Universal Syphilis Screening in the ED Catches More Cases

SAN FRANCISCO — Using only targeted models of syphilis screening in the emergency department (ED) would miss large proportions of active syphilis cases as well as new HIV diagnoses and acute HIV cases, according to new research.

Only screening patients for syphilis who came to the ED for gonorrhea and chlamydia testing would have missed 76.4% of positive syphilis screens as well as 68.7% of new HIV diagnoses, reported Kimberly Stanford, MD, MPH, of the University of Chicago Medical Center.

Even testing those who came in for a complete blood count (CBC) and/or gonorrhea and chlamydia testing would still miss 14.7% of positive syphilis screens and 22.9% of new HIV diagnoses, she said at the annual Conference on Retroviruses and Opportunistic Infections here.

“The bottom line is, if you’re in a high prevalence area and you’re running an ED screening program, which I think everybody should be, universal screening probably is going to be your best bet until we start to get this epidemic under control,” Stanford said during a press conference.

Her institution implemented opt-out, routine ED syphilis screening in 2019 for all patients under age 65 who had not been screened in the past year. An alert for the screening pops up in the electronic medical record (EMR) during triage, when the order screen opens, or any time the nurse opens the chart until the alert is addressed.

Out of more than 37,000 people screened during the first 2 years after implementing universal screening in 2019, the ED identified 624 patients with syphilis, 83 new diagnoses of HIV, and 21 acute cases of HIV.

The researchers then calculated how many positive syphilis screens and new HIV diagnoses would have been identified or missed under seven different targeted approaches instead of universal screening.

Using orders-based screening would only have caught 82.7% of all positive syphilis screens if screening patients with any blood test, 75.6% if screening patients getting CBCs, 23.6% if screening patients getting tested for gonorrhea and chlamydia, and 85.3% if screening patients getting CBCs and/or gonorrhea and chlamydia composite testing.

In addition, using orders-based HIV screening for individuals with any blood test would only have caught 75.9% of the new HIV diagnoses and 81% of the acute HIV cases. If screening for HIV in individuals getting CBCs, orders-based screening would have caught just 66.3% of new diagnoses and 61.9% of acute cases.

Screening for HIV in patients getting tested for gonorrhea and chlamydia would have identified 31.3% of the new HIV diagnoses and 4.8% of acute HIV cases, and screening in those getting CBCs and/or gonorrhea and chlamydia testing would have found 77.1% and 66.7%, respectively.

The pros of using orders-based screening are that it is straightforward to automate in the EMR and it reduces workload and the burden on the patient if they’re already undergoing a blood draw for other reasons, Stanford said. However, orders-based screening still misses many diagnoses, especially if it only focuses on those getting testing for sexually transmitted infections. In this study, 24.4% of syphilis cases and 38.1% of acute HIV cases would have been missed if only individuals getting CBCs were screened.

Population-based screening revealed similar missed opportunities. Only 22.8% of positive syphilis screens would have been identified if screening only women of reproductive age (under age 50). Just 14.5% of new HIV diagnoses and 19% of acute HIV cases would have been found by screening women of reproductive age.

Screening only individuals with a positive pregnancy test in the ED would have identified just 2.4% of positive syphilis screens, 2.4% of new HIV diagnoses, and none of the acute HIV cases.

If screening only people with a diagnosis code for opioid use/substance use, a population-based program would have found 18.3% of positive syphilis screens, 7.2% of new HIV diagnoses, and none of the acute HIV cases.

Two pros of population-based screening are having a much smaller target, which reduces the workload of blood draws and follow-up, and targeting the highest priority populations. Again, however, this approach misses many diagnoses. Further, the diagnosis code for opioid or substance use is only used in the ED if it is related to the patient’s care, and only 50% of pregnant individuals were actually screened since many learned of their pregnancy after the blood draw.

Joseph Cherabie, MD, of Washington University School of Medicine in St. Louis, said a universal screening program in the ED is both “very reasonable and very feasible” for institutions with EMR systems that allow pop-up reminders.

More importantly, however, he said the idea of screening all patients requires a “paradigm shift” in the way healthcare providers think.

“We still live in an era where I have patients who go to an urgent care and ask for testing, and they’re told, ‘Oh, you don’t look like you have HIV, so we’re not going to test you for that,’ or ‘You don’t look like you have syphilis, so we’re not going to do that,’ or ‘We don’t know how to interpret these results, so we’re not going to do it,'” Cherabie told MedPage Today.

“With the increasing rates of congenital syphilis, as well as syphilis overall, we need proper diagnoses, and opt-out testing is a great way to do that, especially in the emergency department, where more and more people are going for a variety of different reasons,” said Cherabie, who was not involved in the study. “Any interaction with a healthcare system is an opportunity to test for syphilis and screen for it.”

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