while patient is on-site and arrange referral for desensitization and treatment with
penicillin.
4. Parenteral penicillin G is the only therapy with documented efficacy for syphilis
during pregnancy. Pregnant women with syphilis in any stage who report
penicillin allergy should be desensitized and treated with penicillin (see CDC
Management of Patients Who Have a History of Penicillin Allergy).
5. For penicillin allergic, or Tetracycline intolerant patients, Erythromycin 500mg p.o.
QID for 15 days.
B. Latent Syphilis of indeterminate duration or with onset of symptoms more than 12 months
prior to treatment.
1. In patients without known HIV infection:
• If no signs or symptoms of neurosyphilis are present, give Benzathine
penicillin G, 7.2 million units total, administered in three doses of 2.4 million
units IM, one week apart for three consecutive weeks. If a dose is one week or
more late, begin series again.
 If allergic to penicillin and not pregnant, give Doxycycline, 100mg p.o. BID for 28
days
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COLUMBUS COUNTY HEALTH DEPARTMENTS
SYPHILIS and CONTACTS TO SYPHILIS POLICY
2. If patient with known HIV infection, refer to ID clinic or to the patient's private
physician for possible LP. If CSF shows no signs of neurosyphilis, or PMD agree give:
 Benzathine penicillin G, 7.2 million units total, administered in three doses of 2.4
million units IM, one week apart for three consecutive weeks.
 If penicillin allergic, see section B (3) below.
3. Pregnant and HIV infected patients with neurosyphilis who are allergic to penicillin
must be desensitized and treated immediately in order to prevent congenital syphilis a
complication of syphilis. Consult with a physician while patient is on-site and refer patient
to PMD for desensitization. (Desensitization usually occurs in a hospital setting).
4. Neurosyphilis (If diagnosed by a physician and referred to health department for
treatment).
 Upon referral from physician, a patient who is not HIV infected and whom compliance
with therapy can be assured, may be treated per referring physician order. The
order must include the medication to be given, how many days to be given,
and route to be given (i.e. IM, P.O.). The usual treatment for Neurosyphilis is
Procaine penicillin 2.4 million units, IM q day, plus probenecid 500mg, p.o. QID
both for 10 to 14 days.
 There is no alternative therapy for penicillin allergic patients with
neurosyphilis. Treatment should be given following skin testing and/or
desensitization. Consideration should be given to giving either regimen at home with
the assistance of a home health agency.
5. Congenital Syphilis: Infants born to mothers with a positive non-treponemal antibody for
syphilis should be called to the Regional HIV/STD Control Branch Office within 24
hours and reported on a Communicable Disease Report Card as a possible case of
congenital syphilis and be immediately referred to physician for evaluation and
decisions about therapy.
Follow Up after Treatment
-
A. Primary and Secondary Syphilis Infection
1. Non-pregnant and non HIV infected patients with early syphilis should return for
examination and repeat quantitative non-treponemal tests at 6 and 12 months after
treatment. A four-fold decline in titer should be expected at 6 months.
2. Pregnant patients should be evaluated monthly:
 Non-treponemal antibody titers have not declined four-fold by 3 months; or

Signs or symptoms persist or recur, refer the patient to private physician for LP to
evaluate for neurosyphilis. The decision to treat as a re-infection or as a treatment
failure must be made in consultation with OBGYN physician.
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COLUMBUS COUNTY HEALTH DEPARTMENTS
SYPHILIS and CONTACTS TO SYPHILIS POLICY
B. Latent Syphilis Infection without Neurosyphilis or HIV Infection
1. Patients should return for examination and repeat non-treponemal test 6 and 12 months
after treatment.
2. A fourfold decline in titer is expected at 6-12 months.
3. If titer increase four fold, if an initially high titer (>1:32) fails to decrease or if the
patient should be referred for evaluation to assess whether treatment failure is due to reinfection, untreated congenital syphilis, and/or neurosyphilis.
C. Neurosyphilis Infection (Requires Consultation and Referral to MD). Patients with
neurosyphilis must be carefully followed with periodic serologic testing and clinical
evaluation.
1. Patients with symptomatic neurosyphilis (see assessment protocol) should be followed
clinically by a physician until signs and symptoms resolve. In addition they should
have serologic and CSF follow-up as directed in 2.
2. Patients with CSF pleocytosis and no symptoms of Neurosyphilis (see assessment
protocol) should have a repeat clinical examinations and quantitative non-treponemal
tests at 3, 6, and 12 months after therapy and CSF examinations every six months until the
cell count is normal. If the cell count has not decreased 6 months after treatment,
retreatment should be strongly considered in consultation with physician.
D. Syphilis in HIV infected patients: Patients should return for examination and repeat quantitative
testing and 3, 6, 9, and 12 months and 24 months after therapy. If titers have risen of failed to
fall as described in A or B, above, the patient should be referred to physician for LP. If there is
no CSG pleocytosis, the patient should be retreated with Benzathine penicillin G, 7.2 million
unit’s total, to be administered as 2.4 million units IM weekly for three consecutive weeks. If
CSF pleocytosis is present, the patient should be treated for neurosyphilis.
E. Congenital Syphilis (to be followed by private physician, recommendations are as follows):
1. Treat infants: Repeat non-treponemal antibody test for syphilis every 2 months until
the STS is non-reactive. If titer has not declined within two months following therapy,
does not continue to decline at 4 months following therapy, or has not become non-reactive
by six months after therapy, refer to physician.
2. Untreated infants: Repeat treponemal and non-treponemal antibody test for syphilis and
refer for clinical examination by a physician at 1, 2, 3, 6, and 12 months after birth. If
non-treponemal titer has not begun to decline by three months, is not negative by 6
months, or is rising at any time, refer to physician. If treponemal test remains reactive at
12 months of age, refer to physician.
Patient Instructions
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COLUMBUS COUNTY HEALTH DEPARTMENTS
SYPHILIS and CONTACTS TO SYPHILIS POLICY
A. Avoid sexual contact until patient and partner(s) have completed medication.
B. Counsel patients (male and female) concerning use of condoms.
C. Caution female patients who take oral contraceptives to use a back-up method of birth control
while on antibiotic therapy and for seven days after completion.
D. Caution female patients not to get pregnant if taking Doxycycline.
E. Counsel patients regarding the importance of early re-evaluation if symptoms persist or recur.
F. Counsel about the risk of HIV infection and recommend HIV testing.
G. Counsel the patient regarding the possibility of developing a Jarisch-Herxheimer reaction
within 24 hours after treatment for syphilis. Symptoms may include fever, malaise, headache,
musculoskeletal pain, nausea, and tachycardia. A primary lesion may swell and the lesions of
secondary syphilis may increase or appear for the first time. Reassure the patient that if this
occurs, it is normal and they should drink fluids and take oral analgesics if needed. If the
patient is pregnant, she should also be told to note the frequency of fetal movement. If fetal
movements decrease dramatically, she should call her prenatal clinic or physician.
H. Refer immediately to a DIS for sex partner notification in order to prevent further spread of
the disease.
1. Counsel regarding TB and offer TB testing.
Laws and Rules:
10A NCAC 4 1A .0204, 10A NCAC 41 A .0202, 10A NCAC 41 A .0102, 10A NCAC 41 A .0101
Reference(s):
NC Sexually Transmitted Disease Public Health Program Manual
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