Year: 2019
Type: article
Abstract: The United States is experiencing a resurgence in syphilis cases, with a 71% increase in new diagnoses in the past 5 years.1 Left untreated, syphilis can lead to a host of medical complications, as well as increase the risk of HIV infection. Congenital syphilis rates are rising even faster than adult syphilis rates, with a 185% increase from 2014 to 2018, a change that has paralleled increases in primary and secondary syphilis among reproductive-aged women.1 This dramatic rise in syphilis cases may be due in part to a "lack of screening by physicians [and] patients not asking for screening."2 Given this rapidly growing domestic syphilis epidemic, new strategies are required for identifying those at highest transmission risk. Populations at highest risk for syphilis are often also those who may not have access to primary care. The highest rates of syphilis, for example, are seen in young black men between the ages of 20 and 34.1 Congenital syphilis is found in black infants at more than six times the rate of white infants and almost twice the rate of Latinx.1 These populations often rely on the emergency department (ED) for their medical needs. Visits to the ED thus represent a key opportunity to stem the spread of syphilis through screening, treatment, and referral. Screening programs in the ED work. Routinized HIV screening, for example, is increasingly a component of ED care and is supported by the CDC as a successful screening intervention strategy.3 With the appropriate infrastructure, these programs can effectively reach a large population that would otherwise be missed through traditional screening recommendations and can be implemented with minimal disruption to workflow. Our ED, for example, leverages the electronic medical record (EMR) to select patients who are appropriate candidates for screening and automatically prompt nurses in triage to order the screening tests for these patients. This type of screening infrastructure, which already exists in many EDs, can easily be modified to add syphilis screening with essentially no additional end-user effort required. As a quality improvement project in our ED, syphilis testing was bundled with the HIV screening prompt, leading to an increase from an average of 250 syphilis tests per month in the ED to more than 1200 monthly tests after implementation of the EMR-driven protocol, with high rates of positivity. To further decrease resource utilization in an ED context, we recommend a reverse sequence testing algorithm for syphilis screening. Screening is performed using an antibody test that reflexes to confirmatory testing if positive, allowing for detection of all stages of infection and reducing false positives.4 Given the difficulties of locating patients once they leave the ED, particularly in the populations who utilize the ED as their primary source of care, point-of-care syphilis tests that result while the patient is in the ED are also showing promise as a way to ensure that patients are properly treated and not lost to follow-up.5 Through a partnership with outpatient providers in a diversity of insurance contexts, patients testing positive for syphilis in the ED can be brought into clinic for treatment irrespective of ability to pay. In our hospital, a dedicated infectious diseases staff member reviews all positive tests and contacts patients to schedule outpatient treatment. During follow-up visits, these patients can be screened for HIV and other sexually transmitted infections, if this screening was not done during the ED visit, and they can be provided with counseling, including HIV preexposure prophylaxis (PrEP) initiation if appropriate. Equally important, these patients are directly linked to primary care during this visit. Through this multidisciplinary model, screening for syphilis during routine ED visits may lead not only to a reduction in syphilis rates but also to a reduction in new cases of HIV, as well as engagement in key primary care services. Emergency departments in syphilis-prevalent regions should strongly consider implementing universal screening efforts. In the context of the current dramatic rise in the number of syphilis cases, it is imperative that we find novel means of reaching those at highest risk. As these populations disproportionately utilize the ED for medical care, ED screening programs are a logical space for engagement. With automated ordering algorithms and an infrastructure in place to ensure prompt follow-up of positive cases, screening of ED patients has the potential to significantly improve the diagnosis and treatment of syphilis in the most impacted communities with minimal disruption to ED workflow, potentially averting not just serious complications of the disease but also cases of congenital syphilis and HIV. Such an approach represents an important strategy to address a major public health issue that impacts all of our patients.
Source: Academic Emergency Medicine
DOI: 10.1111/acem.13897
Institution: University of Chicago
Language: English
Subfield: Physiology
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W2994491734