Diagnosis Of Pelvic Inflammatory Disease Research Articles

O1-S04.06 Pelvic inflammatory disease occurring between the time of testing and treatment for gonorrhoea and chlamydia

BackgroundWe conducted a prospective study to confirm our impression that incarcerated adolescents sometimes developed pelvic inflammatory disease (PID) during the brief interval between testing and treatment for gonorrhoeal and chlamydial...

P1-S3.09 Estimating the incidence of pid following chlamydia infection in sex workers

BackgroundThere is a lack of consensus on the true incidence of PID following chlamydia infection with few published prospective studies. We have used data from an old prospective cohort of...

P1-S3.10 The role of Chlamydia trachomatis in the development of symptomatic pelvic inflammatory disease: a multi-parameter synthesis

BackgroundChlamydia trachomatis (CT) is an important risk factor for the development of Pelvic Inflammatory Disease (PID), but despite much study the extent of its causal role remains unclear. Knowledge of...

Association Between Stroke and Patients With Pelvic Inflammatory Disease

The aim of this study is to estimate the risk of stroke in a 3-year period after pelvic inflammatory disease (PID) using a nationwide population-based study. Our study cohort consisted of all patients with a diagnosis of PID (N = 64,515) between 2004 and 2005 with a control cohort (1:2) of age-matched controls (N = 129, 030). Each patient was tracked from hospitalization until the end of 2006. Cox regressions were performed to compute the 3-year stroke-free survival rates after adjusting for possible confounding factors. We found that women with PID were more likely to have strokes than the control population. After adjusting for potential confounding factors, the adjusted hazard ratio of stroke was 1.63 (95% CI, 1.45-1.85) for PID patients as compared to the general population cohort. Sensitivity analysis using a bootstrap approach further ensured the validity of the results of our study. We concluded that patients with PID have an association with stroke. Further research is necessary to investigate the pathophysiology between PID and stroke.

Poor Provider Adherence to the Centers for Disease Control and Prevention Treatment Guidelines in US Emergency Department Visits With a Diagnosis of Pelvic Inflammatory Disease

Pelvic inflammatory disease (PID) is commonly diagnosed in US emergency departments (EDs). We aimed to estimate national rates of provider adherence to the Centers for Disease Control and Prevention (CDC) treatment guidelines for PID among patient visits, with a diagnosis of acute PID in US ED settings. A multiyear cross-sectional analysis was performed on ED visits from females >12 years old, using the National Hospital Ambulatory Medical Care Survey database from 1999 to 2006. The ED diagnoses of acute PID were identified from the database. Specific antibiotics ordered or provided during ED visits diagnosed with PID were identified and compared to contemporary CDC treatment guidelines to determine provider adherence. Analyses were performed using procedures for multiple-stage survey data. Overall, 1,605,000 discharged ED patient visits with a diagnosis of acute PID were identified. ED provider adherence to CDC treatment guidelines was 30.5% (95% confidence intervals [CI], 24.4%-36.7%). Doxycycline was the most commonly missing medication from the recommended regimens while azithromycin was the most prescribed antibiotic that was not recommended until 2006 CDC guidelines. Additionally, among the visits without being given any CDC-recommended antibiotics, 38.4% were prescribed neither antibiotics nor pain relievers. In multivariate analysis, those without specialty consultation during ED visits and those before the announcement of 2002 guidelines were 4.95 (95% CI, 1.71-14.29) and 1.93 (95% CI, 1.14-3.27) times less likely to receive CDC-recommended antibiotic regimens versus their counterparts. Poor provider adherence to the CDC-recommended treatment guidelines for PID has been widespread in US EDs, especially for women who did not receive specialty consultation.

Differential Diagnosis of Abdominal Pain and GI Complaints in Children

Differential Diagnosis of Abdominal Pain and GI Complaints in Children

Quality of Care for Pelvic Inflammatory Disease: Room for Improvement

Pelvic inflammatory disease (PID) is a clinical syndrome characterized by upper genital tract inflammation and frequently associated with sexually transmitted or genital tract microorganisms. The Centers for Disease Control and Prevention (CDC) has developed STD treatment guidelines intended to assist health care providers in selecting antibiotic treatment strategies based on objective clinical evidence.1 Several studies over the past 2 decades have demonstrated poor provider adherence to recommended treatment for PID.2‐5 The authors of these reports called for aggressive quality improvement measures to improve adherence to PID treatment guidelines. With an ongoing focus on improving quality of care, one would expect to see improvement in provider adherence to PID antibiotic regimens over the past decade. In this issue, Shih and colleagues report on provider adherence to CDC guidelines for outpatient treatment of PID in emergency and urgent care settings. 6 The authors used data from a national database (National Hospital Ambulatory Medical Care Survey; NHAMCS) to determine whether provider selection of antibiotics for outpatient PID was consistent with CDC guidelines during the 1999‐2006 period. The authors concluded that a guideline-recommended antibiotic regimen was provided only 30% of the time, with partially appropriate antibiotics provided 47% of the time, and completely inconsistent treatment (or no treatment) provided 22% of the time. The authors conclude that provider adherence to PID antibiotic treatment guidelines remains low and has not improved significantly since the previous studies on this topic. Why is adherence to the guidelines so low? Although research has consistently shown poor adherence to PID antibiotic treatment guidelines, little is actually known about why providers are not adherent. It could be that many providers are not aware of the latest guidelines from CDC or other major organizations. Ubiquitous internet access now provides healthcare providers with nearly immediate access to latest treatment guidelines (one needs only to type “PID treatment guidelines” into an internet search engine, and the latest CDC guidelines will be the first link). However, many providers may use other sources of information (eg, review articles or text books) or may continue to practice in a manner that they learned previously. Alternatively, it could be that providers either do not agree with the guidelines, find them impractical, or are aware of new data that has emerged since the latest version of the guidelines were written. For example, the Shih study found that one of the most common reasons for provider nonadherence was the provision of azithromycin, rather than doxycycline, as part of the outpatient antibiotic regimen. Although azithromycin was not included as a recommended treatment for PID in the 2006 CDC guidelines, it appears to be an effective treatment option (although the optional dose and duration remains unknown). 1,7 The recommended oral regimens for PID generally require twice-daily medication for 2 weeks, and young women with PID often have significant challenges with adherence to these antibiotic regimens.8 Another possible explanation for the low adherence rates in the Shih study could be measurement error related to misclassification of PID and/or the antibiotic regimens used. In the NHAMCS survey, use of provider-coded diagnosis of PID has not been validated against actual medical records or other means; thus, providers completing the survey could have indicated a PID diagnosis for a variety of pelvic complaints. However, other studies that used chart review or questionnaires to identify PID have found similar rates of nonadherence to CDC guidelines. 2,4,5 Some providers in the NHAMCS did not report providing any antibiotics for PID, and while failure to provide any antibiotics is clearly inappropriate, it is possible that either the PID diagnosis was not correct or that the provider did not accurately list all medications provided on the survey form. Should antibiotic treatment that is only partially in agreement with guidelines always be classified as poor quality of care? Recent clinical trials provide evidence of efficacy for several

Estimation of the Rate of Pelvic Inflammatory Disease Diagnoses: Trends in England, 2000–2008

Pelvic inflammatory disease (PID) is difficult to define and diagnose; therefore, a standardized methodology for identifying and monitoring PID diagnoses is required. We estimated the rate of PID in general practice in England, and investigated variations by definition of PID, time, age, and geographical area. We analyzed the United Kingdom General Practice Research Database between 2000 and 2008. Definitions of "definite," "probable," and "possible" PID among female patients (aged 16 to 44 years) were determined according to medical codes that denoted diagnoses or symptoms indicative of PID. Diagnoses rates were calculated per 100,000 person-years (py). Trends were assessed using Poisson regression. The rate of clinical PID diagnoses was 281/100,000 py (95% confidence interval [95% CI]: 277-286) for definite cases; 326/100,000 py (95% CI: 321-331) for definite and probable cases; and 1117/100,000 py (95% CI: 1107-1126) for definite, probable, and possible cases. During 2000 to 2008, the rate of definite/probable PID decreased by 10.4% per year (95% CI: 9.7-11.1; P<0.001). Rates declined in all areas and among all age groups with greatest decline in women aged 16 to 19 years. Meanwhile, the rate of possible PID increased. The definition of PID used has a major effect on the rate and trends over time. There was heterogeneity in rates of definite/probable PID by age and region, but homogeneity with regard to a trend of declining rates. Ongoing monitoring of PID diagnoses, with standard case definitions, will contribute to the evaluation of chlamydia screening in England.

The implications of abdominal palpation with Ou MC manipulation for women with acute abdomen

ObjectivesAbdominal palpation with Ou MC manipulation (APOM) has showed to be more sensitive than bimanual pelvic examination for the diagnosis of pelvic inflammatory disease in women with acute abdomen (JEM. 2010;). This study compared APOM with traditional abdominal palpation (AP) for diagnostic reliability and enquired into the mechanism of APOM. MethodsFrom January 2006 through December 2009, 113 women with acute abdomen attending an emergency department received AP and APOM. Of the 113 women, 91 had pelvic organ disease, whereas 21 had nonpelvic organ disease and 1 had pelvic and nonpelvic organ disease concurrently. ResultsExcluding the case with concurrent pelvic and nonpelvic organ disease, the sensitivity of APOM for the diagnosis of pelvic organ disease was significantly greater than that of AP (P = .003). Abdominal palpation with Ou MC manipulation also showed greater specificity of excluding pelvic organ disease than did AP (P = .003). Overall, 37.2% of patients with muscle guarding had repeated APOM or APOMs with aggravated isolation, which made the location of the diseased organ more distinct to identify. ConclusionsThe delimitation by APOM as a separation zone may allow positional recognition of the tenderness with decreased overlap of signs. However, in cases with muscle guarding, initial APOM might not be able to locate tenderness effectively until repeated APOM or APOMs with aggravated isolation lead to extensive space shielding and isolation of visceral organs. This implies that tenderness location by APOM may also relate to space shielding and pelvic organ isolation.

A Practical Approach to the Diagnosis of Pelvic Inflammatory Disease

The diagnosis of acute pelvic inflammatory disease (PID) is usually based on clinical criteria and can be challenging for even the most astute clinicians. Although diagnostic accuracy is advocated, antibiotic treatment should be instituted if there is a diagnosis of cervicitis or suspicion of acute PID. Currently, no single test or combination of diagnostic indicators have been found to reliably predict PID, and laparoscopy cannot be recommended as a first line tool for PID diagnosis. For this reason, the clinician is left with maintaining a high index of suspicion for the diagnosis as he/she evaluates the lower genital tract for inflammation and the pelvic organs for tenderness in women with genital tract symptoms and a risk for sexually transmitted infection. This approach should minimize treating women without PID with antibiotics and optimize the diagnosis in a practical and cost-effective way.

Pelvic Inflammatory Disease

Pelvic inflammatory disease (PID) is an inflammatory process elicited by the migration of pathogenic microorganisms from the lower to upper genital tract. Although PID is known to increase the risk of tubal factor infertility, many other aspects of this disease remain less well defined. For example, while PID is often caused by Chlamydia trachomatis or Neisseria gonorrhoeae infection, frequently, neither of these bacterial pathogens is isolated from the upper genital tract of women with PID. This etiologic ambiguity also creates uncertainty regarding the decision to include antibiotics effective against genital mycoplasmas and anaerobic vaginal flora in PID treatment. Moreover, since clinical signs and laboratory measurements do not precisely identify all PID cases, and as the accuracy with which imaging modalities identify upper genital tract inflammation is not firmly established, PID remains a diagnostic challenge. It is clear, however, that better understanding of disease pathogenesis, diagnosis, and treatment is needed to improve the care provided women with PID, and this issue of Infectious Diseases in Obstetrics and Gynecology was constructed to deliver specific focus on these topics. Three papers in this issue examine the role of C. trachomatis in PID pathogenesis. The first examines findings from C. trachomatis infection control programs that have altered our understanding of the host immune response to chlamydial infection, and considers implications of these findings for prophylactic vaccine development. The second paper concisely reviews how non-human primate models of chlamydia infection have improved our understanding of PID pathogenesis, while the third explores a possible association between C. trachomatis-specific humoral immunity and genital tract inflammation. The fourth PID pathogenesis-focused paper is a case report that reminds readers of the link between Actinomyces israelii and this disease among women using intrauterine devices, while the fifth reviews evidence supporting Mycoplasma genitalium as a cause of PID. The five remaining papers in this issue address PID diagnosis and treatment. The first diagnosis-related paper defines a practical approach for the identification of women with PID, while the second tests an algorithm for PID case identification in epidemiological research using administrative diagnostic codes rather than the more unwieldy medical record review. The third describes an investigation among a cohort of women with high prevalence of HIV-1 that found that the conventional markers of histologic endometritis (i.e., neutrophils and plasma cells) are, at least in this population, unreliable surrogate markers for laparoscopically confirmed salpingitis. The fourth paper reviewed existing literature regarding serologic diagnosis of C. trachomatis infection in order to construct an algorithm for chlamydial serologic antibody testing in clinical work-up of the infertile couple. We close this issue with a comprehensive review of the antimicrobial therapies currently available for PID treatment. Thomas L. Cherpes Peter A. Rice Richard L. Sweet

Acute pelvic inflammatory disease: Diagnostic performance of CT

To evaluate retrospectively the performance of computed tomography (CT) for the diagnosis of acute pelvic inflammatory disease (PID) by the use of clinical and laboratory data as the reference standard. The study was approved by the institutional review board. A total of 190 women of reproductive age (age range, 16-49 years; mean age, 29.3 ± 7.6 years) with complaints of non-traumatic acute lower abdominal pain underwent subsequent abdominopelvic CT. The diagnosis of acute PID was confirmed by the clinical and laboratory findings. Two radiologists performed a blinded, independent, retrospective review of the CT findings of acute PID. Discordant findings were resolved by a consensus review with a third radiologist. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of each CT finding for the diagnosis of acute PID were determined. Kappa statistics were used to estimate agreement between readers. Pelvic inflammatory disease was present in 48 (25.3%) of the 190 patients. The most specific CT finding for the diagnosis of acute PID was tubal thickening of both fallopian tubes (95.1%). The most sensitive CT finding was mid-pelvic fat stranding (60.4%). The CT finding of tubal thickening is highly specific for the diagnosis of acute PID, although overall CT sensitivity is poor.

Management of first-episode pelvic inflammatory disease in primary care: results from a large UK primary care database

Prompt and effective treatment of pelvic inflammatory disease (PID) may help prevent long-term complications. Many PID cases are seen in primary care but it is not known how well management follows recommended guidelines. To estimate the incidence of first-episode PID cases seen in UK general practice, describe their management, and assess its adequacy in relation to existing guidelines. Cohort study. UK general practices contributing to the General Practice Research Database (GPRD). Women aged 15 to 40 years, consulting with a first episode of PID occurring between 30 June 2003 and 30 June 2008 were identified, based on the presence of a diagnostic code. The records within 28 days either side of the diagnosis date were analysed to describe management. A total of 3797 women with a first-ever coded diagnosis of PID were identified. Incidence fell during the study period from 19.3 to 8.9/10 000 person-years. Thirty-four per cent of cases had evidence of care elsewhere, while 2064 (56%) appeared to have been managed wholly within the practice. Of these 2064 women, 34% received recommended treatment including metronidazole, and 54% had had a Chlamydia trachomatis test, but only 16% received both. Management was more likely to follow guidelines in women in their 20s, and later in the study period. These analyses suggest that the management of PID in UK primary care, although improving, does not follow recommended guidelines for the majority of women. Further research is needed to understand the delivery of care in general practice and the coding of such complex syndromic conditions.

109: Differential Diagnosis of Pelvic Inflammatory Disease and Appendicitis In the Emergency Department

109: Differential Diagnosis of Pelvic Inflammatory Disease and Appendicitis In the Emergency Department

Pelvic Inflammatory Disease

Pelvic inflammatory disease (PID) is an infection-caused inflammatory continuum from the cervix to the peritoneal cavity. Most importantly, it is associated with fallopian tube inflammation, which can lead to infertility, ectopic pregnancy, and chronic pelvic pain. The microbial etiology is linked to sexually transmitted microorganisms, including Chlamydia trachomatis, Neisseria gonorrheae, Mycoplasma genitalium, and bacterial vaginosis-associated microorganisms, predominantly anaerobes. Pelvic pain and fever are commonly absent in women with confirmed PID. Clinicians should consider milder symptoms such as abnormal vaginal discharge, metrorrhagia, postcoital bleeding, and urinary frequency as potential symptoms associated with the disease, particularly in women at risk of sexually transmitted infection. The diagnosis of PID is based on the findings of lower genital tract inflammation associated with pelvic organ tenderness. The outpatient treatment of mild-to-moderate PID should include tolerated antibiotic regimens with activity against the commonly isolated microorganisms associated with PID and usually consists of an extended spectrum cephalosporin in conjunction with either doxycycline or azithromycin. Clinically severe PID should prompt hospitalization and imaging to rule out a tuboovarian abscess. Parenteral broad-spectrum antibiotic therapy with activity against a polymicrobial flora, particularly gram-negative aerobes and anaerobes, should be implemented. Screening for and treatment of Chlamydia infection can prevent PID.

Risk of Sequelae afterChlamydia trachomatisGenital Infection in Women

Chlamydia trachomatis infection, the most common reportable disease in the United States, can lead to pelvic inflammatory disease (PID), infertility, ectopic pregnancy, and chronic pelvic pain. Although C. trachomatis is identified among many women who receive a diagnosis of PID, the incidence and timing of PID and long-term sequelae from an untreated chlamydial infection have not been fully determined. This article examines evidence reviewed as part of the Centers for Disease Control and Prevention Chlamydia Immunology and Control Expert Advisory Meeting; 24 reports were included. We found no prospective studies directly assessing risk of long-term reproductive sequelae, such as infertility, after untreated C. trachomatis infection. Several studies assessed PID diagnosis after untreated chlamydial infection, but rates varied widely, making it difficult to determine an overall estimate. In high-risk settings, 2%-5% of untreated women developed PID within the approximately 2-week period between testing positive for C. trachomatis and returning for treatment. However, the rate of PID progression in the general, asymptomatic population followed up for longer periods appeared to be low. According to the largest studies, after symptomatic PID of any cause has occurred, up to 18% of women may develop infertility. In several studies, repeated chlamydial infection was associated with PID and other reproductive sequelae, although it was difficult to determine whether the risk per infection increased with each recurrent episode. The present review critically evaluates this body of literature and suggests future research directions. Specifically, prospective studies assessing rates of symptomatic PID, subclinical tubal damage, and long-term reproductive sequelae after C. trachomatis infection; better tools to measure PID and tubal damage; and studies on the natural history of repeated chlamydial infections are needed.

Chlamydia Screening and Pelvic Inflammatory Disease: Insights from Exploratory Time–Series Analyses

Screening for chlamydia has been reported to reduce pelvic inflammatory disease (PID) at the individual level. However, information on population-level association (or causality) is scant. This study aims to examine the association between chlamydia and gonorrhea screening and PID diagnoses using time-series analyses. Monthly chlamydia and gonorrhea screening and PID diagnosis rates were extracted for a cohort of 207,695 continuously enrolled privately insured women from January 2001 to December 2006. An autoregressive integrated moving average model was used to examine whether rates of PID diagnoses in a given month were associated with rates of chlamydia and gonorrhea screening in previous months. Monthly screening rates increased from about 300 to almost 700 per 100,000 for chlamydia and from 250 to almost 650 per 100,000 for gonorrhea, whereas PID diagnosis rates declined during the same period (40-20 per 100,000). Increases in screening rates were associated with decreases in PID diagnosis rates 4 months later. On average, a one-unit (or 10%) increase in the growth of chlamydia and gonorrhea screening rates, separately, in the prior fourth month was significantly associated with a 0.36 (or 3.6%, p<0.05) and 0.32 (or 3.2%, p<0.10) decrease in the growth rate of the PID diagnosis rate, respectively. Although analyses such as these cannot prove causality, the results are consistent with the hypothesis that increases in chlamydia and gonorrhea screening coverage can lead to reductions in PID at the population level. A population-level focus offers advantages over individual-level analyses of screening and PID, such as the ability to capture indirect benefits of increased screening.

Missed Pelvic Inflammatory Disease Diagnoses and Treatment Detected Through Health Department Surveillance in Two Western New York Emergency Departments

Background: In New York State, gonococcal (GC) and chlamydia (CT) associated pelvic inflammatory disease (PID) is under-reported because diagnosis is not lab-based and report forms do not capture PID diagnoses. We piloted a surveillance tool to capture GC and CT associated PID cases that were not reported to the health department (HD) among females testing GC and/or CT positive in high volume emergency departments (EDs).

Pelvic Inflammatory Disease Among Privately Insured Women, United States, 2001-2005

We explored the utility of using insurance claims data for surveillance of pelvic inflammatory disease (PID). PID rates are an important indicator of population level trends in reproductive morbidity; however, data available to monitor PID trends are limited. National survey data are currently used to estimate PID rates in the United States, but a declining number of cases threaten their future usefulness. We performed a retrospective analysis of PID diagnosis rates using administrative claims data from 2001 to 2005. Diagnostic codes were used to identify women aged 15 to 44 in the study population that were diagnosed with acute PID as inpatients, in emergency departments, and in outpatient ambulatory settings. Rates of PID diagnoses among privately insured women declined significantly from 2001 to 2005 among all age groups examined and within all geographic regions. Annual PID diagnosis rates decreased from 317.0 to 236.0 per 100,000 enrollees, representing a 25.5% decline over the study period. The highest rates of PID were among 25- to 29-year-olds (352.8 per 100,000 in 2005) and among those residing in the South (314.3 per 100,000 in 2005). Most women (70.1%) received PID care through physician offices and other outpatient facilities; of these women, approximately 40% were treated by an obstetrician/gynecologist. The decline in PID diagnoses corresponds with previous reports from national surveys. Claims data offer a much needed new data source that will allow for continued monitoring of PID among a broad population in both inpatient and outpatient clinical settings.

Toward Improving the Diagnosis and the Treatment of Adolescent Pelvic Inflammatory Disease in Emergency Departments

To assess the utility of an abbreviated teaching tool (ATT) in improving emergency medicine pediatricians' knowledge of the diagnosis and the treatment of pelvic inflammatory disease (PID). An 18-question internet-based survey, which included questions about the diagnosis and the treatment of PID, was administered to members of the American Academy of Pediatrics Section on Emergency Medicine. Participants were randomized to receive either a weblink to the Centers for Disease Control and Prevention (CDC) sexually transmitted disease treatment guidelines (weblink group) or a 1-page ATT that summarized the CDC guidelines (ATT group) to assist with completion of the survey. We compared the accuracy of responses between the 2 groups. Two hundred thirty-seven subjects responded to the survey (109 from the weblink group and 128 from ATT group). There were no significant differences between the groups with respect to sex, geographic location, practice setting, years of experience, or reported frequency of recent PID diagnoses. Ninety-seven percent of the ATT group correctly identified the appropriate antibiotic regimen in compliance with the CDC guidelines compared with 61% of the weblink group (OR, 19.4; 95% confidence interval, 6.6-76.9); the ATT group was also more likely to correctly identify appropriate treatment options overall (OR, 9.6; 95% confidence interval, 4.9-19.3). Although the overall PID knowledge in our sample was low, the physicians with access to a 1-page teaching tool summarizing the CDC treatment recommendations for PID performed significantly better when asked questions involving PID treatment as compared with providers with access to the CDC Web site. Further studies should investigate whether access to a similar tool can improve patient care.