Subsequent Sexually Transmitted Infection After Outpatient Treatment of Pelvic Inflammatory Disease
Trent M, Chung SE, Forrest L, Ellen JM
Arch Pediatr Adolesc Med. 2008;162:1022-1025
Summary
The authors reviewed many of the factors that make sexually transmitted infections (STIs) more difficult to treat in adolescents, including the fact that much of the care for STIs occurs in acute care settings and without assurances of proper follow-up, both for repeat testing and counseling. Repeat infections put adolescents at increased risk for infertility and ectopic pregnancy.
This study was completed to determine the rate of repeat STIs among patients treated at 1 outpatient pediatric center in an urban setting. The adolescents were approached for enrollment when they were treated at the outpatient clinic for their first episode of pelvic inflammatory disease (PID). The outpatient clinic employs a practice guideline and a local quality improvement effort in order to ensure uniform treatment of PID and to improve follow-up of infected individuals. Under their approach, individuals receive a full course of medication at discharge.
The authors identified subjects through completed PID treatment records. Additional components of the subjects' medical records were reviewed to gather laboratory findings, patient demographics, and outcomes from the index visit. Investigators employed the institution's electronic medical record to identify subsequent infections with Neisseria gonorrhoeae or Chlamydia trachomatis.
The patients were tracked for 48 months after the index infection. The outcome of interest was the rate of subsequent STIs or PID > 30 days after any previous STI or PID diagnosis. The authors identified 110 subjects for follow-up. The cohort was 89% black and had a mean age of 16.8 years.
At the index enrollment, 39% of the subjects were positive for either N gonorrhoeae or C trachomatis. Seventy-three percent of the subjects made at least 1 subsequent visit (not necessarily for STIs) to the enrolling clinic during the 48-month follow-up period. Of those with at least 1 subsequent outpatient clinic visit, 34% experienced at least 1 subsequent diagnosis/episode of STI or PID with either N gonorrhoeae or C trachomatis. Forty-four percent of these repeat infections were associated with PID. Of those with a repeat infection, 30% had 2 or more repeat infections. For those with a repeat infection, the average time until repeat infection was 377 days.
The authors concluded that adolescents with an initial diagnosis of PID are at significant risk for repeat STIs or PID in the 48 months after diagnosis.
Viewpoint
Perhaps more than anything, this study highlighted the importance of follow-up for patients identified with PID. The high rate of repeat diagnosis, and the relatively long median time to second episode, suggests that outpatient follow-up after diagnosis has the potential to lower rates of subsequent infection. There were also many limitations to the study, including the fact that subsequent visits were tracked only electronically, meaning that visits outside of the medical care system of the study hospital were missed. That omission likely underestimated the rate of repeat STIs or PID, however, and does not change the basic message that a diagnosis of PID should serve as a "red flag" identifying a patient who is at notable risk for subsequent episodes.
Abstract