What’s your approach to PID treatment in teens?
EXECUTIVE SUMMARY
According to a new survey of clinicians who treat teen girls with pelvic inflammatory disease (PID), national guidance designed to inform decisions about hospitalization versus outpatient care has lead to provider uncertainty in choosing the most effective treatment approach.
• Due to biologic and behavioral factors, teens are vulnerable to developing PID, which can result in an increased risk for ectopic pregnancy, tubal infertility, and chronic pelvic pain.
• National guidance no longer universally recommends treating adolescents with mild to moderate disease in an inpatient setting. Patients who are treated at home receive antibiotics by mouth for 14 days and are asked to return to the clinician’s office within 72 hours for re-evaluation.
According to a new survey of clinicians who treat teen girls with pelvic inflammatory disease (PID), national guidance designed to inform decisions about hospitalization versus outpatient care leaves some scratching their heads.1 Why is there uncertainty among providers in choosing the most effective treatment for the infection?
Pelvic inflammatory disease affects more than 800,000 women each year in the United States.2 Due to biologic and behavioral factors, teens are vulnerable to developing PID, which can result in an increased risk for ectopic pregnancy, tubal infertility, and chronic pelvic pain.
There have been major shifts in PID care in the United States in the last 15 years, notes the study’s lead author, Maria Trent, MD, MPH, associate professor of pediatrics in the Division of General Pediatrics and Adolescent Medicine at the Johns Hopkins School of Medicine in Baltimore. The primary change stems from the fact that the Centers for Disease Control and Prevention (CDC) no longer universally recommends treating adolescents with mild to moderate disease in the inpatient setting,3 Trent states. However, the medical and psychosocial factors that make adolescents vulnerable continue to exist, and there is limited data on how to best manage early and middle adolescents, she notes.
In the current study, researchers specifically evaluated when clinicians think that inpatient treatment for an adolescent with mild to moderate PID is indicated, states Trent. They used common clinical scenarios for which a patient’s ability to tolerate an outpatient regimen (a CDC criteria for hospitalization) could be difficult as a first step in understanding and refining the national guidance for adolescent management, she explains. Patients who are treated at home receive antibiotics by mouth for 14 days and are asked to return to the clinician’s office within 72 hours for re-evaluation. (See box on p. 93 for recommended outpatient oral treatment.)
Despite data showing that teens with PID often fail to adhere to outpatient treatment regimens and miss follow-up appointments,4 the CDC no longer recommends in-hospital treatment, although clinicians have the flexibility to hospitalize patients if they so choose.
Clinicians were presented with 17 clinical vignettes involving a hypothetical teen with PID, then were asked to choose between hospital and outpatient treatment for each scenario. The clinicians had to weigh various factors, such as the patient’s severity of illness and age, if she was pregnant, had recent surgical procedures, was afraid of sharing her diagnosis with a partner, or was able and willing to follow outpatient treatment regimen.
Data from the current study indicate the guidelines might be falling short of informing flexibility in choosing inpatient or outpatient care, particularly in cases that involve patients with recent abortions or whose social circumstances make it unlikely they would comply with the complex outpatient treatment, researchers note. Such ambivalence was apparent in the survey when clinicians were uncertain about patients’ ability to care for themselves, their willingness to take medications, or their willingness to share diagnoses with sexual partners, they state. Decision-making algorithms would be helpful in providing guidance, while giving physicians autonomy and flexibility, note researchers. Lack of clarity, however, might lead clinicians to make decisions predicated on personal bias rather than on evidence stemming from best practices, they state.
Taking the next step
What might be the next step in helping clinicians make the most informed treatment when it comes to PID treatment, particularly in teens?
Trent says additional research is warranted to explore alternative, developmentally appropriate and cost-effective management strategies designed to improve short-term adherence and prevention of adverse outcomes, such as infertility, ectopic pregnancy, and chronic pelvic pain.
"Our team is currently evaluating a technology-enhanced community health nursing intervention as a potential strategy to meet this need in clinical and public health practice, she notes.
CDC Recommended Regimen for Outpatient Treatment
• 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.
Source: Workowski KA, Berman S; Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep 2010; 59(RR-12):1-110.
REFERENCES
1. Trent M, Lehmann H, Butz A, et al. Clinician perspectives on management of adolescents with pelvic inflammatory disease using standardized patient scenarios. Sex Transm Dis 2013; 40(6):496-498.
2. Sutton MY, Sternberg M, Zaidi A, et al. Trends in pelvic inflammatory disease hospital discharges and ambulatory visits, United States, 1985-2001. Sex Transm Dis 2005; 32:778-784.
3. Workowski KA, Berman S; Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep 2010; 59(RR-12):1-110.
4. 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.
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