• Swab of lesion, ulcer or fluid from vesicle for HSV testing (culture/NAAT) and for dark-field microscopy or FA for T.pallidum (where available).

• Swab of lesions for HSV (culture or NAAT)

and dark-field examination or direct/indirect fluorescent antibody (DFA/IFA) or NAAT (e.g., PCR) test on swabs from ulcers. Contact your local laboratory regarding these tests, as they are not widely available.

Note: Dark-field microscopy and direct/indirect fluorescent antibody tests are not reliable for rectal lesions, as there may be cross-reaction with non-pathogenic treponemes in anal specimens. NAAT (e.g., PCR) testing may be an option for such specimens.

• Serology for syphilis:
   - Non-treponemal test (RPR/VDRL) and

- Treponemal test (MHA-TP/TP-PA/FTA-ABS) or treponemal specific EIA

• Serology for suspected primary syphilis:

- Should include a non-treponemal test (e.g., RPR/VDRL).
- In regions experiencing outbreaks of syphilis and where NTT is the screening test, it may be appropriate to screen at baseline with both non-treponemal and treponemal tests

OR

- A treponemal-specific enzyme immunoassay (EIA) AND if the treponemal-specific EIA is positive, confirmation by a second treponemal-specific test is recommended (e.g., TP-PA, MHA-TP, FTA-ABS or INNO-LIA™).

• Syphilis serology as dark-field microscopy and fluorescent antibody tests are not reliable for rectal lesions.

• Syphilis serology should be performed in all patients with lesions. If the initial serologic testing is negative and syphilis is suspected, serological testing should be repeated in 2-4 weeks.

Note:  Dark-field examination and direct/indirect fluorescent antibody tests (DFA/IFA) are not reliable for rectal lesions, as there may be cross-reaction with non-pathogenic treponemes in rectal specimens. NAAT (e.g., PCR) testing may be an option for such specimens.

Quinolones may be considered as an alternative treatment option ONLY IF:

(1) antimicrobial susceptibility testing is available and quinolone susceptibility is demonstrated OR

(2) where antimicrobial testing is not available, a test of cure is essential.

For all infections where treatment recommendations include fluoroquinolones.

Note: Fluorquinolone associated tendon rupture (generally Achilles tendon) has been reported predominantly in the elderly on prior systemic treatment with glucocorticoids. At any sign of tendonitis, a physician should be consulted and the quinolone treatment should be discontinued. Quinolones should not be used in patients with a clear history of tendon disorders related to quinolone treatment because they may be at risk of developing tendon disorders again when re-exposed to a quinolone. Please consult the FDA website
http://www.fda.gov/Drugs/DrugSafety/Postmarket
DrugSafetyInformationforPatientsandProviders
/ucm126085.htm
and the latest product monograph for details.

Preferred

• Benzathine penicillin G 2.4 million units IM in a single dose [A-II; A-III for HIV-infected individuals]

Preferred

• Benzathine penicillin G 2.4 million units IM in a single dose * [A-II for NON-HIV; A-III for HIV-infected individuals]
  * Some experts recommend 3 weekly doses (total of 7.2 million units) of benzathine penicillin G in HIV-infected individuals.

• Ceftriaxone 1 g IV or IM daily for 10 days [B-II]

• Ceftriaxone 1 g IV or IM daily for 10 days [B-II]

 †The efficacy data supporting the use of these agents is limited, and as such they should only be used in exceptional circumstances and when close patient follow-up is assured.

Alternative (only in exceptional circumstances)

• Ceftriaxone 1 g IV or IM daily for 10 days [C-III]

Alternative (only in exceptional circumstances) †

• Ceftriaxone 1 g IV or IM daily for 10 days [C-III]

†The efficacy data supporting the use of these agents is limited, and as such they should only be used in exceptional circumstances and when close patient follow-up is assured.

Trace-back period:
(refer to chart)

(Note to be added below the table)
* Trace-back period refers to the time period prior to symptom onset or date of specimen collection (if asymptomatic).

The length of time for the trace-back period should be extended:

1) to include additional time up to the date of treatment
2) if the index case states that there were no partners during the recommended trace-back period, then the last partner should be notified
 3) if all partners traced (according to recommended trace-back period) test negative, then the partner prior to the trace-back period should be notified.

Table 6: Monitoring of serologic tests and other follow-up on page 21.

Table 8a: Summary of medical management of immunocompetent women found to have reactive syphilis serology during pregnancy on page 24.

Table 8b: Management of infants born to women with reactive treponemal tests (TTs) during pregnancy on pages 25-28.

• Perform syphilis serology, both non-treponemal test (RPR, VDRL) and treponemal tests (MHA-TP/TP-PA/FTA-ABS) or syphilis EIA where available (if primary syphilis is suspected, repeat screening in 2-4 weeks if initially negative).

• Serology for suspected primary syphilis should include a non-treponemal test (e.g., RPR/VDRL).
  

- In regions experiencing outbreaks of syphilis and where NTT is the screening test, it may be appropriate to screen at baseline with both non-treponemal and treponemal tests

OR

- A treponemal-specific enzyme immunoassay (EIA) AND if the treponemal-specific EIA is positive, confirmation by a second treponemal-specific test is recommended (e.g., TP-PA, MHA-TP, FTA-ABS or INNO-LIA™).

If the initial serologic testing is negative and syphilis is suspected, serological testing should be repeated in 2-4 weeks.