Infectious Dis. Medical News about Syphilis Infection; Pregnancy

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Screening for Syphilis Infection in Pregnancy: U.S. Preventive Services Task Force Reaffirmation Recommendation Statement
Annals of Internal Medicine, 05/20/09

In 2004, the USPSTF reviewed the evidence on screening for syphilis in pregnant women. In 2008, the USPSTF performed a targeted literature review and determined that the net benefit of screening pregnant women continues to be well established. This literature update included a search for new and substantial evidence on the benefits of screening, harms of screening, and harms of treatment with penicillin. The USPSTF found no new substantial evidence that could change its recommendation, and therefore reaffirms its recommendation to screen all pregnant women. This is a grade A recommendation. Untreated syphilis during pregnancy is associated with stillbirth, neonatal death, bone deformities, and neurologic impairment. There is adequate evidence that screening tests can accurately detect syphilis infection. Screening and treatment may result in potential harms, including false-positive results that require clinical evaluation, unnecessary anxiety to the patient, and harms of antibiotic use. However, the USPSTF concluded that the harm from screening is no greater than small.

Assessment of Risk:
Pregnant women who are at increased risk for syphilis infection include uninsured women, women living in poverty, sex workers, illicit drug users, and women in communities with high syphilis morbidity. The prevalence of syphilis infection differs by region (it is higher in the southern United States and in some metropolitan areas than it is in the United States as a whole) and by ethnicity (it is higher in Hispanic and African-American populations than in the white population). Persons in whom sexually transmitted diseases have been diagnosed may be more likely than others to engage in high-risk behavior, which places them at increased risk for syphilis.
Screening Tests:
Nontreponemal tests commonly used for initial screening are the Venereal Disease Research Laboratory (VDRL) test or the rapid plasma reagin (RPR) test. These are typically followed by a confirmatory fluorescent treponemal antibody absorbed test or Treponema pallidum particle agglutination (TPPA) test.
Treatment:
The Centers for Disease Control and Prevention (CDC) has outlined appropriate treatment of syphilis in pregnancy (http://www.cdc.gov/std/treatment/). In its 2006 sexually transmitted disease treatment guidelines, the CDC recommends parenteral benzathine penicillin G for the treatment of syphilis in pregnancy. Evidence on the efficacy or safety of alternative antibiotics in pregnancy is limited; therefore, women who report penicillin allergies should be evaluated for penicillin allergies and, if present, desensitized and treated with penicillin. Because the CDC updates these recommendations regularly, clinicians are encouraged to access the CDC Web site (http://www.cdc.gov/std/treatment/) to obtain the most up-to-date information.
Screening Intervals:
All pregnant women should be tested at their first prenatal visit. For women in high-risk groups, many organizations recommend repeated serologic testing in the third trimester and at delivery. Most states mandate that all pregnant women be screened at some point during pregnancy, and many mandate screening at the time of delivery. Follow-up serologic tests should be obtained after treatment to document decline in titers. To ensure that results are comparable, follow-up tests should be performed by using the same nontreponemal test that was used initially to document the infection (for example, VDRL or RPR).