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Research Letter |

Are Emergency Departments Appropriately Treating Adolescent Pelvic Inflammatory Disease? FREE

Monika Goyal, MD1,2,3; Adam Hersh, MD, PhD4; Xianqun Luan, MS5; Russell Localio, MS, PhD2,5; Maria Trent, MD, MPH6; Theoklis Zaoutis, MD, MSCE2,5
[+] Author Affiliations
1Children’s National Medical Center, George Washington University, Washington, DC
2Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
3Leonard Davis Institute, University of Pennsylvania, Philadelphia
4University of Utah, Salt Lake City
5Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
6Johns Hopkins School of Medicine, Baltimore, Maryland
JAMA Pediatr. 2013;167(7):672-673. doi:10.1001/jamapediatrics.2013.1042.
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Published online

Of the almost 1 million annually diagnosed cases of pelvic inflammatory disease (PID), 20% occur among adolescents.1 Because reproductive health concerns are the most common reasons for emergency department (ED) visits among adolescent girls, it is critical that ED providers are knowledgeable about the diagnosis and treatment of PID. The objective of this study was to evaluate adherence to the Centers for Disease Control and Prevention (CDC) PID treatment guidelines among a nationally representative sample of adolescent ED PID visits.

This study was considered exempt from formal review by our institutional review board. We conducted a retrospective cross-sectional analysis of the National Hospital Ambulatory Medical Care Survey from 2000 to 2009. The National Hospital Ambulatory Medical Care Survey is an annual, national probability sample survey of hospital EDs conducted by the National Center for Health Statistics branch of the CDC.2 The eligible study population included all sampled ED visits by females between ages 14 and 21 years during 2000 to 2009 with the diagnosis of PID captured by International Classification of Diseases, Ninth Revision codes. Our outcome measure was adherence to CDC recommended PID treatment guidelines by evaluating whether patients were prescribed antibiotics that were considered first- or second-line treatment for PID for the respective year based on the published CDC sexually transmitted disease treatment guidelines for PID management.3 Given that the CDC treatment guidelines changed in 2006, we also calculated the average proportion of appropriately treated PID cases before and after the 2006 CDC treatment guideline change. We used descriptive statistics and logistic regression with appropriate weighting to account for the complex survey methods to calculate all estimates and perform all analyses.

During the study period, there were an estimated 704 882 (95% CI, 571 807-837 957) PID cases in EDs. Among these, only 37.1% (95% CI, 30.6%-45.5%) were prescribed antibiotics that adhered to the CDC recommended treatment guidelines. Prior to 2006, only 30.7% (95% CI, 9.2%-52.3%) of PID cases received appropriate antibiotic therapy. This increased to 49.5% (95% CI, 22.9%-76.6%) after the guideline change (P = .01). The most common antibiotic regimen found among inappropriately treated patients was the combination of ceftriaxone sodium and azithromycin (17.1%).

To our knowledge, this analysis represents the first population-based assessment of recent compliance with CDC recommended treatment guidelines for adolescent ED patients diagnosed with PID. Only 37% of PID cases were treated according to the CDC treatment guidelines in our study. Furthermore, the common use of a third-generation cephalosporin and azithromycin suggests that clinicians may erroneously believe that PID treatment is identical to cervicitis treatment and/or that patients are incapable of adherence to doxycycline. This finding has substantial implications because inadequate treatment of PID may lead to serious long-term sequelae such as chronic pelvic pain or tubal infertility. Additionally, the lack of adherence to the CDC guidelines suggests a need to further study strategies for optimal diffusion and acceptance of the CDC guidelines.

Our finding of low adherence to the CDC treatment guidelines is consistent with those of other single-center studies and studies of adult populations.46 However, to our knowledge, our study is the first to evaluate whether treatment adherence had changed since the dissemination of the CDC 2006 sexually transmitted disease treatment guidelines. Even with the sizeable increase in the percentage of patients who were treated appropriately from prior to 2006 to afterward, more than 50% of patients are still not receiving treatment consistent with national guidelines. Furthermore, these nationally representative data demonstrate the need and potential high impact of using the ED as a strategic setting to further understand these issues and change clinical practice.

Corresponding Author: Dr Goyal, Children’s National Medical Center, 111 Michigan Ave NW, Washington, DC 20010 (mgoyal@cnmc.org).

Published Online: May 3, 2013. doi:10.1001/jamapediatrics.2013.1042

Author Contributions: Dr Goyal had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Goyal, Hersh, Localio, Trent, and Zaoutis.

Acquisition of data: Goyal and Luan.

Analysis and interpretation of data: Goyal, Hersh, Luan, Localio, Trent, and Zaoutis.

Drafting of the manuscript: Goyal, Luan, Localio, and Trent.

Critical revision of the manuscript for important intellectual content: Hersh, Luan, Localio, Trent, and Zaoutis.

Statistical analysis: Goyal, Luan, and Localio.

Obtained funding: Goyal.

Study supervision: Localio and Zaoutis.

Conflict of Interest Disclosures: None reported.

Funding/Support: We thank the Children’s Hospital of Philadelphia Department of Pediatrics (Dr Goyal) and the National Institutes of Health (grant K23 HD070910-01A1 [Dr Goyal]) for providing funding to support this research.

Role of the Sponsors: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.

Pelvic inflammatory disease (PID): CDC fact sheet. Centers for Disease Control and Prevention website. http://www.cdc.gov/std/pid/STDFact-PID.htm. Accessed May 4, 2012.
Ambulatory health care data: National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey descriptions. Centers for Disease Control and Prevention website. www.cdc.gov/nchs/ahcd/about_ahcd.htm. Accessed May 7, 2012.
Workowski  KA, Berman  SM; Centers for Disease Control and Prevention.  Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep. 2006;55(RR-11):1-94.
PubMed
Beckmann  KR, Melzer-Lange  MD, Gorelick  MH.  Emergency department management of sexually transmitted infections in US adolescents: results from the National Hospital Ambulatory Medical Care Survey. Ann Emerg Med. 2004;43(3):333-338.
PubMed   |  Link to Article
Kane  BG, Degutis  LC, Sayward  HK, D’Onofrio  G.  Compliance with the Centers for Disease Control and Prevention recommendations for the diagnosis and treatment of sexually transmitted diseases. Acad Emerg Med. 2004;11(4):371-377.
PubMed
Shih  TY, Gaydos  CA, Rothman  RE, Hsieh  YH.  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. Sex Transm Dis. 2011;38(4):299-305.
PubMed

Figures

Tables

References

Pelvic inflammatory disease (PID): CDC fact sheet. Centers for Disease Control and Prevention website. http://www.cdc.gov/std/pid/STDFact-PID.htm. Accessed May 4, 2012.
Ambulatory health care data: National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey descriptions. Centers for Disease Control and Prevention website. www.cdc.gov/nchs/ahcd/about_ahcd.htm. Accessed May 7, 2012.
Workowski  KA, Berman  SM; Centers for Disease Control and Prevention.  Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep. 2006;55(RR-11):1-94.
PubMed
Beckmann  KR, Melzer-Lange  MD, Gorelick  MH.  Emergency department management of sexually transmitted infections in US adolescents: results from the National Hospital Ambulatory Medical Care Survey. Ann Emerg Med. 2004;43(3):333-338.
PubMed   |  Link to Article
Kane  BG, Degutis  LC, Sayward  HK, D’Onofrio  G.  Compliance with the Centers for Disease Control and Prevention recommendations for the diagnosis and treatment of sexually transmitted diseases. Acad Emerg Med. 2004;11(4):371-377.
PubMed
Shih  TY, Gaydos  CA, Rothman  RE, Hsieh  YH.  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. Sex Transm Dis. 2011;38(4):299-305.
PubMed

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