Pelvic inflammatory disease in adolescents: care delivery in pediatric ambulatory settings

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).

Perceived Social Support, Parental Notification, and Parental Engagement after Pelvic Inflammatory Disease among Urban Adolescent and Young Adults

BACKGROUND

Urban adolescent and young adult women often require adult support throughout their transition to adulthood particularly regarding seeking healthcare. While confidentiality is crucial feature of care delivery, successful adherence to treatment can be multi-factorial. The purpose of this study is to determine factors associated with parental notification and engagement in self-care of young women diagnosed with Pelvic Inflammatory Disease (PID).

METHODS

This study utilizes data from 187 participants in the Technology Enhanced Community Health Nursing (TECH-N) study, a randomized controlled trial of an intervention to prevent recurrent STIs after a diagnosis of mild-moderate PID. Participants were recruited from pediatric ambulatory settings provided baseline demographic, reproductive history, and perceived social support using an audio computerized self-interview at baseline and parental notification collected during a two-week follow-up interview, served as the primary outcome.

RESULTS

Sixty-five percent of participants informed a parent of their PID diagnosis, 74% of whom reported receiving supportive care. Participants who reported a higher sense of responsibility to others were 17% less likely to inform a parent of their diagnosis.

CONCLUSION

Most urban young women with PID notify parents of their diagnosis and obtain support for self-management in the outpatient setting. While autonomy is a critical milestone for transition to young adulthood, these data suggest that proactive youth-managed parental engagement may be an underutilized resource for young women diagnosed with PID.

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.

Improving Adolescent Pelvic Inflammatory Disease Follow-up From the Emergency Department: Randomized Controlled Trial With Text Messages

STUDY OBJECTIVE

Centers for Disease Control and Prevention guidelines recommend follow-up within 72 hours of diagnosis of pelvic inflammatory disease because patients with inadequate treatment are at increased risk of acute and chronic complications. Follow-up rates in adolescents after diagnosis range between 10% and 16%. The primary objective is to assess the effect of text message reminders to adolescent patients receiving a diagnosis of pelvic inflammatory disease on obtaining follow-up care within 72 hours of emergency department (ED) discharge.

METHODS

This was a single-blinded randomized controlled trial of adolescents receiving a diagnosis of pelvic inflammatory disease in the ED. Patients received standard discharge instructions or standard discharge instructions plus text message reminders. Patients in the text message group received daily, tailored text messages for 4 days, with a reminder to schedule and attend primary care provider follow-up. The primary outcome was follow-up within 72 hours of ED discharge.

RESULTS

Ninety-five patients (48 standard; 47 text message) were randomized. Three patients were excluded, leaving 92 patients (46 standard; 46 text message) for analysis. Baseline characteristics were similar between treatment groups. Follow-up was 15.2% in the standard group and 43.5% in the text message group. Patients receiving text message reminders were more likely to follow up compared with the standard group (relative risk 2.9; 95% confidence interval [CI] 1.4 to 5.7). The absolute efficacy difference was 28.3% (95% CI 9.5% to 46.9%), yielding number needed to treat of 4 (95% CI 2.2 to 9.5).

CONCLUSION

Personalized text message reminders were efficacious in improving follow-up for adolescents after ED diagnosis of pelvic inflammatory disease.

Status of adolescent pelvic inflammatory disease management in the United States

PURPOSE OF REVIEW

Pelvic inflammatory disease (PID) is a common and serious reproductive health disorder and disease rates remain unacceptably high among adolescent girls and young adult women in the United States. Despite data demonstrating that women experience major adverse health outcomes after PID, national recommendations for management of adolescents have become increasingly less cautious in an era of cost-containment. In this review, we take an alternative look at published data on adolescents with PID to frame the next steps for optimizing management for this vulnerable population.

RECENT FINDINGS

Several findings emerge from review of the literature. First, there is limited evidence to guide the best practice strategies for adolescents with PID due to low enrolment of early and middle adolescents in national trials. Second, adolescents and adult women in the United States receive suboptimal treatment regimens per Centers for Disease Control and Prevention (CDC) standards. Third, available evidence suggests that adolescents are at an increased risk for poor adherence to CDC recommendations for self-care, reacquisition of sexually transmitted infections (STIs) and PID, and subsequent adverse reproductive health outcomes.

SUMMARY

Efforts to develop and integrate adolescent-focused, evidence-based strategies for PID management and prevention of subsequent STIs and recurrent PID are warranted.

Pelvic inflammatory disease in the adolescent: understanding diagnosis and treatment as a health care provider

BACKGROUND

Pelvic inflammatory disease (PID) is a common clinical syndrome with highest rates in adolescents, but no studies have singularly focused on this population in relationship to established guidelines for diagnosis and treatment. The study objective was to assess knowledge of diagnosis and treatment criteria for PID within an adolescent population and to compare factors associated with adherence to Centers for Disease Control and Prevention guidelines in outpatient settings.

METHODS

Data were collected as part of a retrospective chart review of evaluation, diagnosis, and treatment of sexually transmitted infections in adolescent women in an outpatient setting. Participant charts were eligible for review if they were 12 to 21 years of age and were given an International Classification of Diseases, Ninth Revision/chart diagnosis of PID. Two primary outcome variables were utilized: meeting PID diagnosis guidelines (no/yes) and correct treatment for subject meeting criteria with guidelines (no/yes). The study controlled for race, age, medical venue, and current/past infection with gonorrhea/chlamydia.

RESULTS

Subjects (n = 150) were examined for the primary outcome variables; 78% (117/150) met at least 1 criterion for PID diagnosis. Nearly 75% (111/150) had cervical motion tenderness, 34% (51/150) adnexal tenderness, and 5% (7/150) had uterine tenderness; nearly 11% (16/150) were positive for all 3 criteria. Symptoms associated with PID were compared for subjects meeting diagnosis criteria versus subjects not meeting diagnosis criteria: abdominal pain and vomiting were significantly associated with PID diagnosis at P < 0.05.

CONCLUSIONS

Our findings show that PID diagnosis/treatment often does not follow guidelines in the adolescent population. Pelvic inflammatory disease and cervicitis appear to be confused by providers in the diagnosis process, and educational tools may be necessary to increase the knowledge base of practitioners in regard to PID.

Estimating the direct costs of pelvic inflammatory disease in adolescents: a within-system analysis

We used 2008-2009 physician and hospital charges to estimate the direct cost of medical care per case of pelvic inflammatory disease. The estimated average total charge per episode was $3,025 (SD: $4155). The estimated average charge for patients treated in ambulatory (outpatient clinic and emergency department) settings was $7440 lower than for those treated on inpatient units.

Cervicitis in adolescents: do clinicians understand diagnosis and treatment?

BACKGROUND

Cervicitis is widespread, but no studies have examined cervicitis in accordance with established guidelines for diagnosis and treatment. Study objectives were to describe adherence to Centers for Disease Control and Prevention guidelines for diagnosis and treatment of cervicitis within an adolescent population and to compare factors associated with adherence to guidelines in a primary care setting and the Emergency Department.

METHODS

Data were collected as part of a retrospective chart review of evaluation, diagnosis, and treatment of STI in adolescent women in an outpatient setting. Participant charts were eligible for review if they were 12-21 years of age and were given an ICD-9 and chart diagnosis of cervicitis. Two primary outcome variables: meeting cervicitis guidelines and correct treatment among those meeting cervicitis guidelines (no/yes) were utilized; the study controlled for age, race, venue, past infection with chlamydia or gonorrhea.

RESULTS

Subjects (n = 365) were examined for the primary outcome variables and 75.1% (274/365) met at least one criterion for cervicitis. Of these, 166 (60.9%: 166/274) subjects were found to meet criteria for cervicitis alone, versus subjects meeting criteria for both cervicitis and pelvic inflammatory disease (PID) (39.4%: 108/274). The majority, 89.3%, (326/365) were treated for both chlamydia and gonorrhea, but only 64.7% (211/326) were treated correctly for both infections.

CONCLUSIONS

Our findings suggest that knowledge deficits exist in diagnosis and treatment of cervicitis in adolescent patients and in differentiating between cervicitis and PID. Educational tools, simulated patient exercises, and order sets may be warranted for quality improvement to allow for improved care of this at risk sexually active population.

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.

Results of a randomized controlled trial of a brief behavioral intervention for pelvic inflammatory disease in adolescents

OBJECTIVE

The objective of this research was to examine the effectiveness of a brief behavioral intervention, provided at the time of diagnosis of pelvic inflammatory disease, on subsequent behaviors by patients who were urban adolescents in a community in which sexually transmitted infection was prevalent.

METHODS

121 adolescents aged 15 to 21 years with mild to moderate pelvic inflammatory disease were enrolled in a randomized trial. All participants received standardized care, completed baseline audio computerized self-interviews, received full courses of medication at discharge, and were interviewed after the 2-week treatment course. The intervention group also watched a 6-minute intervention video.

MAIN OUTCOME MEASURES

Medication completion, temporary sexual abstinence during the 14-day treatment period, partner notification, partner treatment, and return for 72-hour follow-up were studied. Data were evaluated using multivariate regression analysis.

RESULTS

Of the participants, 61% were located and could participate in the 2-week interview by the disease intervention specialist. The intervention participants had higher rates of 72-hour follow-up (32% vs. 16%) and partner treatment (71% vs. 53%) in bivariate analyses at a P = 0.1 level. There were no differences in medication completion (66% vs. 66%), sexual abstinence (78% vs. 89%), or partner notification (88% vs. 92%). Only the partner-treatment finding persisted in multivariate models (AOR = 3.10; 95% CI, 1.03-9.39, P = .045).

CONCLUSIONS

Adolescent girls randomized to a community-specific video intervention at diagnosis of pelvic inflammatory disease were three times more likely to have their partners treated than those in the control group. Given the value of partner treatment in secondary prevention of sexually transmitted diseases, this video may be an essential component of discharge programming in urgent care settings. Additional structural supports may be necessary to facilitate improved adherence to other key adherence behaviors.

The impact of lifestyle risk factors on female infertility

BACKGROUND

Over 2 million couples in the United States are infertile. The literature reflects a number of potential lifestyle risks that have been associated with the development of this condition; however, few studies have investigated these risks concurrently. With knowledge of the importance of behavioral threats to fertility, women's health care providers will be in a better position to screen and assist women to modify their fertility risks.

OBJECTIVES

The objectives of this study were (1) to identify lifestyle factors associated with infertility in women by comparing a sample of infertile women with a group of fertile women and (2) to offer recommendations to women's health providers, on counseling women at risk for infertility.

METHODS

A re-examination of the 1995 National Survey of Family Growth (NSFG) allowed for the investigation of lifestyle factors associated with infertility in women. Using a conceptual model of health behavior to guide the selection of variables, together with multiple logistic regression techniques, an explanatory model of infertility was estimated on a sample of 824 women between the ages of 16 and 45 years.

RESULTS

Factors directly related to infertility included increasing age, a history of an ectopic pregnancy, current smoking, obesity, and self reported health status. Protective effects were associated with a history of condom use and having had a Pap smear in the last year.

CONCLUSIONS AND IMPLICATIONS

Routine well-women visits offer an excellent opportunity to begin to address the impact of selected risk factors for infertility. Clinicians can utilize these visits to target appropriate interventions for initiating, repeating, and reinforcing messages on fertility risk.

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.