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

Objective: To examine targeted screening and empiric treatment for syp hilis in an urban ED. Methods: Screening of emergency patients during previously arranged shifts from July 1991 through January 1992 in a un iversity-affiliated, inner-city ED. Emergency patients who perceived t hat they had high-risk factors for syphilis (i.e., cocaine or heroin u se or sexual contact with a user of these substances) were compared wi th emergency patients denying high risk. All presumed high-risk patien ts and alternate patients in the group who denied high risk (control g roup) were screened in the ED with the rapid plasma reagin (RPR) test. Empiric antibiotic treatment was initiated if the patient was RPR-pos itive 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 patient s presenting to the ED, 276 (34%) admitted to high-risk behavior. Of 3 73 patients tested by RPR in the ED (216 high-risk and 157 control pat ients), no significant difference was found between the high-risk and the control patients in untreated syphilis [8 (4%) vs 4 (3%)] or posit ive MHA-TP [47 (22%) vs 25 (16%)]. In the high-risk group, the women w ere 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 posit ive 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 ca ses 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 p ositive syphilis and HIV serologies, regardless of acknowledged drug u se risk factors. Therefore, in areas reporting high syphilis infection rates, consideration should be given to offering screening for syphil is to all emergency patients, along with establishment of adequate cou nseling and follow-up.