PID in teens ups risk for subsequent STDs
PID in teens ups risk for subsequent STDs
Results from a just-published study indicate that teens who are treated for pelvic inflammatory disease (PID) are at risk for subsequent sexually transmitted infections (STIs) and/or PID for 48 months.1 What can clinicians do to stem subsequent infection?
PID covers a spectrum of inflammatory disorders of the upper female genital tract, including any combination of endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis.2 Without treatment, PID can cause permanent damage to the female reproductive organs.
Adolescents already are at high risk for STIs, observes Jeffrey Peipert, MD, MPH, MHA, professor in the Department of Obstetrics and Gynecology at the Washington University School of Medicine in St. Louis. Sexually active adolescents have the highest incidence of Chlamydia trachomatis, Neisseria gonorrhoeae, and PID of any sexually active age group.2
After one episode of STI (either N. gonorrhoeae, C. trachomatis, or PID), teens are at increased risk for additional STIs, explains Peipert. Adolescents who have had PID have a lot at stake: With each repeated episode of PID, the rate of infertility increases. Thus, it is extremely important to prevent STIs after an episode of PID, he states.
To make sure that antibiotic treatment is effective, the Centers for Disease Control and Prevention (CDC) recommends that all women diagnosed with PID be re-evaluated within 72 hours. This second visit ensures that patients defervesce (show abatement of fever) and do not have signs of complications,3 explains Maria Trent, MD, MPH, a pediatrician and adolescent medicine specialist at Johns Hopkins Children's Center in Baltimore. Trent served as lead author for the current study.
Previous research by Trent and associates indicates that teens often are unable to make these 72-hour follow-up appointments.4 "Unfortunately, it is during this visit that they receive the comprehensive, patient-centered contraceptive and risk-reduction counseling that cannot be performed during a visit in an urgent/emergency care environment," she explains.
To perform the current study, researchers used a longitudinal approach to assess the frequency of recurrent STIs and/or PID, the average time until subsequent infection after a baseline diagnosis of PID, and age- and insurance-related associations with subsequent diagnoses. Using electronic medical records, the researchers looked at 110 adolescent girls ages 15-21 treated for PID as outpatients in Baltimore pediatric ambulatory sites, with prospective longitudinal follow-up data including subsequent PID diagnoses and/or infections with N. gonorrhoeae or C. trachomatis. In the four-year study, 80 girls returned for follow-up during the 48-month study period. Under the study protocol, those with confirmed diagnoses of PID were given a course of free medication and asked to return within 72 hours and advised to follow up again at three months and again in six months with a primary care provider.
Of the 80, 27 (34%) were diagnosed with at least one subsequent sexually transmitted infection over a six-month period. Within that 34% subset, eight adolescents had two or more STIs in the six-month period.
Teens need information on STD prevention when it comes to PID, says Peipert. He suggests that counseling messages include the following points:
- Limit the number of sexual partners.
- Always use a condom — consistently and correctly — every time. Research has shown that consistent condom use offers protection (though not absolute) and reduces the chances of repeat PID and chronic pelvic pain.5
- Be careful when choosing a new partner. Never have sex with a man with sores, blisters, lumps, bumps, or discharge.
- An important way to stem subsequent infections is to be sure your partner was treated. [Editor's note: For counseling on PID, use a patient handout developed by the Office on Women's Health in the Department of Health and Human Services.]
Hopkins researchers are looking at several ways to improve follow-up after PID treatment. They are testing a pilot program that involves showing an educational video to teenage girls coming to the hospital emergency department with PID. The team also plans to test the value of house calls to patients by a nurse within 72 hours of diagnosis.
This series of studies is designed to determine the best and most cost-effective method to ensure that adolescents get the much needed clinical follow-up for PID, explains Trent.
"The final results of these studies are pending, but we hope they will yield data that will enable us to develop alternative public health strategies to protect the reproductive health and future fertility of affected patients," she states.
References
- Trent M, Chung SE, Forrest L, et al. Subsequent sexually transmitted infection after outpatient treatment of pelvic inflammatory disease. Arch Pediatr Adolesc Med 2008; 162: 1,022-1,025.
- Gray-Swain MR, Peipert JF. Pelvic inflammatory disease in adolescents. Curr Opin Obstet Gynecol 2006; 18:503-510.
- Centers for Disease Control and Prevention, Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep 2006; 55(RR-11):58-61.
- Trent M, Judy SL, Ellen JM, et al. Use of an institutional intervention to improve quality of care for adolescents Treated in pediatric ambulatory settings for pelvic inflammatory disease. J Adolesc Health 2006; 39:50-56.
- Ness RB, Randall H, Richter HE, et al. Condom use and the risk of recurrent pelvic inflammatory disease, chronic pelvic pain, or infertility following an episode of pelvic inflammatory disease. Am J Public Health 2004; 94:1,327-1,329.
Review PID treatment options from the CDC
Following are pelvic inflammatory disease (PID) treatment options from the Updated Recommended Treatment Regimens for Gonococcal Infections and Associated Conditions — United States, April 2007, published by the Centers for Disease Control and Prevention.1 The agency published the updated options to its Sexually Transmitted Diseases Treatment Guidelines, 2006 following the rise of fluoroquinolone-resistant diseases.2,3
• Parenteral treatment. Parenteral and oral therapy appear to have similar clinical efficacy treating women with PID of mild or moderate severity. Clinical experience should guide decisions regarding transition to oral therapy, which usually can be initiated within 24 hours of clinical improvement.
— Recommended parenteral regimen A: cefotetan 2 g intravenous (IV) every 12 hours; or cefoxitin 2 g IV every six hours plus doxycycline 100 mg orally or IV every 12 hours.
— Recommended parenteral regimen B: clindamycin 900 mg IV every eight hours plus gentamicin loading dose IV or intramuscular (IM) (2 mg/kg of body weight), followed by a maintenance dose (1.5 mg/kg) every eight hours. Single daily dosing may be substituted.
— Alternative parenteral regimens: ampicillin/sulbactam 3 g IV every six hours plus doxycycline 100 mg orally or IV every 12 hours.
• Oral treatment. Oral therapy can be considered for women with mild to moderately severe acute PID, as the clinical outcomes among women treated with oral therapy are similar to those treated with parenteral therapy. Women who do not respond to oral therapy within 72 hours should be re-evaluated to confirm the diagnosis and should be administered parenteral therapy on an outpatient or inpatient basis.
— Recommended oral regimen: ceftriaxone 250 mg IM in a single dose plus doxycycline 100 mg orally twice a day for 14 days, with or without metronidazole 500 mg orally twice a day for 14 days; or cefoxitin 2 g IM in a single dose and probenecid, 1 g orally administered concurrently in a single dose, plus doxycycline 100 mg orally twice a day for 14 days, with or without metronidazole 500 mg orally twice a day for 14 days; or other parenteral third-generation cephalosporin (e.g., ceftizoxime or cefotaxime), plus doxycycline 100 mg orally twice a day for 14 days, with or without metronidazole 500 mg orally twice a day for 14 days.
• Alternative oral regimens. If parenteral cephalosporin therapy is not feasible, use of fluoroquinolones (levofloxacin 500 mg orally once daily or ofloxacin 400 mg twice daily for 14 days) with or without metronidazole (500 mg orally twice daily for 14 days) may be considered if the community prevalence and individual risk of gonorrhea is low. (See "Gonococcal Infections in Adolescents and Adults" in Sexually Transmitted Disease Treatment Guidelines, 2006.) Tests for gonorrhea must be performed prior to instituting therapy, and the patient must be managed as follows if the test is positive:
- If nucleic acid amplification test is positive, parenteral cephalosporin is recommended.
- If culture for gonorrhea is positive, treatment should be based on results of antimicrobial susceptibility. If isolate is fluoroquinolone-resistant N. gonorrhoeae, or antimicrobial susceptibility cannot be assessed, parenteral cephalosporin is recommended.
Although information regarding other outpatient regimens is limited, amoxicillin/clavulanic acid and doxycycline or azithromycin with metronidazole have demonstrated short-term clinical cure. No data have been published regarding the use of oral cephalosporins for the treatment of PID.
References
- Centers for Disease Control and Prevention (CDC). Update to CDC's sexually transmitted diseases treatment guidelines, 2006: Fluoroquinolones no longer recommended for treatment of gonococcal infections. MMWR 2007; 56:332-336.
- Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep 2006; 55(RR-11):58-61.
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