NICE vs BASHH: Management of Syphilis (2025)

This guide provides a comparative overview of the key recommendations for the management of syphilis from the National Institute for Health and Care Excellence (NICE) and the British Association for Sexual Health and HIV (BASHH). Both guidelines are pivotal for UK clinical practice, but they serve different purposes and offer distinct levels of detail. This comparison aims to highlight these differences and provide practical takeaways for clinicians.

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Introduction and Scope

NICE Guideline [NG76]: "Sexually transmitted infections: condom distribution schemes" includes a high-level summary of syphilis management within a broader public health-focused document. Its recommendations are concise and intended for a wide audience, including non-specialists.

BASHH Guideline (2021, with 2024 interim updates): The UK National Guideline on the Management of Syphilis is a comprehensive, specialist-level document. It provides detailed, evidence-based recommendations on diagnosis, treatment, and management of complex cases, and is considered the definitive standard for UK sexual health practice.

Practical Takeaway: For day-to-day specialist management, the BASHH guideline is the primary reference. The NICE document offers a useful summary for GPs, pharmacists, and public health teams involved in condom distribution schemes.

Diagnosis and Assessment

Serological Testing and Interpretation

BASHH: Provides an exhaustive algorithm. It recommends initial screening with a treponemal test (e.g., EIA/CIA). If reactive, this is followed by a quantitative non-treponemal test (RPR/VDRL) to assess disease activity and aid staging. Discordant results and the "serofast" state are discussed in detail.

NICE: Briefly states that diagnosis is based on serological testing, without detailing specific algorithms or the management of complex serology.

Key Difference: BASHH offers the necessary, in-depth diagnostic pathway, while NICE provides only a basic overview.

Staging

BASHH: Defines stages precisely: primary, secondary, early latent (<2 years), late latent (>2 years or duration unknown), and tertiary (neurosyphilis, cardiovascular, gummatous). Staging is critical for determining treatment regimen and duration.

NICE: Mentions staging (early/late) but does not elaborate on the specific criteria or the importance of the 2-year threshold.

Treatment Recommendations

First-Line Therapy for Early Syphilis

Both guidelines agree on a single dose of intramuscular Benzathine benzylpenicillin G (2.4 MU) as the gold standard for primary, secondary, and early latent syphilis.

Practical Takeaway: This is a key area of consensus and the cornerstone of treatment.

Treatment for Late Syphilis and Penicillin Allergy

BASHH:

• Late Latent/Tertiary Syphilis: Recommends Benzathine benzylpenicillin G 2.4 MU IM once weekly for 3 weeks.
• Penicillin Allergy (Non-pregnant): For early syphilis, first-line is Doxycycline 100mg BD orally for 14 days. Ceftriaxone (1g IM/IV daily for 10-14 days) is a second-line option. Desensitisation to penicillin is strongly recommended for all stages, especially in pregnancy and neurosyphilis.

NICE: Recommends doxycycline for penicillin-allergic patients but does not provide dosage or duration specifics for different stages. It lacks detail on ceftriaxone or desensitisation.

Key Difference: BASHH provides a complete, staged management plan for all scenarios, including alternative regimens. NICE offers a simplified version.

Special Situations and Complex Management

Neurosyphilis

BASHH: Provides a detailed diagnostic workup (indicators for lumbar puncture) and a specific treatment regimen: Procaine penicillin 1.8-2.4 MU IM daily plus Probenecid 500mg QDS orally, both for 17-21 days. Alternative regimens are also outlined.

NICE: Does not cover the management of neurosyphilis.

Practical Takeaway: For any suspected neurological involvement, immediate referral to a specialist service and strict adherence to the BASHH neurosyphilis guideline is essential.

Syphilis in Pregnancy

BASHH: Penicillin is the only recommended therapy. For penicillin-allergic pregnant individuals, desensitisation followed by penicillin treatment is mandatory. Detailed management plans for treatment failure and the Jarisch-Herxheimer reaction are included.

NICE: Advises that pregnant patients with syphilis should be referred to a specialist.

Key Difference: BASHH gives definitive, life-saving management instructions. NICE appropriately advises referral but does not guide the specialist management.

HIV Co-infection

BASHH: Management is generally the same as for HIV-negative individuals, but with heightened vigilance. More frequent serological monitoring (e.g., 3, 6, 12, 24 months) is recommended due to a higher risk of neurological involvement and treatment failure. Lumbar puncture should be considered more readily.

NICE: Does not specifically address HIV co-infection.

Practical Clinical Flow: From Suspicion to Follow-up

1. Suspicion & Testing: Based on history, examination, or screening. Use BASHH's serological algorithm.

2. Diagnosis & Staging: Confirm with treponemal and non-treponemal tests. Stage accurately using BASHH criteria (crucial for treatment choice).

3. Treatment:

• Early Syphilis: Benzathine penicillin G 2.4 MU IM, single dose.
• Late Syphilis: Benzathine penicillin G 2.4 MU IM weekly for 3 doses.
• Penicillin Allergy: Refer to BASHH for doxycycline/ceftriaxone regimens. For pregnancy or neurosyphilis, arrange desensitisation.
• Neurosyphilis/Pregnancy: Manage strictly per BASHH guideline; these are never primary care or non-specialist managed conditions.

4. Partner Notification & Health Promotion: Essential for all cases. Trace and treat partners from within the relevant timeframe (3 months plus duration of symptoms for primary syphilis, up to 2 years for early latent).

5. Follow-up: Monitor with quantitative non-treponemal titres (RPR/VDRL) at 3, 6, and 12 months (and 24 months for late latent/HIV). Aim for a 4-fold decline in titre to demonstrate adequate response.

Frequently Asked Questions (FAQs)

1. Which guideline should I use as a GP or a Sexual Health Consultant?

Answer: All clinicians should be aware of the NICE summary, especially its public health aspects. However, for any aspect of direct patient diagnosis, treatment, or management, the BASHH guideline is the definitive UK standard. Specialists must use BASHH.

2. A patient has a penicillin allergy. Can I prescribe doxycycline in pregnancy?

Answer: No. Doxycycline is contraindicated in pregnancy. The BASHH guideline is unequivocal: for a pregnant patient with a penicillin allergy, admission for penicillin desensitisation is required. This is a critical safety recommendation.

3. How do I interpret a patient whose RPR titre fails to decline (serofast state)?

Answer: This is covered in depth by BASHH. It may indicate re-infection, treatment failure, or be a known phenomenon (more common in later stages). Management involves re-assessment, re-treatment consideration, and excluding neurosyphilis, particularly in HIV-positive individuals. NICE does not address this.

4. What is the role of ceftriaxone in UK syphilis management?

Answer: According to BASHH, ceftriaxone is a second-line alternative for non-pregnant patients with penicillin allergy, typically administered for 10-14 days. It should not be used if there is a history of anaphylaxis to penicillin. Its use is not detailed in the NICE guideline.

5. When should I perform a lumbar puncture?

Answer: BASHH outlines clear indications: neurological/ophthalmic/otic symptoms, treatment failure, tertiary syphilis, or HIV co-infection with late latent syphilis or a CD4 count ≤350 cells/μL. NICE does not provide this guidance.

Source Links and Updates

BASHH UK National Guideline for the Management of Syphilis:
[2021 Full Guideline] https://www.bashhguidelines.org/media/1268/syphilis-2021.pdf
[2024 Interim Update] (Check the BASHH website for the latest amendments, often regarding doxycycline or ceftriaxone use.)

NICE Guideline [NG76]: Sexually transmitted infections: condom distribution schemes:
https://www.nice.org.uk/guidance/ng76
Note: The syphilis management recommendations are contained within this broader document.

Summary and Key Takeaways

• BASHH for Practice, NICE for Context: BASHH provides the granular, specialist-level detail required for safe and effective syphilis management. NICE offers a high-level summary within a public health context.
• Staging is Paramount: Accurate staging (using BASHH criteria) directly determines the correct treatment regimen and duration.
• Penicillin is King, Desensitisation is Key: IM penicillin remains first-line for all stages. Desensitisation is the recommended pathway for penicillin-allergic pregnant patients and for neurosyphilis.
• Complex Cases are for Specialists: Pregnancy, neurosyphilis, HIV co-infection, and suspected treatment failure require immediate specialist management guided by the BASHH protocol.
• Vigilant Follow-up: Serial RPR/VDRL titres are essential to monitor treatment response, with more frequent monitoring in HIV co-infection.