EXECUTIVE SUMMARY

Research analyzing trends in the nation’s emergency departments indicates low rates of HIV and syphilis screening among teens diagnosed with pelvic inflammatory disease, despite the high risk for such infections. Data also suggest low rates of adherence to national treatment guidelines.

  • A complication of undiagnosed or undertreated sexually transmitted infection, pelvic inflammatory disease can signal patients at heightened risk for syphilis or HIV.
  • Pelvic inflammatory disease occurs when microorganisms ascend from the vagina or cervix to the fallopian tubes and other upper genital tract structures; it can lead to infertility, ectopic pregnancy, and chronic pelvic pain.

Research analyzing trends in the nation’s emergency departments indicates low rates of HIV and syphilis screening among teens diagnosed with pelvic inflammatory disease (PID), despite the high risk for such infections. Data also suggest low rates of adherence to national PID treatment guidelines as well.1

A complication of undiagnosed or undertreated sexually transmitted infection (STI), PID can signal patients at heightened risk for syphilis or HIV, state the research paper authors. PID occurs when microorganisms ascend from the vagina or cervix to the fallopian tubes and other upper genital tract structures; it can lead to infertility, ectopic pregnancy, and chronic pelvic pain.2 Timely treatment with antibiotics can prevent severe damage to the reproductive organs; clinicians should refer to recommended treatment regimens in the Centers for Disease Control and Prevention (CDC) 2015 STD Treatment Guidelines.3 (Check the guidance online at http://bit.ly/2k86xqp.)

“As a clinician who practices exclusively in the emergency department (ED), I saw an opportunity to make real and lasting improvements to the health of teens and adolescents who receive care in the ED setting,” says Monika Goyal, MD, MSCE, assistant professor of pediatrics and emergency medicine, director of research, division of emergency medicine, and attending physician at Children’s National Health System at George Washington University. “As a first step, the field needed a stronger evidence base to characterize the unmet need in order to begin to consider potential interventions tailored to teens and youths.”

To that end, during the past 10 years, Goyal has developed a research program dedicated to improving the timely diagnosis and appropriate treatment of STIs among adolescents seen in the emergency department.

Check the Numbers

To determine the frequency of HIV and syphilis screening among adolescents diagnosed with PID, Goyal and fellow researchers performed a cross-sectional study, using the Pediatric Health Information System database of 48 children’s hospitals from 2010 through 2015, looking at all ED visits by females 21 years of age or younger with an ICD 9 or ICD 10 code diagnosis of PID to calculate the frequency of HIV, syphilis, gonorrhea, and chlamydia testing. The researchers used separate multivariable logistic regression analyses to identify patient-level factors such as age, race/ethnicity, insurance status, and disposition, as well as hospital-level factors such as geographic region and bed number, associated with HIV and syphilis testing. Researchers also calculated the rates of prescribed antibiotics that adhered to published CDC PID treatment guidelines for the concurrent year.

The analysis detected 10,698 PID diagnoses. The girls’ mean age was recorded as 16.7; nearly 54% were non-Latino black, and 37.8% ultimately were hospitalized. While data indicate that testing for other sexually transmitted infections, such as gonorrhea and chlamydia, occurred in more than 80% of patients diagnosed with PID, just 27.7% underwent syphilis screening, and just 22% were screened for HIV.1 The CDC recommends that all women diagnosed with PID be screened for HIV, and also calls for syphilis screening for people at high risk for infection.3

The CDC recommends that presumptive treatment for PID should be started in sexually active young women and other women at risk for STIs if they are experiencing pelvic or lower abdominal pain, if no cause for the illness other than PID can be identified, and if one or more of the following minimum clinical criteria are present on pelvic examination:

  • cervical motion tenderness; or
  • uterine tenderness; or
  • adnexal tenderness.4

Time to Make a Difference

Young people 15-24 years of age account for half of the nearly 20 million new STIs that occur each year in the United States.5 Many of them view the emergency department as the primary place to receive healthcare, says Goyal. If clinicians could increase STI screening rates in the ED setting, there could be a “tremendous impact” on the STI epidemic, notes Goyal.

Goyal and her research team have developed an audio-computer–assisted self-interview sexual health survey that can help ED clinicians increase testing rates among high-risk adolescents. Their research, presented at the 2016 American Academy of Pediatrics National Conference and Exhibition in San Francisco, indicates that providing sexual health survey-derived decision support to emergency department clinicians led to increased testing rates for STI in adolescents at high risk for infection, particularly in those presenting asymptomatic for infection.6

Because chlamydia and gonorrhea often have no symptoms, many women may not know they are infected and could be at risk for PID, notes Kristen Kreisel, PhD, a CDC epidemiologist.

“If not treated, PID may lead to infertility, ectopic pregnancy, and chronic pelvic pain,” states Kreisel. “Annual chlamydia and gonorrhea screening of sexually active women 25 years and younger is critical to reduce the burden of these STIs and their potential long-term consequences.” 

REFERENCES

  1. Jichlinski A, Goyal MK, Pastor W, et al. Rates of HIV and Syphilis Testing Among Adolescents Diagnosed With Pelvic Inflammatory Disease. Presented at the American Academy of Pediatrics Section on Emergency Medicine. Chicago; September 2017.
  2. Paavonen J, Westrom L, Eschenbach D. Pelvic inflammatory disease. In: Holmes K, Sparling P, Stamm W, et al, eds. Sexually Transmitted Diseases. 4th ed. New York City: McGraw-Hill; 2008:1017.
  3. Workowski KA, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep 2015;64(No. RR-03):1-137.
  4. Centers for Disease Control and Prevention. Pelvic Inflammatory Disease. Fact sheet. Accessed at http://bit.ly/2l303ts.
  5. Satterwhite CL, Torrone E, Meites E, et al. Sexually transmitted infections among US women and men: Prevalence and incidence estimates, 2008. Sex Trans Dis 2013;40:187-193.
  6. Goyal MK, Fein JA, Badolato GM, et al. A computerized sexual health survey improves testing for sexually transmitted infection in a pediatric emergency department. J Pediatr 2017;183:147-152.