Under the guidance and arrangement of the Disease Control Bureau of the National Health and Family Planning Commission, the STD Control Center of the Chinese Center for Disease Control and Prevention, the STD Group of the Chinese Medical Association’s Dermatology and Venereology Branch, and the STD Subspecialty Committee of the Dermatology Physicians Branch of the Chinese Medical Association organized experts to discuss and develop the Guidelines for Clinical Diagnosis and Prevention of Sexually Transmitted Diseases for dermatologists, obstetricians and gynecologists, urologists, preventive medicine physicians and The guidelines are for reference by dermatologists, obstetricians and gynecologists, urologists, preventive medicine physicians and physicians of other related disciplines in the clinical practice and prevention and control of STDs. The guidelines for the treatment and prevention of four sexually transmitted diseases are published below.
Syphilis
Syphilis is a chronic, systemic sexually transmitted disease caused by the pale spirochete. It can be divided into acquired syphilis and fetal syphilis (congenital syphilis). Acquired syphilis is further divided into early and late syphilis. Early syphilis refers to infection with the syphilis spirochete within 2 years, including stage I, stage II and early recessive syphilis, and stage I and II syphilis can also overlap. Late syphilis has a duration of more than 2 years and includes stage III syphilis, cardiovascular syphilis, and late recessive syphilis. Neurosyphilis can occur in both the early and late stages of syphilis. Fetal syphilis is further divided into early stage (onset within 2 years after birth) and late stage (onset after 2 years of birth).
I. Diagnosis
1. Stage I syphilis.
(1) epidemiological history: unsafe sex, multiple sexual partners or history of sexual partner infection.
(2) Clinical manifestations: 1. Hard chancre: the incubation period is usually 2 to 4 weeks. It is often single, but can also be multiple. It is a nodule of corn grain size above the skin surface, and later develops into a round or oval shallow ulcer of about 1 to 2 cm in diameter. The nodules are typically well-defined, with slightly elevated margins and a flat, clean surface; the infiltration is obvious on palpation and is cartilage-like in hardness; there is no obvious pain or mild tenderness. They are mostly found in the external genital area. 2. Enlarged lymph nodes in the groin or near the affected area: they can be unilateral or bilateral, painless, isolated from each other without adhesion, medium in quality, not septic and broken, and their surface skin is not red, swollen or hot.
(3) Laboratory examination: 1. Using dark-field microscopy or silver-plated microscopy, take the exudate of sclerosing chancre or lymph node puncture fluid, syphilis spirochetes can be detected, but the detection rate is low; 2. Non-syphilis spirochetes serological test is positive. If the infection is less than 2 to 3 weeks, the test may be negative and should be rechecked after 4 weeks of infection; 3.
(4) Diagnostic classification: 1, suspected cases: should meet both clinical manifestations and laboratory tests in two, may or may not have an epidemiological history; or meet both clinical manifestations and laboratory tests in three, may or may not have an epidemiological history; 2, confirmed cases: should meet both the requirements of suspected cases and laboratory tests in one, or meet both the requirements of suspected cases and both types of syphilis serological test is positive.
2.Second stage syphilis.
(1) Epidemiological history: history of unsafe sex, multiple sexual partners or sexual partner infection, or history of blood transfusion (the blood donor is a patient with early syphilis).
(2) Clinical manifestations: There may be a history of stage I syphilis (often appearing 4-6 weeks after the onset of hard chancre), and the disease lasts for 2 years. 1. Skin and mucosal lesions: The types of lesions are diverse, including macules, maculopapular rash, papules, scaly lesions, follicular rash and pustular rash, etc. They are distributed on the body and extremities, and are often generalized and symmetrical. Dark erythematous and desquamative macules on the palms and plantars, and eczema or flat warts on the vulva and perianal area are the characteristic damages. The rash is usually not pruritic. Oral mucosal plaques and worm-like alopecia may occur. The number of second-stage recurrent syphilis lesions is small, and the lesions are peculiar in shape, often ring-shaped or bow-shaped or arc-shaped; 2. Superficial lymph nodes may be enlarged throughout the body; 3. Syphilitic bone and joint, eye, visceral and neurological damage may occur.
(3) Laboratory tests: 1, using dark-field microscopy or silver-plated staining microscopy method, take the second-stage skin lesions, especially flat warts, wet papules, can be detected syphilis spirochetes. Oral mucosal spots are not easily distinguished from other spirochetes in the oral cavity, so this method is not used for examination; 2, positive serological test for non-syphilis spirochetes; 3, positive serological test for syphilis spirochetes.
(4) Diagnostic classification: 1. Suspected cases should meet both clinical manifestations and two of the laboratory tests, and may or may not have an epidemiological history; 2. Confirmed cases should meet both the requirements of suspected cases and one of the laboratory tests, or both the requirements of suspected cases and both types of syphilis serological tests are positive.
3. Stage III syphilis.
(1) Epidemiological history: history of unsafe sex, multiple sexual partners or sexual partner infection, or history of blood transfusion.
(2) Clinical manifestations: There may be a history of stage I or II syphilis with a disease duration of more than 2 years. 1. Late stage syphilis: a. Skin and mucous membrane damage: nodular syphilis rash on the head, face and extremities, proximal joint nodules near large joints, dendritic swelling of the skin, mouth, tongue and throat, mucous membrane dendritic swelling of the palate and nasal septum can lead to perforation of the palate and septum and saddle nose. b. Bone syphilis, ocular syphilis, other visceral syphilis, involving respiratory tract, gastrointestinal tract, liver and spleen, genitourinary system, endocrine glands and skeletal muscles, etc.; 2. Cardiovascular syphilis, which can occur as simple aortitis, aortic valve atresia insufficiency, aortic aneurysm, etc.
(3) Laboratory tests: 1. Positive serological test for non-syphilis spirochetes, very few advanced syphilis may be negative; 2. Positive serological test for syphilis spirochetes.
(4) Diagnostic classification: 1. Suspected cases should meet both the clinical manifestations and one of the laboratory tests, and may or may not have an epidemiological history; 2. Confirmed cases should meet both the requirements of suspected cases and positive serological tests for both types of syphilis.
4.Neurosyphilis.
(1) Epidemiological history: history of unsafe sex, multiple sexual partners or sexual partner infection, or history of blood transfusion.
(2) Clinical manifestations: 1) asymptomatic neurosyphilis: no obvious neurological symptoms and signs; 2) meningeal neurosyphilis: manifestation of fever, headache, nausea, vomiting, cervical ankylosis, optic papilledema, etc.; 3) meningeal vascular syphilis: manifestation of occlusive cerebrovascular syndrome, such as hemiplegia, paraplegia, aphasia, epileptic-like seizures, etc.; 4) cerebral parenchymal syphilis: psychiatric symptoms may appear, manifesting as paralytic Dementia, inattention, mood changes, delusions, as well as mental retardation, judgment and memory, personality changes, etc.; neurological symptoms, such as tremor, speech and writing disorders, ataxia, muscle weakness, seizures, tetraplegia and incontinence, etc. If the spinal cord is damaged by syphilis spirochetes, the disease is called spinal consumption. Lightning-like pain, sensory abnormalities, tactile pain and temperature perception disorders; hyperalgesia and loss of deep sensation; position and vibration perception disorders may occur.
(3) Laboratory tests: 1. Positive non-syphilis spirochete serology test, very few advanced patients may be negative; 2. Positive syphilis spirochete serology test; 3. Cerebrospinal fluid examination: white blood cell count ≥ 5 × 106/L, protein amount > 500 mg/L, and no other causes of abnormalities. Positive cerebrospinal fluid fluorescent spirochete antibody absorption test (FTA-ABS) and/or venereal disease research laboratory (VDRL) test. In the absence of conditions for FTA-ABS and VDRL, the syphilis spirochete gelatin agglutination test (TPPA) and rapid plasma reactin ring card test (RPR)/toluidine red unheated serological test (TRUST) may be used instead.
(4) Diagnostic classification: 1. suspected cases: should meet both the clinical manifestations, laboratory tests 1, 2 and 3 in the routine cerebrospinal fluid examination abnormal (excluding other causes of abnormalities), may or may not have an epidemiological history; 2. confirmed cases: should meet both the requirements of suspected cases and laboratory tests 3 and 3 in the positive cerebrospinal fluid syphilis serological test.
5. Occult syphilis (latent syphilis).
(1) Epidemiological history: history of unsafe sex, multiple sexual partners or sexual partner infection, or history of blood transfusion. 1. Early latent syphilis: disease duration < 2 years: a. A clear history of high-risk sexual behavior within the past 2 years, and no history of high-risk sexual behavior 2 years ago. b. Within the past 2 years, there are clinical manifestations consistent with stage I or II syphilis, but not diagnosed and treated. c. Within the past 2 years, sexual partners with a clear history of syphilis infection; 2. Late stage occult syphilis: duration of disease > 2 years. Those who cannot determine the disease duration are treated as advanced latent syphilis.
(2) Clinical manifestations: no clinical symptoms and signs.
(3) Laboratory tests: 1. Positive serological test for non-syphilis spirochetes, a few advanced late-stage recessive syphilis may be negative; 2. Positive serological test for syphilis spirochetes; 3. No significant abnormalities in cerebrospinal fluid examination.
(4) Diagnostic classification: 1, suspected cases: should meet one of the laboratory tests, no previous history of syphilis diagnosis and treatment, no clinical manifestations; 2, confirmed cases: meet both the requirements of suspected cases and both types of syphilis serological tests are positive. If conditions are feasible cerebrospinal fluid examination to exclude asymptomatic neurosyphilis.
6.Fetal syphilis.
(1) epidemiological history: the birth mother is a syphilis patient.
(2) Clinical manifestations: 1, early fetal syphilis: generally < 2 years old, similar to acquired stage II syphilis, dysplasia, lesions are often erythema, papules, flat warts, blisters - blisters; syphilitic rhinitis and laryngitis; osteomyelitis, osteochondritis and periostitis; may have generalized lymph node enlargement, hepatosplenomegaly, anemia, etc.; 2, late fetal syphilis: generally > 2 years old, similar to acquired stage III syphilis. Inflammatory damage (interstitial keratitis, neurogenic deafness, nasal or palatal gum swelling, klepton’s joint, tibial periostitis, etc.) or marked damage (rounded forehead, saddle nose, peyote shin, bony hypertrophy of the clavicothoracic joint, Hechin’s teeth, radiolucency of the skin around the mouth, etc.); 3, latent fetal syphilis: that is, untreated fetal syphilis, no clinical symptoms, positive syphilis serology test, cerebrospinal fluid examination (3) recessive fetal syphilis: that is, fetal syphilis without treatment, no clinical symptoms, positive syphilis serology test, cerebrospinal fluid examination, age < 2 years is early recessive fetal syphilis, > 2 years is late recessive fetal syphilis.
(3) Laboratory tests: 1. Microscopic examination: using dark-field microscopy or silver-plated staining microscopy, take the skin and mucous membrane damage or placenta specimens of children with early fetal syphilis, and syphilis spirochetes can be detected; 2. (3) Positive serological test, positive IgM antibody test has confirmatory significance, negative cannot exclude fetal syphilis.
(4) Diagnostic classification: suspected cases: all babies born to mothers with syphilis without effective treatment, or cases of stillbirth, stillbirth, or miscarriage, where the evidence is not sufficient to confirm the diagnosis of fetal syphilis. Confirmed cases: Any of the following laboratory tests and follow-up results: 1) dark-field microscopy, or silver-plated staining for syphilis spirochetes in early congenital syphilis skin/mucosal damage and tissue specimens, or positive nucleic acid test for syphilis spirochetes; 2) positive serum IgM antibody test for syphilis spirochetes in infants; 3) non-syphilis spirochete serologic test titer ≥ 4 times the mother’s titer at birth The infant was born with a non-syphilis spirochete serological test titer ≥ 4 times the mother’s titer and a positive syphilis spirochete serological test; 4. The infant was born with a negative non-syphilis spirochete serological test or a titer that did not reach 4 times the mother’s titer, but was found to change from negative to positive during subsequent follow-up, or the titer increased with clinical symptoms and a positive syphilis spirochete serological test; 5. The infant born to a syphilitic mother continued to have a positive syphilis spirochete antigen serological test until 18 months of age during follow-up.
II. Treatment
(1) General principles: 1. Early detection, timely and regular treatment, the earlier the treatment, the better the effect; 2. Irregular treatment may increase recurrence and contribute to the early occurrence of late damage; 3, after treatment to be followed up for a sufficient period of time; 4, all sex partners at the same time for examination and treatment.
2. Treatment options.
(1) Early syphilis (including stage I, stage II and latent syphilis with duration < 2 years) recommended regimen: procaine penicillin G 800,000 U/d, intramuscular injection for 15 d; or benzathine penicillin 2.4 million U, divided into bilateral gluteal intramuscular injections, once a week, for a total of 2 times. Alternative regimen: ceftriaxone 0.5 to 1 g, once daily, intramuscular injection or intravenous administration for 10 d. For allergy to penicillin, use the following drugs: doxycycline 100 mg, twice daily for 15 d; or tetracycline hydrochloride 500 mg, four times daily for 15 d (prohibited for those with hepatic and renal insufficiency).
(2) Late syphilis (stage III skin, mucous membrane, bone syphilis, late recessive syphilis or recessive syphilis where the stage of disease cannot be determined) and stage II recurrent syphilis recommended regimen: procaine penicillin G, 800,000 U/d, intramuscular injection, 20 d for 1 course, or consider giving a second course, with 2 weeks of discontinuation between courses; or benzathine penicillin 2.4 million U, divided into bilateral gluteal intramuscular injection, once a week. 3 times in total. For penicillin allergy, use the following drugs: doxycycline 100 mg twice daily for 30 d; or tetracycline hydrochloride 500 mg four times daily for 30 d (contraindicated in hepatic and renal insufficiency).
(3) Recommended regimen for cardiovascular syphilis: If there is heart failure, treat heart failure first, and when the heart function can be compensated, inject penicillin, which needs to be started in small doses to avoid the occurrence of Jihai’s reaction, which may cause aggravation of the disease or death. Aqueous penicillin G, 100,000 U on day 1, 1 intramuscular injection; 100,000 U on day 2, 2 intramuscular injections daily; 200,000 U on day 3, 2 intramuscular injections daily; from day 4 onwards, the following regimen was followed: procaine penicillin G, 800,000 U/d, intramuscular injection, 20 d for 1 course, 2 courses (or more) in total, with 2 weeks off between courses; or benzathine penicillin 2.4 million U, divided into bilateral gluteal intramuscular injection, 1 time per week, 3 times in total. For those who are allergic to penicillin, use the following drugs: doxycycline 100 mg twice daily for 30d; or tetracycline hydrochloride 500 mg four times daily for 30d (prohibited for those with hepatic and renal insufficiency).
(4) Recommended regimen for neurosyphilis and ophthalmic syphilis: Penicillin G in water 18-24 million U intravenously (3-4 million U every 4 hours) for 10-14 d. If necessary, followed by benzathine penicillin G 2.4 million U intramuscularly once a week for 3 times. Or procaine penicillin G, 2.4 million U/d 1 intramuscular injection, together with oral propofol, 0.5 g each time, 4 times a day for 10-14d, followed by benzathine penicillin G 2.4 million U, 1 intramuscular injection once a week for 3 times, if necessary. Alternative regimen: Ceftriaxone 2 g, administered intravenously once daily for 10-14 d. For those allergic to penicillin, use the following drugs: doxycycline 100 mg twice daily for 30 d; or tetracycline hydrochloride 500 mg four times daily for 30 d (contraindicated in hepatic and renal insufficiency).
(5) Early fetal syphilis (< 2 years old) Recommended regimen: for abnormal cerebrospinal fluid: aqueous penicillin G, 100,000~150,000 U/kg-1・d-1, for newborns within 7 d after birth, 50,000 U/kg each time, intravenous drip every 12 hours, and every 8 hours thereafter, until a total course of 10~14 d or procaine penicillin G, 50,000 U/kg-1・d-1, intramuscular If the cerebrospinal fluid is normal: benzathine penicillin G, 50,000 U/kg, 1 intramuscular injection in both buttocks. If there is no condition to check the cerebrospinal fluid, it can be treated as abnormal cerebrospinal fluid. For those who are allergic to penicillin, there is no evidence of effective use of other treatment regimens, erythromycin treatment can be tried.
(6) Late fetal syphilis (> 2 years old) recommended regimen: aqueous penicillin G, 150,000 U・kg-1・d-1, intravenous infusion in divided doses for 10 ~ 14 d, or procaine penicillin G, 50,000 U/kg daily, intramuscular injection for 10 d as a course of treatment (penicillin dosage for older children should not exceed that for adult patients of the same age). For normal cerebrospinal fluid: benzathine penicillin G, 50,000 U/kg, 1 injection in both gluteal muscles. Alternative regimen: for those allergic to penicillin, previous use of cephalosporin antibiotics without allergy can be chosen under close observation: ceftriaxone 250mg, 1 time daily, intramuscular injection for 10 to 14d< Tetracycline is prohibited in children 8 years old.
(7) Syphilis in pregnancy: pregnant women newly diagnosed with syphilis during pregnancy should be treated according to the appropriate syphilis staging. The treatment principles are the same as for non-pregnant patients, but tetracycline and doxycycline are prohibited, and quantitative non-syphilis spirochete serology tests are performed once a month after treatment to observe for recurrence and reinfection. One course of anti-syphilis treatment is recommended for patients with syphilis in pregnancy in the early 3 months of pregnancy and one course in the last 3 months of pregnancy. For those allergic to penicillin and cephalosporins, since tetracyclines cannot be applied during pregnancy and lactation, macrolides can be tried instead: erythromycin 500 mg four times daily for 15 d for early syphilis and 30 d for late syphilis and syphilis of unknown duration. erythromycin is poorly effective in the treatment of syphilis and clinical and serological follow-up should be intensified after treatment. After cessation of breastfeeding, retreatment with doxycycline is required.
(8) Treatment of syphilis patients with combined HIV infection: 1. All HIV-infected patients should be screened for syphilis serology; all syphilis patients should be screened for HIV antibodies; 2. When the diagnosis cannot be established by routine syphilis serology, skin lesion biopsy should be taken and immunofluorescent staining or silver staining should be performed to find syphilis spirochetes; 3. All syphilis patients with combined HIV infection should be considered for lumbar puncture examination Cerebrospinal fluid to exclude neurosyphilis; 4, syphilis patients combined with HIV infection is still unclear whether to increase the dose or course of treatment syphilis, for stage I, II and occult syphilis is recommended to check the cerebrospinal fluid to exclude neurosyphilis, if not achieved, it is recommended to use neurosyphilis treatment program for treatment; 5, close monitoring and regular follow-up of patients.