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International Journal of STD & AIDS UK national guidelines ...

GuidelinesUK national guidelines on themanagement of syphilis 2015M Kingston1, P French2, S Higgins3, O McQuillan1,A Sukthankar1, C Stott1, B McBrien1, C Tipple4, A Turner5,AK Sullivan6, Members of the Syphilis guidelines revision group2015, Keith Radcliffe7, Darren Cousins7, Mark FitzGerald7,Martin Fisher7, Deepa Grover7, Stephen Higgins7,Margaret Kingston7, Michael Rayment7and Ann Sullivan7 AbstractThese guidelines are an update for 2015 of the 2008 UK guidelines for the management of syphilis. The writing grouphave piloted the new BASHH guideline methodology, notably using the GRADE system for assessing evidence and makingrecommendations. We have made significant changes to the recommendations for screening infants born to motherswith positive syphilis serology and to facilitate accurate and timely communication between the teams caring for motherand baby we have developed a birth plan. Procaine penicillin is now an alternative, not preferred treatment, for all stagesof syphilis except neurosyphilis, but the length of treatment for this is shortened.

Nov 05, 2015 · complicated in 10% of patients.22 The ascending aorta is the predominant site of damage resulting in dilatations and aortic valve regurgitation. Rarely, the coronary ostia may become involved and saccular aneurysms may develop.31 Kingston et al. 3 Downloaded from std.sagepub.com

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Transcription of International Journal of STD & AIDS UK national guidelines ...

1 GuidelinesUK national guidelines on themanagement of syphilis 2015M Kingston1, P French2, S Higgins3, O McQuillan1,A Sukthankar1, C Stott1, B McBrien1, C Tipple4, A Turner5,AK Sullivan6, Members of the Syphilis guidelines revision group2015, Keith Radcliffe7, Darren Cousins7, Mark FitzGerald7,Martin Fisher7, Deepa Grover7, Stephen Higgins7,Margaret Kingston7, Michael Rayment7and Ann Sullivan7 AbstractThese guidelines are an update for 2015 of the 2008 UK guidelines for the management of syphilis. The writing grouphave piloted the new BASHH guideline methodology, notably using the GRADE system for assessing evidence and makingrecommendations. We have made significant changes to the recommendations for screening infants born to motherswith positive syphilis serology and to facilitate accurate and timely communication between the teams caring for motherand baby we have developed a birth plan. Procaine penicillin is now an alternative, not preferred treatment, for all stagesof syphilis except neurosyphilis, but the length of treatment for this is shortened.

2 Other changes are summarised at thestart of the , diagnosis, treatmentDate received: 5 November 2015; revised: 1st December 2015; accepted: 2 December 2015 New in the 2015 guidelinesImportant penicillin is now an alternative treatmentwhere benzathine penicillin is suitable. This is dueto the pain associated with treatment courses requir-ing multiple injections and inconvenience and costfor patients and to macrolide antibiotics limits their util-ity; they are to be used only when there are no suit-able alternatives and with assured asymptomatic disease there is no need for fullroutine examination or chest X-ray (CXR)..Amended recommendation to period of sexualabstinence following treatment of early duration for the recommended treatment ofneurosyphilis is changed to 14 days, consistent withexpert opinion and other minimal follow-up neonates will not need serology of a syphilis birth graded recommendations at the end of eachsection, using the GRADE main objective is to reduce the number of sexuallytransmitted infections (STIs) and the complicationsNICE has accredited the process used by BASHH to produce its European guideline for the managementof syphilis.

3 Accreditation is valid for 5 years from information on accreditation can be viewed at Centre for Sexual Health, Manchester, UK2 Mortimer Market Centre, London, UK3 North Manchester General Hospital, Manchester, UK4 Jefferiss Wing Centre for Sexual Health, Imperial College Health CareNHS Trust, London, UK5 The Public Health England/Clinical Virology Laboratory, ManchesterRoyal Infirmary, Manchester, UK6 CEG Editor7 Clinical Effectiveness Group, British Association for Sexual Health andHIV, Macclesfield, UKCorresponding author:Margaret Kingston, Manchester Centre for Sexual Health, TheHathersage Centre, 280 Upper Brook Street, Manchester M13 : Journal of STD & AIDS0(0) 1 26!The Author(s) 2015 Reprints and : Int J STD AIDS OnlineFirst, published on December 31, 2015 as at Imperial College London Library on February 9, from that can arise in people either presenting with signs andsymptoms of an STI or undergoing investigation forpossible , this guideline offers recommendationson the diagnostic tests, treatment regimens and healthpromotion principles needed for the effective manage-ment of syphilis, covering the management of the initialpresentation, as well as how to prevent transmissionand future is aimed primarily at people aged 16 years or older(although there is a section referring to the manage-ment of congenital syphilis [CS] in children)

4 Presentingto health-care professionals, working in departmentsoffering level 3 care in STI management within theUnited , the principles of the rec-ommendations should be adopted across all levels(levels 1 and 2 may need to develop, where appropriate,local care pathways).The recommendation of this guideline may not beappropriate for use in all clinical situations. Decisionsto follow these recommendations must be based on theprofessional judgement of the clinician and consider-ation of individual patient circumstances and strategyThe previous UK and USA guidelines for the manage-ment of syphilis were ,3 Literature reviews included searching Medline forthe years 2007 to 2014 and the Cochrane library usingthe keywords syphilis and syphilis and HIV plus add-itional MeSH headings neurosyphilis , cardiovascularsyphilis , latent syphilis and syphilis and treatment .A search on Embase from 2007 2014 was also con-ducted.

5 Only English language papers were guidelines writing group piloted an updated ver-sion of the BASHH Framework for GuidelineDevelopment. The previous version last published in2010 is available at: (last accessed 19 January 2013). Following pilot-ing of this updated framework, incorporating feedbackfrom this and another group of guideline authors, theupdated framework will be published. The majorchange is the adoption of the GRADE system forassessing evidence ( ) [last accessed 19 January 2014].Equality impact assessmentThis was completed using the NICE tool for thisaccessed at: is an appendix to this involvement, piloting andfeedbackThe document was reviewed by the ClinicalEffectiveness Group of BASHH, and their commentsincorporated. The draft guideline was placed on theBASHH website and any comments received aftertwo months were reviewed by the authors and actedon appropriately.

6 The document was also piloted bytarget users and the public panel of BASHH, andtheir feedback considered by the , transmission and is caused by infection with the spirochetebacteriumTreponema is transmitted by direct contact with an infectiouslesion or by vertical transmission (trans-placentalpassage) during one-third of sexual contacts of infectious syphilis willdevelop the disease (transmission rates of 10 60%are cited).6, of bacterial entry is typically genital in hetero-sexual patients, but 32 36% of transmissions amongmen who have sex with men (MSM) may be at extra-genital (anal, rectal, oral) sites through oral-anal orgenital-anal one study, oral sexaccounted for of syphilis transmissions, par-ticularly in drug use (sharing nee-dles) and blood transfusion (rare as routinescreening is performed in the UK and treponemalsurvival beyond 24 48 h at 4 C is unlikely) are alsopotential routes of , pallidumreadily crosses the placenta and verticaltransmission can occur at any stage of risk of transmission varies with syphilis stageand is greatest in early ,13 Accordingly,transmission was associated with rapid plasmareagin (RPR) titres 8 (RR , p< ) in onecohort predominates among white MSM aged25 34, many of whom (40%)

7 Are HIV-1 2014, there were 4317 cases of infectious syphilis,of which 3477 cases were in MSM. Compared with2013, this represents a 46% rise among MSM and a33% rise were 263 cases in women in2014. Rates of CS are correspondingly low ( live births in 2011) and predominantly amongchaotic and socio-economically deprived womenpresenting to antenatal services in the ,162 International Journal of STD & AIDS 0(0) at Imperial College London Library on February 9, from Classification and clinical is a multi-stage, multi-system disease, whichis broadly defined as congenital or (adult) diseaseEarly contact,T. palliduminvade through themucosal surface or abraded skin and divide at thepoint of entry to produce the chancre of primary dis-ease. This incubation period is typically 21 days(range 9 90), but is dependent on infectious dose larger doses resulting in ulcers more ,17 Primary syphilis is characterised by a single papuleand moderate regional lymphadenopathy.

8 Thepapule subsequently ulcerates to produce a chancre,which is classically anogenital (penile, labial, cervicalor peri-anal), single, painless and indurated with aclean base discharging clear serum but not , chancres may also be multiple, painful,purulent, destructive, extra-genital (most frequentlyoral) and may cause the syphilitic balanitis ,19 When present at extra-genital sitesand painless, they may pass unnoticed. In the contextof HIV-1 co-infection, they may be multiple, deeperand persist into the secondary stage of after infection, the bacteria disseminate widelyvia blood and lymphatics. They are subject to localimmune clearance and ulcers resolve over 3 8 , 25% of patients will develop signs of sec-ondary syphilis approximately 4 10 weeks after theappearance of the initial ,22 Secondarysyphilis is multi-system and typically occurs threemonths after often presents with awidespread mucocutaneous rash and generalisedlymphadenopathy.

9 The rash may be maculo-papular(50 70%), papular (12%) or macular (10%) and itmay, but does not usually, ,23,24It can affectthe palms and soles (11 70%) and hair follicles,resulting in alopecia. Two more important mucocu-taneous signs are mucous patches (buccal, lingualand genital) and highly infectious condylomata lataaffecting warm, moist areas (mostly the perineumand anus).8,23 HIV-1 infection does not appear toimpact on the mucocutaneous manifestations of sec-ondary syphilis may result inhepatitis; glomerulonephritis (mediated by antibody-treponeme complex deposition) and 28A small proportion of patients (1 2%) willdevelop neurological complications during second-ary are typically acute meningitis(headache, neck stiffness, photophobia, nausea)and cranial nerve palsies including eighth nervepalsy with resultant hearing loss and possible involvement may result in uveitis(most commonly posterior), optic neuropathy, inter-stitial keratitis and retinal syphilis will resolve spontaneously in3 12 weeks and the disease enters an asymptomaticlatent is defined as early within twoyears, and late thereafter (ending with the develop-ment of tertiary disease).

10 The distinction betweenearly and late latent disease is somewhat arbitrary,but important as approximately 25% of patients willdevelop a recurrence of secondary disease during theearly latent (tertiary) disease occurs in approximately one-third ofuntreated patients around 20 40 years after initialinfection. It is divided into gummatous disease(15% of patients); cardiovascular (10%) and lateneurological complications (7%).22 The clinical mani-festations of late syphilis are highly variable and arerarely seen due to the use of treponemocidal anti-biotics for other indications. The clinical features ofsymptomatic late syphilis are summarised in Table the Oslo study, 15% of patients developed gum-matous granulomatous lesions withcentral necrosis can occur within two years oflatency, but are typically seen after an average15 can occur anywhere, but mostoften affect skin and bones. They rapidly resolveon administration of syphilis typically occurs 15 30 yearsafter infection.


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