#364 Screening for syphilis: A USPSTF Update with Dr. Katrina Donahue

November 2, 2022 | By Paul Williams

Video

We ran the numbers, and it’s still important!

Should patients be screened for syphilis? If so, which ones? Dr. Katrina Donahue (USPSTF) talks us through this re-affirmation of the USPSTF syphilis screening guideline, including who might be high risk and how to screen them.

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Credits

• Producers: Elena Gibson, MD and Paul Williams MD, FACP
• Writer: Elena Gibson, MD
• Show notes: Paul Williams MD, FACP
• Infographic and Cover Art: Elena Gibson, MD
• Hosts: Paul Williams MD, FACP and Elena Gibson MD 
• Production team: Podpaste
• Guest: Katrina Donahue MD

USPSTF Recommendation for Screening for Syphilis Infection in Nonpregnant Adults and Adolescents

What are the updated recommendations?

• The USPSTF recommends screening for syphilis infection in persons who are at increased risk for infection: A grade (Offer or provide this service)

What’s the fine print?

• This recommendation applies to asymptomatic, nonpregnant adolescents and adults who have ever been sexually active.
• The USPSTF recommends screening for syphilis in patients at an increased risk of infection.
• Rates of syphilis have been increasing over the past 20 years from a record low in the year 2000 (USPSTF 2022)
• When deciding who to screen, clinicians should consider community prevalence and sociodemographic and behavioral risk factors associated with increased risk of syphilis infection.
  • For example, the prevalence of syphilis is higher in men who have sex with men, persons with HIV infection, and persons with a history of incarceration, sex work, or military service (Henninger, 2022)
  • Patients who use methamphetamines or who inject drugs are also at increased risk of syphilis (Workowski, 2021)
  • Clinicians should also be aware of the prevalence of syphilis infection in the community in which they serve, which can be found through local health departments and the CDC.
• There is no specific prevalence or risk threshold defined to trigger screening, and a validated risk assessment tool was identified as a future research need.
• The usual screening tests utilize treponemal and nontreponemal testing to identify syphilis infection.
  • Traditional screening uses an initial nontreponemal test (e.g., VDRL or RPR) followed by a confirmatory treponemal test (e.g., T pallidum particle agglutination [TP-PA] test). This is performed by most labs.
  • Reverse sequence testing uses an initial treponemal test followed by a nontreponemal test for reactive samples. This is done more in high-volume labs.
• Point-of-care testing exists, but the USPSTF is recommending more research be done.
• The optimal intervals for screening need to be established, and no specific interval is recommended.
  • Men who have sex with men or persons with HIV may benefit from screening at least annually or more (Workowski, 2021).
• Potential harms of screening include false-positive tests that require additional evaluation and may lead to unnecessary treatment and patient anxiety.
  • The magnitude of these potential harms is considered small.
• The USPSTF has issued separate recommendations for screening for syphilis in pregnant persons and for other sexually transmitted infections, including hepatitis B, hepatitis C, genital herpes, HIV, chlamydia, and gonorrhea.

How is this different from the last recommendation?

• This is not significantly different from the 2016 update and is considered a reaffirmation of that recommendation.  Guidelines are typically re-examined every five years, and in this instance, the USPSTF concluded with high certainty that the net benefit of screening in nonpregnant persons at increased risk for infection is substantial.

How can this be incorporated into practice?

• These recommendations can be used to have conversations about risk factors for syphilis in nonpregnant patients and adolescents.  Screening in patients at increased risk can identify infection and allow for treatment before it leads to complications or is transmitted to others.

Links

1. USPSTF Final Recommendation Statement: Syphilis Infection in Nonpregnant Adolescents and Adults: Screening
2. JAMA 2022 evidence report and systematic review for this guideline 
3. JAMA 2022 recommendation statement for this guideline
4. 2021 MMWR Sexually Transmitted Infection Treatment Guidelines

Goal

Listeners will explain the USPSTF recommendation for screening for syphilis in nonpregnant adults and adolescents.

Learning objectives

After listening to this episode listeners will…  

1. Become familiar with the USPSTF recommendation regarding screening for syphilis in nonpregnant adults and adolescents.
2. Identify what risk factors might place a person at higher risk for syphilis infection.
3. Choose an evidence-based screening test for syphilis screening.
4. Utilize these recommendations to have important conversations with their patients regarding evidence-based preventive care.

Disclosures

Dr. Donahue reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

 Gibson E, Williams PN, and Donahue K. “#364 Screening for syphilis: A USPSTF Update with Dr. Katrina Donahue”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list November 2, 2022.