Adherence to oral therapies in pelvic inflammatory disease

A pharmacist-driven deprescribing protocol for negative urine and sexually transmitted infection cultures in the emergency department increases antibiotic-free days

PURPOSE

Emergency department (ED) pharmacists commonly perform positive culture follow-ups that result in optimized antibiotic prescribing. The purpose of this study was to evaluate the potential positive impact on the outcome of antibiotic-free days through an ED pharmacist-driven protocol to contact patients with negative urine cultures and sexually transmitted infection (STI) test results who were discharged with antibiotics.

METHODS

This was a single-center, prospective, observational, pre-post intervention study to determine antibiotic use in patients with negative urine cultures who were discharged from the Loyola Medical University Center ED with antibiotics prescribed. Patients were identified through daily positive culture reports. The primary outcome was days free of antibiotics, defined as the number of calendar days within 28 days after urine culture or STI test collection on which the patient did not receive any antibiotic treatments.

RESULTS

One hundred ninety-two patients were screened. Sixty-three and twenty-six patients met the inclusion criteria in the pre- and postintervention groups, respectively. The study identified 163/465 (35.1%) antibiotic free days for the preintervention group, compared to 150.5/187 (80.5%) antibiotic-free days for the postintervention group. A majority of the patients did not have urinary tract infection as the chief complaint. The most common urinary and STI symptoms upon ED admission in the pre- and postintervention groups were dysuria (19.2% vs 28.1%) and unusual discharge (30.8% vs 28.6%), respectively.

CONCLUSION

This study showed that a pharmacist-driven protocol increased the number of antibiotic-free days for patients prescribed empiric antibiotic therapy and discharged from the ED with subsequent negative urine cultures and STI results. We propose taking a novel approach in discontinuation of antibiotics by implementing an expansion of ED culture programs to include negative cultures that promote antimicrobial stewardship.

Moxifloxacin monotherapy for treatment of uncomplicated pelvic inflammatory disease: A systematic review and meta-analysis with trial sequential analysis of randomized controlled trials

PURPOSE

The aim of this study was to evaluate the efficacy and safety of moxifloxacin monotherapy for the treatment of uncomplicated pelvic inflammatory disease (uPID).

METHODS

The literatures from PubMed, ScienceDirect, Google Scholar, Cochrane library and the http://clinicaltrials.gov/ were retrieved until February 2023. Only randomized controlled trials (RCTs) comparing the efficacy and safety of moxifloxacin with other antibiotics for treating uPID were included. The primary outcomes were clinical cure rate (CCR), bacteriological success rates (BSR) and risk of drug-related adverse events (AEs). We used random-effects modelled meta-analysis, trial sequential analysis, and the Grading of Recommendations Assessment, Development, and Evaluation. This study was registered in the International Prospective Register of Systematic Reviews (registration number: CRD42023428751).

RESULTS

A total of four RCTs that enrolled 3201 women patients with uPID were included. In the per-protocol populations, no significant difference was observed between patients given moxifloxacin and those given other antibiotics with regard to CCR at test-of-cure (TOC) (2485 patients, odds ratio [OR] = 0.84, 95% confidence interval [CI] 0.68-1.04, p = 0.12). Similarly, there was no statistically significant difference between patients given moxifloxacin and those given other antibiotics in terms of BSR at TOC (471 patients, OR = 1.17, 95% CI 0.70-1.96, p = 0.56) in the microbiologically valid population. However, drug-related AEs occurred less frequently with moxifloxacin than with other antibiotics (2973 patients, OR = 0.74, 95% CI 0.64-0.86, p < 0.0001), especially gastrointestinal AEs (2973 patients, OR = 0.59, 95% CI 0.47-0.74, p < 0.00001).

CONCLUSIONS

In the treatment of uPID, moxifloxacin monotherapy can achieve similar efficacy as other combination therapy regimens. Moreover, moxifloxacin had a better safety profile than that of comparators. Based on its additional advantages (i.e., better safety profile, no dosage adjustment and better compliance), moxifloxacin may be a more fascinating option compared with the currently used regimens.

A Comparison of Single-Dose Versus Multidose Metronidazole by Select Clinical Factors for the Treatment of Trichomonas vaginalis in Women

BACKGROUND

In a randomized controlled trial of 2 g (single-dose) metronidazole (MTZ) versus 500 mg twice daily for 7 days (multidose) for Trichomonas vaginalis treatment, multidose was superior. We examined if the effect was similar by select clinical factors to determine if treatment recommendations could be targeted.

METHODS

The primary outcome was T. vaginalis repeat infection at test-of-cure (TOC) 4 weeks after completion of therapy. Analyses were stratified by T. vaginalis history, baseline genital symptoms, and concurrent diagnosis of bacterial vaginosis (BV) per Nugent score at baseline.

RESULTS

Women who returned for TOC (n = 540) were included. At baseline, 52.9% had a self-reported history of T. vaginalis; 79.3%, genital symptoms; 5.8%, a gonorrhea diagnosis; and 47.5%, BV. During follow-up, 97.4% took all MTZ as instructed and 34.5% had interval condomless sex with a baseline partner. At TOC, 14.8% tested positive for T. vaginalis. In stratified analysis, women randomized to single-dose MTZ had a higher rate of TOC T. vaginalis positivity than those randomized to multidose if they were symptomatic at baseline (21.4% vs. 10.8%, P = 0.003) or had a reported history of T. vaginalis (24.1% vs. 12.6%, P = 0.01). Test-of-cure T. vaginalis positivity was higher for women receiving a single dose (18.9%) versus multidose (10.8%), irrespective of baseline BV status (P > 0.06). In multivariable analysis, only a history of T. vaginalis and single-dose MTZ were independently associated with a positive TOC for T. vaginalis.

CONCLUSIONS

Although multidose MTZ is recommended for all women with T. vaginalis, it is especially important for women with a T. vaginalis history and, given high posttreatment infection rates, a TOC should be performed.

Pelvic inflammatory disease in the adolescent and young adult: An update

Pelvic inflammatory disease (PID) is an infection of the female upper genital tract that is typically polymicrobial with classic core involvement of Neisseria gonorrhoeae and/or Chlamydia trachomatis, though other endogenous flora from the vagino-cervical areas can be involved as well. It is often a sexually transmitted disease but other etiologic routes are also noted. A variety of risk factors have been identified including adolescence, young adulthood, adolescent cervical ectropion, multiple sexual partners, immature immune system, history of previous PID, risky contraceptive practices and others. An early diagnosis and prompt treatment are necessary to reduce risks of PID complications such as chronic pelvic pain, ectopic pregnancy and infertility. Current management principles of PID are also reviewed. It is important for clinicians to screen sexually active females for common sexually transmitted infections such as Chlamydia trachomatis and provide safer sex education to their adolescent and young adult patients. Clinicians should provide comprehensive management to persons with PID and utilize established guidelines such as those from the US Centers for Disease Control and Prevention (CDC).

Treatment of mild-to-moderate pelvic inflammatory disease with a short-course azithromycin-based regimen versus ofloxacin plus metronidazole: results of a multicentre, randomised controlled trial

OBJECTIVE

A multicentre, randomised non-inferiority trial compared the efficacy and safety of 14 days of ofloxacin and metronidazole (standard-of-care (SoC)) versus a single dose of intramuscular ceftriaxone followed by 5 days of azithromycin and metronidazole (intervention arm (IA)) in women with mild-to-moderate pelvic inflammatory disease (PID).

METHODS

Women with a clinical diagnosis of PID presenting at sexual health services were randomised to the SoC or IA arms. Treating clinicians and participants were not blinded to treatment allocation but the clinician performing the assessment of primary outcome was blinded. The primary outcome was clinical cure defined as ≥70% reduction in the modified McCormack pain score at day 14-21 after starting treatment. Secondary outcomes included adherence, tolerability and microbiological cure.

RESULTS

Of the randomised population 72/153 (47.1%) reached the primary end point in the SoC arm, compared with 68/160 (42.5%) in the IA (difference in cure 4.6% (95% CI -15.6% to 6.5%). Following exclusion of 86 women who were lost to follow-up, attended outside the day 14-21 follow-up period, or withdrew consent, 72/107 (67.3%) had clinical cure in the SoC arm compared with 68/120 (56.7%) in the IA, giving a difference in cure rate of 10.6% (95% CI -23.2% to 1.9%). We were unable to demonstrate non-inferiority of the IA compared with SoC arm. Women in the IA took more treatment doses compared with the SoC group (113/124 (91%) vs 75/117 (64%), p=0.0001), but were more likely to experience diarrhoea (61% vs 24%, p<0.0001). Of 288 samples available for analysis, Mycoplasma genitalium was identified in 10% (28/288), 58% (11/19) of which had baseline antimicrobial resistance-associated mutations.

CONCLUSION

A short-course azithromycin-based regimen is likely to be less effective than the standard treatment with ofloxacin plus metronidazole. The high rate of baseline antimicrobial resistance supports resistance testing in those with M. genitalium infection to guide appropriate therapy.

TRIAL REGISTRATION NUMBER

2010-023254-36.

Influence of Provider Communication on Emerging Adults' Medication Cognitions and Provider Satisfaction

OBJECTIVE

This study examined how the content of medical provider communication related to medication prescriptions influenced emerging adults' (EA) medication-related cognitions and satisfaction with care.

METHODS

In total, 257 EA (ages 18-25) were randomized to one of three audio vignettes depicting a medical appointment in which the EA imagined him/herself as the recipient of an oral antibiotic prescription. Provider communication content varied by vignette as follows: the positive outcome expectancy (POE) vignette focused on enhancing patient POE related to antibiotic use; the negative outcome expectancy (NOE) vignette focused on reducing patient NOE; and the standard care vignette focused on providing factual medication information. Following the vignette, participants self-reported on demographics, select medication-related cognitions, and provider satisfaction from vignette.

RESULTS

Those in the NOE vignette condition reported higher provider satisfaction, perceived the provider to have given more information, and evidenced lower NOE and higher POE about the antibiotic compared with those in the other conditions. Intent to adhere did not vary by vignette condition.

CONCLUSIONS

Brief, provider-initiated communication focused on reducing patient NOE may have unique value in altering EA's medication-related cognitions. Given that medication-related beliefs are known correlates of adherence, future research should replicate and expand these findings in the context of real-world medical encounters and through the utilization of objective indices of medication adherence to more fully understand the potential significance of provider language emphasizing reduction of NOE on medication adherence.

Is It Time to Stop Using Single-dose Oral Metronidazole for the Treatment of Trichomoniasis in Women?

The 2015 Centers for Disease Control Sexually Transmitted Disease treatment guidelines currently recommend a single 2-g dose of oral metronidazole as the preferred regimen for treatment of trichomoniasis in human immunodeficiency virus (HIV)-negative women. Mounting recent evidence has shown that the 7-day oral metronidazole dosing regimen is more efficacious than the single 2-g dose. This commentary reviews the implications associated with these new data and discusses issues surrounding it that should be considered moving forward.

Efficacy of a Technology-Enhanced Community Health Nursing Intervention vs Standard of Care for Female Adolescents and Young Adults With Pelvic Inflammatory Disease: A Randomized Clinical Trial

Importance

Pelvic inflammatory disease (PID) is a common reproductive health disorder that disproportionately affects female adolescents and young adults. Despite data indicating poor adherence and adverse outcomes among those who experience subsequent Neisseria gonorrhoeae and Chlamydia trachomatis infection, few trials have been designed to address this public health need.

Objective

To examine the efficacy of a technology-enhanced community health nursing (TECH-N) intervention vs standard of care for improving PID self-management behaviors and 90-day longitudinal prevalence of N gonorrhoeae and C trachomatis infection.

Design, Setting, and Participants

This randomized clinical trial of the TECH-N intervention was conducted among female patients 13 to 25 years of age diagnosed with mild to moderate PID who were being discharged to outpatient treatment from September 6, 2012, to December 8, 2016, at a large academic medical center. The final analysis of data was completed in November 2018. This study compared the efficacy of the intervention with that of the standard of care using an intention-to-treat analysis.

Interventions

Enrolled participants completed an audio computer-assisted self-interview, provided specimens for N gonorrhoeae and C trachomatis testing, and were randomized to standard treatment (n = 137) or the TECH-N intervention (n = 149). Intervention participants received text-messaging support and a community health nurse visit within 5 days of diagnosis. Change in the prevalence of N gonorrhoeae and C trachomatis infection was estimated with logistic regression. The N gonorrhoeae and C trachomatis positivity rate over time was evaluated using generalized estimating equations.

Main Outcomes and Measures

The primary outcome was the prevalence of N gonorrhoeae and C trachomatis infection at 90-day follow-up. The secondary outcome was adherence to the Centers for Disease Control and Prevention recommendations for self-care.

Results

A total of 286 patients (mean [SD] age, 18.8 [2.5] years; 268 [93.7%] African American) participated in the study. Although the study groups were demographically similar, the intervention group had a higher baseline rate of C trachomatis infection (45 of 139 [32.4%] vs 25 of 132 [18.9%], P = .01). Although N gonorrhoeae and C trachomatis positivity was not statistically different between groups at 90-day follow-up (6 of 135 [4.4%] vs 13 of 125 [10.4%], P = .07), the differential rate of decrease was significantly higher in the intervention group (48 of 140 [34.4%] to 6 of 135 [4.4%] compared with 34 of 133 [25.6%] to 13 of 112 [10.4%], P = .02). Intervention participants were more likely to receive the Centers for Disease Control and Prevention-recommended short-term follow-up visit compared with the control group (131 of 139 [94.2%] vs 20 of 123 [16.3%], P < .001).

Conclusions and Relevance

Adolescent and young adults with PID in the TECH-N intervention were more likely to experience decreases in N gonorrhoeae and C trachomatis positivity compared with the control group and to receive short-term clinical assessment. These findings suggest that the TECH-N intervention should be considered as a potential enhancement of standard of care approaches for management of female adolescents and young adults with mild to moderate PID in urban communities facing significant sexually transmitted infection disparities.

Trial Registration

ClinicalTrials.gov identifier: NCT01640379.

[Treatment of uncomplicated pelvic inflammatory disease: CNGOF and SPILF Pelvic Inflammatory Diseases Guidelines]

This review of the treatment of uncomplicated pelvic inflammatory disease (PID) focuses on the susceptibility profile of the main microbiological causes as well as on the advantages and inconvenients of relevant antibiotics. As bacterial resistance is expanding in the community, the rules of adequate antibiotic prescribing are integrated in the treatment proposals. While the pathogenic role of anaerobic bacteria in uncomplicated PID remains discussed, the choice to provide anaerobes coverage is proposed. Thus, the antibiotic treatment has to cover Chamydia trachomatis, Neisseria gonorrhoeae, anaerobes as well as Streptococcus spp, gram negative bacteria and the ermerging Mycoplasma genitalium. On the basis of published trials and good practice antibiotic usage, the ceftriaxone-doxycycline-metronidazole combination has been selected as the first line regimen. Fluoroquinolones (moxifloxacin alone, or levofloxacin or ofloxacin combined with metronidazole) are proposed as alternatives because of their ecological impact and their side effects leading to restricted usage. When fluoroquinolone are used, ceftriaxone should be added in case of possible sexually transmitted infection. When detected, M. genitalium should be treated by moxifloxacin. Moreover, this review highlights the need to better describe the microbiological epidemiology of uncomplicated PID in France or Europe.

Patient Satisfaction and Treatment Adherence for Urban Adolescents and Young Adults with Pelvic Inflammatory Disease

Objectives

Urban adolescents with pelvic inflammatory disease (PID) often seek care in emergency departments (ED). This study examines the effect of the ED patient experience - wait time (WT) and length of stay (LOS) - on satisfaction and medication adherence among urban adolescents with PID.

Methods

Adolescents with PID were enrolled in an urban teaching hospital ED. Chart data were matched with 2-week interview queries about satisfaction and medication adherence. Chi-square and logistic regression analyses evaluated the relationships between WT, LOS, provider type, satisfaction, and medication adherence.

Results

Of 83 participants, 96% report satisfaction with care, but only 45% report medication adherence. Mean WT was 55 minutes and mean LOS 200 minutes. Patients with higher LOS were less adherent with medication; this relationship became non-significant after adjustments. Patients seen by trainees had much longer LOS, but no differences in satisfaction or medication adherence.

Conclusions

Urban adolescents with PID report satisfaction with ED care despite prolonged LOS and medication adherence is poor. Optimization of ED workflows may improve outcomes in young women with PID.

Pelvic inflammatory disease: improving awareness, prevention, and treatment

Purpose

Pelvic inflammatory disease (PID) is a common disorder of the reproductive tract that is frequently misdiagnosed and inadequately treated. PID and its complications, such as infertility, ectopic pregnancy, and chronic pelvic pain, are preventable by screening asymptomatic patients for sexually transmitted infections (STIs) and promptly treating individuals with STIs and PID.

Recent findings

The rates of adverse outcomes in women with PID are high and disproportionately affect young minority women. There are key opportunities for prevention including improving provider adherence with national screening guidelines for STIs and PID treatment recommendations and patient medication adherence. Nearly half of all eligible women are not screened for STIs according to national quality standards, which may increase the risk of both acute and subclinical PID. Moreover, in clinical practice, providers poorly adhere to the Centers for Disease Control and Prevention recommendations for treatment of PID. Additionally, patients with PID struggle to adhere to the current management strategies in the outpatient setting.

Conclusion

Novel evidence-based clinical and public health interventions to further reduce the rates of PID and to improve outcomes for affected women are warranted. We propose potential cost-effective approaches that could be employed in real-world settings.

Intrasubject Medication Adherence Patterns

The purpose of this prospective descriptive study was to explore the patterns of intrasubject (between medication) adherence of two similarly timed, twice-daily medications using the Medication Event Management System® electronic monitoring cap. Medication adherence was measured for 6 months using electronic monitoring in 25 adult renal-transplant recipients. Data were available from 7,119 electronic medication events. Results indicated that two twice-daily medications scheduled to be taken simultaneously were taken within 5 min of each other 77% of the time and within 10 min, 92% of the time. When only the first scheduled dose of the day was examined, the results are 79% and 95%, respectively. These findings are important to researchers and clinicians who must evaluate medication adherence in transplant recipients while balancing cost and subject burden. This study provides empirical support for monitoring a single immunosuppressive medication electronically to estimate medication adherence with double or triple immunosuppressive drug therapy.

MAGIC Study: Aims, Design and Methods using SystemCHANGE™ to Improve Immunosuppressive Medication Adherence in Adult Kidney Transplant Recipients

BACKGROUND

Among adult kidney transplant recipients, non-adherence to immunosuppressive medications is the leading predictor of poor outcomes, including rejection, kidney loss, and death. An alarming one-third of kidney transplant patients experience medication non-adherence even though the problem is preventable. Existing adherence interventions have proven marginally effective for those with acute and chronic illnesses and ineffective for adult kidney transplant recipients. Our purpose is to describe the design and methods of the MAGIC (Medication Adherence Given Individual SystemCHANGE™) trial

METHODS/DESIGN

We report the design of a randomized controlled trial with an attention-control group to test an innovative 6-month SystemCHANGE™ intervention designed to enhance immunosuppressive medication adherence in adult non-adherent kidney transplant recipients from two transplant centers. Grounded in the Socio-Ecological Model, SystemCHANGE™ seeks to systematically improve medication adherence behaviors by identifying and shaping routines, involving supportive others in routines, and using medication taking feedback through small patient-led experiments to change and maintain behavior. After a 3-month screening phase of 190 eligible adult kidney transplant recipients, those who are <85 % adherent as measured by electronic monitoring, will be randomized into a 6-month SystemCHANGE™ intervention or attention-control phase, followed by a 6-month maintenance phase without intervention or attention. Differences in adherence between the two groups will be assessed at baseline, 6 months (intervention phase) and 12 months (maintenance phase). Adherence mediators (social support, systems-thinking) and moderators (ethnicity, perceived health) are examined. Patient outcomes (creatinine/blood urea nitrogen, infection, acute/chronic rejection, graft loss, death) and cost effectiveness are to be examined.

DISCUSSION

Based on the large effect size of 1.4 found in our pilot study, intervention shows great promise for increasing adherence. Grounded in the socio-ecological model, SystemCHANGE™ seeks to systematically improve medication adherence behaviors by identifying and shaping routines, involving supportive others in routines, and using medication taking feedback through small patient-lead experiments to change and maintain behavior. Medication adherence will be measured by electronic monitoring. Medication adherence persistence will be examined by evaluating differences between the two groups at the end of the 6-and 12- month phases. Mediators and moderators of medication adherence will be examined. Patient outcomes will be compared and a cost-effectiveness analysis will be conducted.

TRIAL REGISTRATION

ClinicalTrials.gov Registry: NCT02416479 Registered April 3, 2015.

Management of Pelvic Inflammatory Disease in Selected U.S. Sexually Transmitted Disease Clinics: Sexually Transmitted Disease Surveillance Network, January 2010-December 2011

BACKGROUND

Pelvic inflammatory disease (PID) remains an important source of preventable reproductive morbidity, but no recent studies have singularly focused on US sexually transmitted disease (STD) clinics in relationship to established guidelines for diagnosis and treatment.

METHODS

Of the 83,076 female patients seen in 14 STD clinics participating in the STD Surveillance Network, 1080 (1.3%) were diagnosed as having PID from 2010 to 2011. A random sample of 219 (20%) women were selected, and medical records were reviewed for clinical history, examination findings, treatment, and diagnostic testing. Our primary outcomes were to evaluate how well PID diagnosis and treatment practices in STD clinic settings follow the Centers for Disease Control and Prevention (CDC) treatment guidelines and to describe age group-specific rates of laboratory-confirmed Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) in patients clinically diagnosed as having PID in the last 12 months, inclusive of the PID visit.

RESULTS

Among the 219 women, 70.3% of the cases met the CDC treatment case definition for PID, 90.4% had testing for CT and GC on the PID visit, and 68.0% were treated with a CDC-recommended outpatient regimen. In the last 12 months, 95.4% were tested for CT or GC, and positivity for either organism was 43.9% in women aged 25 years or younger with PID, compared with 19.4% of women older than 25 years with PID.

CONCLUSIONS

Compliance with CDC guidelines was documented for many of the women with PID, though not all. Our findings underscore the need for continued efforts to optimize quality of care and adherence to current guidance for PID management given the anticipated expertise of providers in these settings.

Self-management interventions in stages 1 to 4 chronic kidney disease: an integrative review

The prevalence, effect on health outcomes, and economic impact of chronic kidney disease (CKD) have created interest in self-management interventions to help slow disease progression to kidney failure. Seven studies were reviewed to identify knowledge gaps and future directions for research. All studies were published between 2010 and 2013; no investigations were conducted in the United States. Knowledge gaps included the focus on medical self-management tasks with no attention to role or emotional tasks, lack of family involvement during intervention delivery, and an inability to form conclusions about the efficacy of interventions because methodological rigor was insufficient. Educational content varied across studies. Strategies to improve self-management skills and enhance self-efficacy varied and were limited in scope. Further development and testing of theory-based interventions are warranted. There is a critical need for future research using well-designed trials with appropriately powered sample sizes, well-tested instruments, and clear and consistent reporting of results.

Pelvic inflammatory disease: current concepts in pathogenesis, diagnosis and treatment

Pelvic inflammatory disease (PID) is characterized by infection and inflammation of the upper genital tract in women and can cause significant reproductive health sequelae for women. Although a definitive diagnosis of PID is made by laparoscopic visualization of inflamed, purulent fallopian tubes, PID is generally a clinical diagnosis and thus represents a diagnostic challenge. Therefore, diagnosis and treatment algorithms advise a high index of suspicion for PID in any woman of reproductive age with pelvic or abdominal pain. Antibiotic therapy should be started early, and given for an adequate period of time to reduce the risk of complications. Coverage for anaerobic organisms should be considered in most cases.

Improving adherence to guidelines for the diagnosis and management of pelvic inflammatory disease: a systematic review

BACKGROUND

Evidence suggests adherence to clinical guidelines for pelvic inflammatory disease (PID) diagnosis and management is suboptimal. We systematically reviewed the literature for studies describing strategies to improve the adherence to PID clinical guidelines.

METHODS

The databases MEDLINE and EMBASE, and reference lists of review articles were searched from January 2000 to April 2012. Only studies with a control group were included.

RESULTS

An interrupted time-series study and two randomised controlled trials (RCTs) were included. The interrupted time-series found that following a multifaceted patient and practitioner intervention (practice protocol, provision of antibiotics on-site, written instructions for patients, and active followup), more patients received the recommended antibiotics and attended for followup. One RCT found a patient video on PID self-care did not improve medication compliance and followup. Another RCT found an abbreviated PID treatment guideline for health-practitioners improved their management of PID in hypothetical case scenarios but not their diagnosis of PID.

CONCLUSION

There is limited research on what strategies can improve practitioner and patient adherence to PID diagnosis and management guidelines. Interventions that make managing PID more convenient, such as summary guidelines and provision of treatment on-site, appear to lead to better adherence but further empirical evidence is necessary.

The contribution falls have to increasing risk of nursing home placement in community-dwelling older adults

PURPOSE

To determine whether a fall, as an adverse event in combination with other risk factors, influences nursing home placement (NHP).

METHOD

A retrospective longitudinal study of 6,515 high-risk, community-dwelling, dually eligible (Medicare/Medicaid) participants in a waiver program during 2002-2007 are examined. Data are obtained from the Minimum Data Set-Home Care linked with Medicaid claim files. The authors fit multiple factors to a logistic curve, using generalized linear modeling to predict increased risk of NHP when a fall occurred.

RESULTS

Prior NHP and an increased rate of falls (Odds Ratio [OR] = 1.52, 95% Confidence Interval [CI] = 1.25-1.84) and prior NHP and the same rate of falls (OR = 1.55, 95% CI = 1.26-1.91) both increased NHP.

CONCLUSION

An adverse event such as a fall and prior NHP is a strong predictor of future NHP and should be taken into consideration while developing care plans for community-dwelling older adults.

Taking immunosuppressive medications effectively (TIMELink): a pilot randomized controlled trial in adult kidney transplant recipients

BACKGROUND

Immunosuppressive medication non-adherence is one of the most prevalent but preventable causes of poor outcomes in adult renal transplant recipients, yet there is a paucity of studies testing interventions in this area.

METHODS

Using a randomized controlled trial design, 30 adult renal transplant recipients were screened for medication non-adherence using electronic monitoring. Fifteen non-adherent participants were randomized to receive either a continuous self-improvement intervention or attention control management. The six-month continuous self-improvement intervention involved the participant and clinical nurse specialist collaboratively identifying the person's life routines, important people, and possible solutions to enhance medication taking. The participant then received individual monthly medication taking feedback delivered via a graphic printout of daily medication taking generated from electronic monitoring.

RESULTS

The mean medication adherence score for the continuous self-improvement intervention group (n = 8) was statistically significantly higher than the attention control group's (n = 5) mean medication adherence score (p = 0.03). The continuous self-improvement intervention effect size (Cohen's d) was large at 1.4. Participants' perceptions of the intervention were highly favorable.

CONCLUSIONS

The continuous self-improvement intervention shows promise as an effective and feasible approach to improve medication adherence in adult renal transplant recipients. A fully-powered study with a diverse sample is needed to confirm these preliminary findings.

Adverse adolescent reproductive health outcomes after pelvic inflammatory disease

OBJECTIVE

To compare longitudinal adolescent and adult reproductive outcomes after pelvic inflammatory disease (PID).

DESIGN

Secondary analysis of longitudinal data from the Pelvic Inflammatory Disease Evaluation and Clinical Health study.

SETTING

A large multicenter randomized clinical trial assessing PID treatment strategies in the United States.

PARTICIPANTS

Eight hundred thirty-one female patients aged 14 to 38 years with a diagnosis of PID.

MAIN EXPOSURE

Adverse longitudinal outcomes were compared in adolescents (≤19 years) and adults (>19 years).

OUTCOME MEASURES

Primary outcome measures included recurrent sexually transmitted infection at 30 days, recurrent PID, chronic abdominal pain, infertility, pregnancy, and times to recurrent PID and pregnancy. Cox proportional hazards modeling was used to examine the effect of young age on times to pregnancy and recurrent PID.

RESULTS

Adolescents were more likely than adults to have positive results of sexually transmitted infection testing at baseline and at 30 days. There were no significant group differences in chronic abdominal pain, infertility, and recurrent PID at 35 or 84 months, but adolescents were more likely to have a pregnancy at both time points. Adjusted hazard ratios (95% confidence intervals) also demonstrated that adolescents had shorter times to pregnancy (1.48 [1.18-1.87]) and recurrent pelvic inflammatory disease (1.54 [1.03-2.30]).

CONCLUSION

Adolescents may require a different approach to clinical care and follow-up after PID to prevent recurrent sexually transmitted infections, recurrent PID, and unwanted pregnancies.

A comparison of treatment outcomes for moxifloxacin versus ofloxacin/metronidazole for first-line treatment of uncomplicated non-gonococcal pelvic inflammatory disease

Large randomized controlled trials support the efficacy of moxifloxacin for the treatment of uncomplicated pelvic inflammatory disease (PID). This study compares the clinical outcome and tolerability of treatment with moxifloxacin 400 mg once a day or ofloxacin 400 mg plus metronidazole 400 mg both twice daily in patients diagnosed with PID. A retrospective case-notes review was performed on patients diagnosed clinically with PID before and after local guidelines were changed to recommend moxifloxacin as first-line treatment for uncomplicated PID. Before the guidelines changed, 114/134 (85%) patients received the recommended first-line therapy versus 206/257 (80%) after the change, P = 0.3. There was no difference in the clinical outcomes between the two groups; significant improvement/resolved 77% versus 70%; marginal improvement 3% versus 11%; no change/worse 20% versus 18%, P = 0.14. Moxifloxacin is confirmed to be an effective alternative to ofloxacin/metronidazole for the treatment of PID in a large urban genitourinary clinic setting.

Social desirability bias in family planning studies: a neglected problem

Studies on family planning methods traditionally have relied on self-reports of unknown validity and reproducibility. Social desirability bias, a type of information bias, occurs when study participants respond inaccurately - but in ways that will be viewed favorably by others. Several lines of evidence reveal that this bias can be powerful in sexual matters, including reports of coitus, use of contraceptives and induced abortion. For example, studies using vaginal prostate-specific antigen testing reveal underreporting of unprotected coitus and overreporting of barrier contraceptive use. Medication Event Monitoring System studies, which electronically record the time of pill dispensing from a bottle or pack, indicate widespread exaggeration of adherence to pill-taking regimens, including oral contraceptives. Comparisons of provider data and self-reports of induced abortions reveal extensive underreporting of induced abortion. Reliance on self-reported data underestimates contraceptive efficacy. Although techniques to minimize this bias exist, they are infrequently used in family planning studies. Greater skepticism about self-reports and more objective means of documenting coitus and contraceptive use are needed if contraceptive efficacy is to be accurately measured.

Time from sexually transmitted infection acquisition to pelvic inflammatory disease development: influence on the cost-effectiveness of different screening intervals

OBJECTIVES

To prevent pelvic inflammatory disease (PID), some experts recommend screening for sexually transmitted infection (STI) every 12 months, with more frequent screening suggested in higher-risk women. Nevertheless, the time from STI acquisition to PID development, possibly an important factor to consider in screening interval choice, is unknown and its influence on the effectiveness and cost-effectiveness of screening is unclear.

METHODS

Using a Markov model, we estimated PID cases averted and the incremental cost-effectiveness resulting from 6- or 12-month screening strategies for high-risk young women (6%/year infection risk, 2.8%/year PID risk with 12-month screening) while varying PID development time from 1 to 12 months after initial infection. Lower-risk women and alternative parameter values were examined in sensitivity analyses.

RESULTS

Relative to 12-month screening, 6-month screening decreases PID cases from 6.0% (1 month development time)to 19.4% (12 months); the incremental cost per quality-adjusted life-year (QALY) gained compared with the other strategies varies from $16,600 (12 months development time) to $31,800 (1 month) for high-risk women. In lower-risk women, every 6-month screening is more economically unfavorable, with greater costs per QALY gained at shorter PID development time.

CONCLUSION

From a cost-effectiveness standpoint, uncertainty about PID development time is not a significant factor in choosing a screening interval in high-risk women, but could be important in lower-risk groups. Significant increases in PID cases averted occur with more frequent screening when PID development time is lengthened, which may allow estimation of this interval through the use of more sophisticated modeling techniques.

Antibiotic therapy for acute pelvic inflammatory disease: the 2006 Centers for Disease Control and Prevention sexually transmitted diseases treatment guidelines

Pelvic inflammatory disease (PID) is a substantial cause of reproductive morbidity in young women. A systematic review of the literature related to PID management was performed in preparation for the 2006 Centers for Disease Control and Prevention sexually transmitted diseases treatment guidelines. This search was conducted using PubMed and was limited to articles written in English and published between 1 January 2002 and 31 January 2005 that were related to PID treatment. Studies were evaluated for new data on PID with regard to site, route, and timing of antimicrobial administration; regimen adherence; experience in adolescents and women >35 years of age; coinfection with human immunodeficiency virus; and management of sex partners. Strong evidence suggests that neither site nor route of treatment administration affects the short- or long-term major outcome of women with mild or moderate clinical presentations. Data on these outcomes in women with more severe clinical presentations are inadequate to provide guidance as to the preferred agents or route of administration. Important contributions to the literature that impact the 2006 guidelines are described in this article.

Comparing Ceftriaxone Plus Azithromycin or Doxycycline for Pelvic Inflammatory Disease

OBJECTIVE

To evaluate the equivalence of ceftriaxone plus doxycycline or azithromycin for cases of mild pelvic inflammatory disease (PID).

METHODS

Patients with PID received an intramuscular injection of 250 mg of ceftriaxone, and were randomly assigned to receive 200 mg/d of doxycycline for 2 weeks, or 1 g of azithromycin per week, for 2 weeks. The degree of pain was assessed on days 2, 7, and 14 and clinical cure was assessed on day 14.

RESULTS

From 133 patients eligible for the study, 13 were excluded for having conditions other than PID, 11 were lost on follow-up, and three had oral intolerance to the antibiotics, yielding 106 for protocol analysis. No significant difference was observed regarding the degree of pain between the doxycycline and azithromycin groups. Clinical cure per protocol was 98.2% (56 of 57; 95% confidence interval [CI], 0.9-0.99) with azithromycin, and 85.7% (42 of 49; 95% CI, 0.72-0.93) with doxycycline (P=0.02). In a modified intention to treat analysis, clinical cure was 90.3% (56 of 62; 95% CI, 0.80-0.96) with azithromycin, and 72.4% (42 of 58; 95% CI, 0.58-0.82) with doxycycline (P=.01); a relative risk of 0.35, and a number needed to treat of six for benefit with azithromycin.

CONCLUSION

When combined with ceftriaxone, 1g of azithromycin weekly for 2 weeks is equivalent to ceftriaxone plus a 14-day course of doxycycline for treating mild PID.

Hospitalization for Pelvic Inflammatory Disease: A Cost-Effectiveness Analysis

OBJECTIVE

Nulliparous women are frequently hospitalized for treatment of pelvic inflammatory disease (PID).

GOAL

The goal of this study was to determine the economic feasibility of hospitalizing adolescents and young women for PID.

STUDY DESIGN

The authors conducted a Markov decision model, estimating the cost-effectiveness of hospitalization compared with outpatient therapy for mild to moderate PID for adolescents and young women, calculating costs per quality-adjusted life-year (QALY) gained under various assumptions about hospitalization effects on complications.

RESULTS

If hospitalization decreases PID complications by 10%, 20%, or 30%, the cost/QALY gained is 145,000 dollars, 67,400 dollars, or 42,400 dollars, respectively, compared with outpatient therapy. Assumptions about hospitalization effects on the development of chronic pelvic pain heavily weight the analysis; costs/QALY gained by hospitalization increase considerably if chronic pain is unaffected.

CONCLUSION

Hospitalization for PID treatment to possibly preserve fertility in nulliparous young women and adolescents is unlikely to be economically reasonable even if substantial improvements in PID complication rates are assumed.

Use of an institutional intervention to improve quality of care for adolescents treated in pediatric ambulatory settings for pelvic inflammatory disease

PURPOSE

To evaluate the impact of a quality improvement intervention for outpatient management of pelvic inflammatory disease (PID) on provider compliance with published guidelines and to explore issues affecting patient adherence to outpatient care regimens.

METHODS

This study utilized an interrupted time series design. The intervention included an algorithm and clinical practice guideline based on the 2002 Centers for Disease Control STD Guidelines, a complete course of medications to be given at discharge after initial doses given in the site, standardized discharge instructions, close follow-up at 24-48 hours and after two weeks of treatment by a member of the PID team, and a referral for follow-up.

RESULTS

At baseline, 38% of patients did not receive an appropriate medication regimen and only 10% of clinic outpatients returned for follow-up evaluations within 72 hours. In the postintervention group, 91% of patients received an appropriate outpatient regimen and 43% of emergency department and clinic patients returned for care. Based on the results of logistic regression models, adolescents in the postintervention group were 8.4 times more likely (adjusted odds ratio [AOR]: 8.4, confidence interval [CI]: 2.6-26.8, p <. 001) to receive an appropriate outpatient medication regimen than girls in the baseline group. Follow-up interview revealed that 61% of postintervention patients completed all doses of the medication, 67% practiced temporary abstinence, 86% notified their partner for treatment, and 96% were satisfied with their care.

CONCLUSIONS

Interventions utilizing a multi-level approach to the management of outpatient PID improve provider compliance with published guidelines and quality of care delivered to adolescents in academic settings. Many adolescents, however, continue to have difficulty with adherence. Additional research is warranted to address adherence to outpatient regimens for the treatment of PID in adolescent girls.

Moxifloxacin versus ofloxacin plus metronidazole in uncomplicated pelvic inflammatory disease: results of a multicentre, double blind, randomised trial

OBJECTIVE

This multinational, multicentre, prospective, randomised, double blind, parallel group, non-inferiority study compared the efficacy and safety of moxifloxacin monotherapy with ofloxacin plus metronidazole in women with uncomplicated pelvic inflammatory disease.

METHODS

Women from hospitals throughout 13 countries received a 14 day course of either oral moxifloxacin, 400 mg once daily (n = 384), or oral ofloxacin, 400 mg twice daily plus oral metronidazole, 500 mg twice daily (n = 365).

RESULTS

Of the 741 patients in the intent to treat (ITT) population, 564 (74.2%) were valid for the per protocol (PP) analyses; 112 (19.9%) of these were included in the microbiologically valid population (MBV). Clinical resolution rates in the PP population at the test of cure visit (TOC, 5-24 days post-therapy, primary efficacy end point) were 90.2% (248/275) for moxifloxacin and 90.7% (262/289) for ofloxacin plus metronidazole (95% CI: -5.7% to 4.0%). At follow up (28-42 days post-therapy), resolution rates in the PP population were 85.8% (236/275) and 87.9% (254/289) for moxifloxacin and comparator, respectively (95% CI: -8.0% to 3.1%). Bacteriological success rates in the MBV population at TOC were 87.5% (49/56) for moxifloxacin and 82.1% (46/56) for comparator (95% CI: -8.3% to 18.8%). Against Chlamydia trachomatis and Neisseria gonorrhoeae, bacteriological success rates with moxifloxacin were 88.5% (23/26) and 100% (13/13) and for comparator 85.7% (18/21) and 81.8% (18/22), respectively. Drug related adverse events occurred less frequently with moxifloxacin (22.5% (85/378)) versus the comparator (30.9% (112/363)) (p = 0.01).

CONCLUSION

In uncomplicated PID, once daily moxifloxacin monotherapy was clinically and bacteriologically as efficacious as twice daily ofloxacin plus metronidazole therapy and was associated with fewer drug related adverse events.

The STARK study: a cross-sectional study of adherence to short-term drug regiments in urban Kenya

The purpose of the STARK study (Short-Term Adherence Research in Kenya) was to identify factors that predict adherence to short-term drug regimens in Nairobi, Kenya. The participants (N = 357) in the study were recruited from the RAFIKI Foundation Clinic, a free primary healthcare clinic in Kibera, Nairobi's largest slum. Quantitative surveys were administered to all the participants regarding their adherence patterns and to a subgroup of mothers (N = 233) regarding their adherence in giving medicine to their children. 40 participated in four focus groups. 52% of participants reported taking all of their prescribed medication and 47% took it until they felt better. Over 65% of mothers reported giving all prescribed medication to their children. The most frequently cited barriers to adherence included lack of food and clean water, stress, and financial problems. By identifying obstacles to adherence and strategies to overcome them, this study showed that a community- based clinic with committed healthcare workers in Kenya can empower an economically disadvantaged population to be adherent.