Symptomatic secondary syphilis: empirical antimicrobial treatment or await microbiology?

Men who have sex with men (MSM) with symptomatic secondary syphilis present with characteristic symptoms of rash, fever and lymphadenopathy; due to delays in microbiology results and some patients failing to return for treatment, empirical treatment is sometimes offered. We reviewed all patients presenting with secondary syphilis diagnosed on the basis of clinical symptoms and signs and reviewed treatment. Of the 36 patients, 16 MSM (44%; 95% confidence interval (CI) 27.8-60.2%) were treated empirically, whereas treatment was delayed for 20 (56%; 95% CI 39.8-72.2%) waiting for microbiology results. Treatment delays were longer for HIV-negative than HIV-positive MSM (10 vs 5 days respectively; P = 0.01); the cumulative treatment delay was 143 days. Concerns over antimicrobial resistance and overuse of antimicrobials should drive the use of point-of-care testing for syphlis.