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January 25, 2021

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  • Treat all patients with signs or symptoms consistent with primary or secondary syphilis when they present for care. Clinicians should perform serological tests on patients with signs or symptoms of syphilis, but should not wait for the results of such tests to provide treatment, particularly among pregnant women, persons who are living homeless and other persons for whom medical follow-up is difficult to ensure.
  • Know the symptoms of primary syphilis: A syphilitic chancre is usually a firm ulcer at the site of inoculation; it is usually painless and may be associated with localized lymphadenopathy.
  • Know the many symptoms of secondary syphilis: Rash is the most common symptom and may present as a generalized maculopapular rash on the torso with or without palmar and plantar lesions, though the rash may also be pustular; other presentations of rash include condyloma lata, mucous patches, alopecia; other symptoms include generalized malaise, lymphadenopathy, sore throat and arthralgias.
  • Test ALL PREGNANT women for syphilis at their first prenatal visit and AGAIN with routine 3rd trimester labs, typically at 24-28 weeks gestation.
  • Pregnant women who present late for prenatal care or have fragmented care should be screened for syphilis (along with HIV, HBsAg and STI testing), whenever they present for care (e.g. emergency departments, jail, urgent care and labor and delivery).
  • Refer non-contracepting women of childbearing potential diagnosed with syphilis for contraception if the diagnosed woman does not desire pregnancy.
  • Medical providers should test sexually active persons experiencing homelessness, persons who exchange money or drugs for sex, and persons who use methamphetamine, heroin or cocaine for syphilis when they present for care, including in emergency rooms. Non-pregnant persons without signs or symptoms of syphilis, or a known exposure to syphilis do not require testing more than every 90 days.
  • Treat any persons who reports sexual exposure to someone with syphilis, even in the absence of signs or symptoms of infection. Treatment is not dependent on the results of serological testing, which can be falsely negative early in infection. Test these individuals for syphilis but treatment should not be withheld awaiting test results.
  • Know the treatment of early syphilis (primary, secondary and early latent): benzathine penicillin (bicillin) 2.4 million units intramuscularly once. Patients with late latent syphilis or syphilis of unknown duration require three injections spaced one week apart.
  • Report all cases of syphilis to PHSKC STD Program using the STD Case Report Form.
  • Call Rolf Pederson 206.744.4376, Dr. Lindley Barbee 206-744-2595 or Dr. Matthew Golden 206-744-6829 for syphilis related questions in King County. Outside of King County, call your local health jurisdiction, or call Zandt Bryan 360-890-5816, Katrina Miller 360-236-3425, or Kari Haecker 360-890-6897 for assistance in locating public health staff who can assist you and your patient. Case reporting information and forms for public health jurisdictions can be found on the DOH website.

In 2019, there were nearly 1000 cases of syphilis diagnosed in King County residents and over 2000 cases of syphilis diagnosed statewide. Although the number of cases in 2020 will likely be lower, STD testing has decreased in the face of the COVID pandemic, possibly leading to an increase in undiagnosed infections. The syphilis epidemic in Washington state over the past 20 years has predominantly affected men who have sex with men (MSM). However, in recent years the number of cases among heterosexuals has increased, more than doubling between 2015 and 2019 in King County and increasing by 5 times across the state. At least 50% of heterosexual syphilis cases have been among residents of south King County. Outside of King County, cases among heterosexuals have been highest in the Spokane area, the Yakima Valley/Tri-Cities region, and in southwest Washington. More recently, the number of cases occurring in persons who are experiencing homelessness has risen substantially, increasing 86% over the last year in King County. Nearly half of all syphilis cases among persons living homeless in King County occurred among individuals who self-identified as heterosexual. Similarly, a large proportion of cases of syphilis in heterosexuals across the state are diagnosed in people whose housing is unstable. Many of these cases initially presented to emergency departments where their clinical diagnosis was missed, or they were inappropriately treated.

The rise in syphilis cases among heterosexuals has resulted in an increase in congenital syphilis. Congenital syphilis can result in miscarriage, neonatal death, preterm delivery and long-term health problems in the affected child. This is the most devastating consequence of syphilis. The congenital syphilis rate in the US more than doubled between 2016 to 2018. After not having any cases for many years, King County has had four cases of congenital syphilis since 2019, and the state of Washington reached a historic high of 17 cases of congenital syphilis in 2019. Nationally, congenital syphilis most frequently occurs in women who have not had prenatal care or who enter prenatal care very late, but all 4 cases in King County occurred in women engaged in prenatal care who tested negative for syphilis at their first prenatal appointment in the first trimester and acquired syphilis sometime later during pregnancy. These cases may have been avertable with repeat testing later in pregnancy. In response to the rise in congenital syphilis, the Department of Health and PHSKC recommend testing all pregnant women for syphilis in the early third trimester with other routine labs, approximately 24- 28 weeks gestation. For many cases of congenital syphilis diagnosed outside of King County, the only medical care many received prior to delivery was during justice involvement. Pregnant women not engaged in routine prenatal care should be tested at any time they engage with the health care system (i.e. the emergency department, jail, urgent care, labor and delivery, or other clinic visits).

For questions regarding these treatment recommendations please contact Dr. Lindley Barbee (, or Dr. Matthew Golden ( For other clinical questions about STI, contact either Drs. Barbee or Golden or use the National Network of Prevention Training Centers Clinical Consult Line (