Treatment of infants with reactive syphilis serology, New Jersey: 1992 to 1996

Diagnosis of congenital syphilis is problematic: infants with congenital syphilis are often asymptomatic, and signs in symptomatic infants are frequently subtle and nonspecific. Furthermore, there are no readily available diagnostic tests that provide a definitive diagnosis. Previously, the diagnosis of congenital syphilis was based on a complex set of clinical and laboratory criteria, and only infants with clinically apparent illness or laboratory findings indicating congenital syphilis were classified as cases and reported to health departments and the Centers for Disease Control and Prevention (CDC). To systematize diagnosis and case-reporting, the CDC developed a standardized surveillance case definition in 1988. This case definition includes symptomatic infants as well as asymptomatic infants of mothers with untreated or inadequately treated syphilis during pregnancy. It is intended to be highly sensitive to better estimate the burden of disease in the community. Treatment guidelines for congenital syphilis are intentionally conservative and err on the side of overtreatment so that all potentially infected infants are treated. The congenital syphilis surveillance case definition is compatible with the American Academy of Pediatrics (AAP) and CDC treatment guidelines; thus, the number of infants identified and reported to state health departments and the CDC should reflect the number of infants treated. Hundreds of infants with reactive serologic tests for syphilis (STS) are reported each year to the New Jersey Department of Health and Senior Services (NJDHSS). The majority of these infants do not meet the case definition for congenital syphilis, and most are treated although treatment guidelines indicate that treatment is not necessary.

To determine whether infants with reactive STS in New Jersey are being treated according to the AAP treatment guidelines.

Medical records of newborns with reactive STS reported to NJDHSS between July 1, 1992, and June 30, 1996, were reviewed to determine status of infection and compliance with the AAP treatment guidelines. The 1995 NJDHSS Uniform Billing and Hospital Discharge Data was used to estimate the mean cost of hospitalization per day for infants with the diagnosis of congenital syphilis. Results. During the study period, 1669 newborns with reactive STS were reported to the NJDHSS Sexually Transmitted Disease Program. Medical record review was completed for 1480 infants (88%). Infants were classified by CDC surveillance criteria as follows: 0 confirmed cases; 515 (35%) presumptive cases; 16 (1%) syphilitic stillbirths; and 949 (64%) cases that did not meet the definition for congenital syphilis. Of the 512 presumptive cases that survived the immediate perinatal period, 478 (93%) were treated with antibiotics and 459 (90%) were treated according to the AAP treatment guidelines. Only 27 infants (6%) were treated with a single intramuscular dose of benzathine penicillin. Thirty-four infants (7%) were not treated; instead, their physicians chose to follow them clinically and serologically. All of those treated were asymptomatic, and most were born to mothers with a history of adequate treatment before or during pregnancy, but who were without serologic follow-up. Of the 949 infants that did not meet the case definition, 329 infants (35%) were not treated and 620 (65%) were treated with antibiotics. The 508 (82%) infants treated with antibiotics were treated with intravenous or intramuscular antibiotics for 10 days; only 62 (10%) were treated with a singular intramuscular dose of benzathine penicillin. According to NJDHSS Uniform Billing Hospital Discharge Data, 267 infants weighing >/= 2500 g were discharged with a diagnosis of congenital syphilis in 1995. The median number of hospital days for these infants was 10, and the mean cost of hospitalization per day was $1010. Sources of payment of hospital charges for most infants were public in