CCMS Medicine Spring 2017 - 12

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Unfortunately, some of the most effective public health
preventive measures used in the past half century have been
discarded, primarily for "cost effective" reasons (mass screening
programs, premarital testing, routine STS testing on admission
to hospital). Yet, the disease can still be prevented or aborted
with early diagnosis and treatment, but clinicians are periodically
placed in a difficult position when the production of essential
antibiotics (especially procaine penicillin G, and Bicillin) is
reduced for whatever reasons. At this writing, the FDA notes that
Pfizer, the sole manufacturer of Bicillin-LA, has been experiencing
delays in providing that product. It has also had a more recent
manufacturing delay on procaine penicillin-G, and estimates
this product would not begin to be available until April 2017.
Physicians should check both the CDC and FDA websites for
any changes or updates on this crucial problem, as well as for
recommended alternate treatment schedules (see # 3, below).
In the US, a case of CS is considered a "sentinel event,
reflecting numerous missed opportunities for prevention"
...there are two major opportunities for prevention: 1st, primary
prevention of syphilis among women of reproductive age and
MSMs; 2nd, prevention of mother-to-infant transmission among
pregnant women already infected with syphilis.
So, what is a clinician to do?

STD Treatment Guidelines
Treatment guidelines for sexually transmitted diseases from
CDC's Division of STD Prevention
1. Be sure to take a good "social history" on every sexually active
person, especially patients in their reproductive age groups. Test
every sexually active person for syphilis, and especially every
pregnant woman at the first visit and again in the 3rd trimester.
2. Keep a high index of suspicion for syphilis even if, or especially
when, the patient already has a different STD. Test all STD
patients for syphilis, and test all syphilis patients for other STDs,
including HIV.
3. Keep abreast of the CDC's current guidelines on the diagnosis
and treatment of, including any "special circumstances" (e.g.,
penicillin shortages, penicillin allergy, pregnancy, drug addiction).
Visit 2015 STD Treatment Guidelines for a downloadable copy
(MMWR RR-64(3), June 5, 2015) of their current guidance.
4. Remember that the secondary skin lesions and the oral/nasal
mucous secretions of these patients are "teeming with spirochetes"

12 C H E S T E R C O U N T Y M e d i c i n e | S P R I N G 2 0 1 7

on darkfield exam (Figure 8) and easily transmissible unless strict
precautions are taken by all.
FIG. 8

5. While the majority of reported STDs are treated by
private sector physicians and public health clinics, many
STDs go unreported - some estimate that only 10-12% are
actually reported to health departments. Thus, many more go
undiagnosed, untreated, and/or unreported, and those could wind
up in your office.
6. Maternal syphilis can be carried by the blood to the placenta
and transmitted to the infant in utero or in the birth passage.
7. Ideally, all pregnant women should be tested for STS at the first
visit, in the third trimester (especially if at high risk), and again at
delivery. Adequate treatment before the 18th week (some say 20th)
of pregnancy generally prevents infection of the fetus (1). Newborns
should not be discharged from the hospital unless the mother's
serology results are known, in case the infant needs to be treated
acutely.
8. Patients should be made aware that all STD services are strictly
confidential, with the caveat that these diseases are mandatorily
reportable to the health department.
9. Patients in their reproductive age groups should be educated as
to safe (or "safer") sex measures and the importance of a long-term
mutually monogamous relationship with a person who has tested
negative for these diseases.
10. If, for whatever reason, a clinician does not see or treat such
patients, or cannot in conscience provide the needed preventive
education to the patients, those patients should be referred to the
nearest public health department where appropriate guidance,
diagnosis, and treatment are usually available free of charge.
Dr. Maher is a retired physician, former Director of the
CCHD, and a long-term member of the CCMS Board. A
list of references is available upon request.
http://chestercms.org/index.html
Table of Contents for the Digital Edition of CCMS Medicine Spring 2017
