lately I had 2 incidents, where I performed mutual masturbation in Berlin, where lately a syphilis outbreak was reported. Hands were going a lot back and forth and I think one of the partners was a transgender person, e.g. a man that was operated to be a woman. I know syphilis rates are especially high in this group so I freaked out and took azithromycin (Z-pack) of 1g (4 pills) in one dose as a preventative measure.

My question:

The incidents happened 8 and 1 day ago. Will the single dose of 1g azithromycin reliably eradicate a possibly incubating syphilis? 

Even though your partner(s) may have been at high risk for syphilis, it is not easily or frequently transmnitted without insertive sex, i.e. by mutual masturbation, even in the presence of substantial genital fluids. All things considered, your risk was low.

The problem with azithromycin and syphilis is that some Treponema pallidum strains are resistant to azithromycin. These strains are very common throughout Western Europe (and North America), rare (so far) in some areas (e.g. Africa). I have no knowledge of the specific situation in Berlin or in the outbreak you say is currently underway in Berlin. You probably could find out pretty quickly from your regional or national public health department(s), or perhaps even news media about the outbreak. But absent that reassurance, I would assume azithromycin would have no prophylactic effect. Public health or a local STD expert/clinic would be better to advise you on both the wisdom of preventivie treatment and reliability of azithromycin -- but probably if they recommend treatment at all, it would be an injeciton of long-acting penicillin. In any case, do not take any more azithro:  if it's reliabiy active against T. pallidum in Berlin, 1 g total is sufficient.

Given your continued potentially risky exposures and concerns and seeming reliance on this forum, I would recommend you find a personal physician with expertise in STDs. In Germany, most STD expertise resides with dermatologists, some of whom advertise both kinds of expertise (e.g. dermatovenereology). There are excellent resources in Berlin. Such a doctor or clinic would know about both local syphliis outbreaks and azithromycin resistance in the area.

Thanks again for the advance thanks. I hope these comments are helpful.

HHH, MD

thank you very much for your timely answer and your effort even to supply me with an expert contact in Berlin. I really do appreciate that! Actually I have scheduled a consultation with Dr. *** next week. Prof. *** who, supposedly is your contact there, is on travels, as you said. 

In advance and to prepare I have some more questions for you. First, I give you some background for my situation, which I consider to be complex. Indeed I was a little surprised that you classify my consistent exposures to mutual masturbation only as "continued potentially risky exposures" (please don't get me wrong, I don't debate or question you - indeed I do trust your expertise). I wrote you before that I am head of a big German organization and a family father who cares for a large extended family and I am typically a good problem solver. There is only this one area in my life where I fail with this: My sexual lifestyle. My wife and me tried several times even with counseling but we don't manage to get back to a sex life together. So I am going for this mutual masturbation (strict and only) exposures for about 20 years now and go for testing at least once a year. And for your information, I normally never frequent gay or transgender CSWs. This time I just realized that most probably it turned out to be one... 

I pretty much understood your situation from our previous conversations. Very brief replies; you will be asking the same at your appointment next week. 1) Correct. 2) If no change in exposures, no testing at all is necessary, except for reassurance. Probably no more often than once a year. 3) Very low syphilis risk, and what small risk there is depends not on the details of the exposure but on local knowledge of syphilis epidemiology -- i.e. at your appointment. It is possible that preventive treatment with penicillin will be recommended, but perhaps only a syphilis blood test in a few weeks. 4) Correct.

I'll be interested in hearing about your clinic visit, but won't have any further comments until then.

just to give you a Feedback: I had my consultation in Berlin today. I was told that the media quite exaggerated the "outbreak" and while there are about 10% more cases in Berlin (mainly in MSM) the term "outbreak" is really out of proportion. But I was also told that most strains are indeed resistant to Azithromycin and that my "prophylaxis" wouldn't be protective. So I was advised to get a syphils test after 6 weeks and I will of course follow this advice.

At the moment I feel down and don't know, how I will manage to get through the waiting period. So I have two more, final questions:

1) I am a "numbers man". How would you rate the probability of a positive test, taking into account that my exposures were mutual masturbation only?

2) I want to resume sexual activity with my wife. Should I wait with that the next 6 weeks?

Thank you again for your help and your engagement even with providing me a contact here in Germany. You are a great example to others. Keep it up!

Karl

1) I will be extraordinarily surprised if you acquired syphiis; the exposure was exceedingly low risk, certainly no higher than one in many thousand, maybe under in in a million.* Undoubtedly your STD consultant agrees:  if she thought there was even slight risk, undoubtedly she would have treated you with penicillin. You could skip the blood test, from a medical/risk perspecitve, except you obviously should do it for the reassurance you will experience from the anticipated negative result. And in the unlikely chance it's positive, you'll still be in the safe period for treatment before signficant chance of complications and serious harm.

2) I would definitely resume sex at home if I were in your situation. Of course in the very unlikely chance of a positive test result, you'll have to face the music. But no (physical) harm will have occurred and the chance is exceedingly low.

* Here is a statistic I sometimes offer to clients in the US, but as a "numbers man" you may appreciate it. Among the 360 million US residents, each year 1 in 1,756 die of traumatic accidents:  falls, vehicular accidents, drowning, firearm injuries (pretty much unique for most western countries, etc, etc. If your chance of syphilis is say 1 in 100,000, in the US your risk of dying in the next 12 months would be 57X higher from an accident. Insteady of worrying about syphilis, it would make more (statistical) sense to remember your seatbelt and not be one of those 160 km/h guys in their Mercedeses or Beamers who blow by me on the autobahns!