SCREENING AND EMPIRIC TREATMENT FOR SYPHILIS IN AN INNER-CITY EMERGENCY DEPARTMENT

Objective: To examine targeted screening and empiric treatment for syphilis in an urban ED. Methods: Screening of emergency patients during previously arranged shifts from July 1991 through January 1992 in a university-affiliated, inner-city ED. Emergency patients who perceived that they had high-risk factors for syphilis (i.e., cocaine or heroin use or sexual contact with a user of these substances) were compared with emergency patients denying high risk. All presumed high-risk patients and alternate patients in the group who denied high risk (control group) were screened in the ED with the rapid plasma reagin (RPR) test. Empiric antibiotic treatment was initiated if the patient was RPR-positive and gave no previous history of syphilis. In addition, serum was submitted to the state laboratory for VDRL and microhemagglutination-Treponema pallidum (MHA-TP) testing. Blinded serologic testing for HIV antibody was performed later on frozen serum. Results: Of 806 patients presenting to the ED, 276 (34%) admitted to high-risk behavior. Of 373 patients tested by RPR in the ED (216 high-risk and 157 control patients), no significant difference was found between the high-risk and the control patients in untreated syphilis [8 (4%) vs 4 (3%)] or positive MHA-TP [47 (22%) vs 25 (16%)]. In the high-risk group, the women were more likely than the men to be MHA-TP-positive (OR = 2.58, 95% CI 1.12-7.98, p = 0.04). Among the women, the MHA-TP was more often positive for the high-risk than for the control patients (34% vs 15%, OR = 2.27, 95% CI 1.12-4.67, p = 0.023). For the high-risk group, seven (3%) new cases of syphilis were managed empirically, vs three (2%) new cases for the control group. HIV antibodies were detected in 16 of 212 (8%) high-risk patients and five of 155 (3%) control subjects (p = 0.13). Conclusion: This inner-city ED population has a high frequency of positive syphilis and HIV serologies, regardless of acknowledged drug use risk factors. Therefore, in areas reporting high syphilis infection rates, consideration should be given to offering screening for syphilis to all emergency patients, along with establishment of adequate counseling and follow-up.