The diagnosis and management of neurosyphilis in england, 2025: a cross-sectional survey

Background Neurosyphilis remains a challenging diagnosis, and the British Association for Sexual Health and HIV (BASHH) guideline recommends lumbar puncture in patients with clinically suspected neurological syphilis. However, the extent to which this guidance is implemented in routine practice across England is uncertain. This study aimed to characterise current approaches to the diagnosis and management of neurosyphilis in England. Methods We conducted an opportunistic cross-sectional, web-based survey of clinicians managing neurosyphilis in England in March 2025. Eligible services had treated at least one case of neurosyphilis within the preceding 12 months. Data were collected on service characteristics, access to and indications for lumbar puncture, laboratory investigations, treatment regimens, and follow-up practices. Results Forty-two responses representing 66 services across England were included. The majority (93%) were level 3 sexual health services, primarily community-based. Neurosyphilis was infrequently encountered (<10 cases/year in 67% of services). Lumbar puncture practice varied widely: 26% routinely performed lumbar puncture in suspected cases, 21% never performed lumbar puncture, and others reserved lumbar puncture for diagnostic uncertainty or suspected treatment failure. Logistical barriers and perceptions that cerebrospinal fluid (CSF) results would not alter management were common reasons for not performing lumbar puncture. The majority of services (65%) initiated treatment without awaiting CSF results. While 70% used first-line penicillin-based regimens, 23% used ceftriaxone first line, and ceftriaxone was often used in penicillin allergy (18% of services). Follow-up was predominantly serological and clinical; repeat CSF testing was uncommon. Conclusions There is substantial variation in neurosyphilis diagnosis and management across England, with frequent divergence from national guidance. Logistical barriers and diagnostic uncertainty contribute to pragmatic, empiric treatment approaches.