Abstract
In recent years, the incidence of infectious syphilis in the UK has increased dramatically. There was a 20% increase in diagnoses between 2016 and 2017, and a 148% increase relative to 2008 1 and there are several reports of cases of congenital syphilis. 2
The guideline authors have provided clinical advice on the management of the babies born with congenital syphilis, as well as regularly providing clinical advice and support to doctors and midwives who are managing pregnant women with positive syphilis serology. We have noted that the continued option of macrolides within the UK guidelines for the management of syphilis in pregnancy, even with the stated caveats and cautions, provides a treatment option that is suboptimal and results in treatment failure with significant adverse outcomes reported. Macrolide antibiotics do not cross the placenta well to treat a foetus that may be affected by syphilis and Treponema pallidum has unacceptably high rates of macrolide resistance reported.3–5
We are therefore making an amendment to the 2015 UK guidelines for the management of syphilis and removing macrolides as a treatment option. This is consistent with the Centres for Disease Control and Prevention (USA) 6 and International Union Against Sexually Transmitted Infections – Europe 7 guidelines. The World Health Organization guidelines, 8 as the UK guidelines did until now, continue to include macrolide treatment as a last option for pregnant women with the caveat that the neonates need to be treated at birth. However in our experience, this may result in treatment failure in pregnancy and transmission to the neonate.
For pregnant women who report intolerance or allergy to penicillin or other beta-lactam antibiotics, we are making the following recommendations for management, which must include consultation with the patient at all stages:
A thorough history of drug allergy is taken and substantiated from primary care practitioners. If a true allergy history is ascertained refer urgently to immunology/allergy services for testing for allergy to penicillin and ceftriaxone (this is consistent with current NICE guidance
9
). A rapid access referral pathway has been established within Manchester (UK), a high prevalence area with a specialist tertiary foetal-maternal medicine unit, which could be adopted in other services.
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If possible following this treat with penicillin (first line) or ceftriaxone (second line). In the rare circumstance of true beta-lactam allergy being confirmed: a. Refer to the tertiary foetal medicine unit for co-management by obstetric, midwifery, paediatric and tertiary GUM (or infection) specialists. Such services exist for the management of HIV-positive pregnant women and are best placed to manage such difficult cases. b. Management should be on a case-by-case and multi-disciplinary basis (including the pregnant woman) where the risk of treatment is balanced against the risk of infection to the neonate and pregnancy loss, stillbirth or congenital infection and subsequent disability. Factors to consider include the stage of syphilis and any previous treatment history. Such teams also have the ability to monitor mother and baby as needed. c. Desensitisation to penicillin and immediate treatment of the mother with penicillin should be considered and discussed within the team including the mother. d. The authors of this guideline amendment are available for sub-specialist clinical advice and referral within the UK as needed.
Footnotes
Acknowledgements
On behalf of the Clinical Effectiveness Group of British Association for Sexual Health & HIV (BASHH).
Declaration of conflicting interests
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Craig Tipple is an employee of GlaxoSmithKline and owns shares in the company.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.