Use of Treponemal Screening Assay Strength of Signal to Avoid Unnecessary Confirmatory Testing

Sex Transm Dis. 2016 Dec;43(12):737-740. doi: 10.1097/OLQ.0000000000000524.


Background: Our reverse syphilis testing algorithm consists of a treponemal IgG multiplex flow immunoassay (MFI) followed by both rapid plasma reagin titer and the Treponema pallidum particle agglutination (TPPA) test on specimens with a reactive MFI result. We report here the impact of a modified reverse algorithm, in which the strength of signal of the MFI is used to avoid unnecessary TPPA testing.

Methods: The Bioplex syphilis IgG MFI was used as the syphilis screening assay, and specimens with equivocal (antibody index 0.9 or 1.0), or reactive (antibody index ≥ 1.1) results were further tested by rapid plasma reagin titer and TPPA test. We performed a retrospective, descriptive analysis of all specimens received for syphilis screening between January and May of 2014. A cost analysis was performed, taking into account labor and reagent expenses.

Results: In our diverse patient population consisting of high-risk incarcerated persons, low-risk obstetrical/gynecological patients and high-risk miscellaneous clinic and inpatients, 430 (65%) of 665 MFI-positive specimens had antibody indices of 8 or greater. Greater than 99% of these specimens were reactive by the TPPA test. Avoiding TPPA testing of specimens with an MFI antibody index ≥8 would save over US $4800 annually in laboratory costs.

Conclusions: The TPPA testing is unnecessary on specimens with MFI antibody indices ≥8. This would substantially reduce the TPPA testing volume and also reduce laboratory expenses.

MeSH terms

  • Agglutination Tests
  • Algorithms
  • Antibodies, Bacterial / immunology*
  • Female
  • Humans
  • Immunoassay
  • Male
  • Retrospective Studies
  • Sensitivity and Specificity
  • Syphilis / diagnosis*
  • Syphilis / microbiology
  • Syphilis Serodiagnosis / economics
  • Treponema pallidum / immunology
  • Treponema pallidum / isolation & purification*


  • Antibodies, Bacterial