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Pelvic Inflammatory Disease: Guidelines for Prevention and Management

Brief Summary

This report provides comprehensive guidelines to aid practitioners and decision makers in achieving PID prevention and management objectives. The main focus of this document is PID related to STD. These guidelines for the prevention and management of PID were established by staff of CDC in consultation with a group of outside experts.

Current data regarding the efficacy of prevention strategies and management approaches form the basis for the guidelines. Because data are incomplete, however, certain aspects of these guidelines represent the current consensus judgment of the consulted experts. Recommend- ations in this document should be considered a source of guidance to health practitioners.

The CDC staff members and outside experts listed below served as authors of this document.

Sevgi O. Aral, Ph.D. Centers for Disease Control

Robert C. Brunham, M.D. University of Manitoba

Willard Cates, Jr., M.D., M.P.H. Centers for Disease Control

David A. Eschenbach, M.D. University of Washington School of Medicine

Michelle Y. Farmer, M.D. Baltimore City Health Department

Sebastian Faro, M.D., Ph.D. Baylor College of Medicine

James L. Gale, M.D. University of Washington School of Public Health and Community

Medicine

David A. Grimes, M.D. University of Southern California School of Medicine

King K. Holmes, M.D., Ph.D. University of Washington School of Medicine

Polly A. Marchbanks, Ph.D. Centers for Disease Control

Zell A. McGee, M.D. University of Utah Medical Center

Sam A. Nixon, M.D. The University of Texas Health Science Center at Houston

Paul J. Wiesner, M.D. Dekalb County Board of Health

James N. Pasley, Ph.D. University of Arkansas for Medical Sciences

Dorothy S. Patton, Ph.D. University of Washington School of Medicine

Herbert B. Peterson, M.D. Centers for Disease Control

Peter A. Rice, M.D. Boston University School of Medicine

Robert T. Rolfs, Jr., M.D. Centers for Disease Control

Dennis Sayers Ohio Department of Health

Julius Schacter, Ph.D. University of California San Francisco (UCSF) School of Medicine

David Soper, M.D. Medical College of Virginia

Richard L. Sweet, M.D. UCSF School of Medicine

  1. Eugene Washington, M.D. UCSF School of Medicine

Judith N. Wasserheit, M.D., M.P.H. National Institutes of Health

Lars Westrom, M.D., M.P.H. University of Lund (Sweden)

Steven Witkin, Ph.D. Cornell University Medical Center

  1. INTRODUCTION

Each year approximately 1 million women in the United States experience an episode of symptomatic pelvic inflammatory disease (PID)

  • (1,2). Women with PID are at increased risk of chronic pelvic pain, ectopic pregnancy, and tubal infertility (3,4). After one episode of PID, a woman's risk of ectopic pregnancy increases sevenfold compared with the risk for women who have no history of PID. Approximately 12% of women are infertile after a single episode of PID, almost 25% after two episodes, and over 50% after three or more episodes (5). Other sequelae associated with PID include dyspareunia, pyosalpinx, tubo- ovarian abscess, and pelvic adhesions (6). Overall, such complications are estimated to occur among 15%-20% of women with PID, and they often require subsequent surgical intervention. These medical consequences of PID are associated with great emotional stress and can have a major effect on a woman's reproductive health.

Many women with PID have minimal symptoms, and some are believed to experience no symptoms ("silent PID"). Concern about asymptomatic PID stems from high rates of PID sequelae such as tubal infertility among women with serologic evidence of previous sexually transmitted infections but no history of overt illness. Whether such patients were truly asymptomatic or unrecognized only because of subtle or atypical clinical signs is uncertain. In either case, the best strategies for preventing PID are: a) prevention of lower-genital-tract infection with Chlamydia trachomatis and Neisseria gonorrhoeae among both men and women, b) when this fails, early detection of lower-tract infection followed by prompt and effective treatment.

Implementing these two strategies requires the establishment and maintenance of effective sexually transmitted disease (STD) control programs nationally and locally. Along with appropriate medical management of illness, essential elements of such programs include: a) educating individuals to adopt healthy behaviors, b) training clinicians to counsel patients about risky behavior, c) screening persons at risk of STD, and d) involving male partners in prevention and management plans.

II. MICROBIAL ETIOLOGY AND PATHOGENESIS

  1. Microbial Etiology

    Multiple organisms have been implicated as etiologic agents in

PID, and most cases of PID are associated with more than one organism (7-9). C. trachomatis, N. gonorrhoeae, and a wide variety of anaerobic and aerobic bacteria are recognized as playing an etiologic role for PID in the United States. Mycoplasmas have also been recovered from the genital tract, but their role in PID is less clear (10).

The proportion of women with PID who are infected with C. trachomatis or N. gonorrhoeae varies widely, probably because of variations among the populations studied, differences in the time intervals of the investigations, variations in the severity of infection, and differing methods of microbial investigation. In the United States, C. trachomatis has been recovered from the cervix of 5%-39% of women diagnosed as having PID and from the fallopian tubes among zero to 10% of patients with PID (4). Serologic evidence of C. trachomatis infection has been found among 20%-40% of women with a history of PID. N. gonorrhoeae has a particularly wide range of recovery rates among women with PID, with isolation rates from the cervix ranging from 27% to 80% and from the fallopian tubes ranging from 13% to 18% (4). However, sampling of microorganisms from the fallopian tube has been difficult.

In addition to C. trachomatis and N. gonorrhoeae, a wide variety of anaerobic and aerobic (facultative) bacteria have been isolated from the upper-genital tracts of 25%-50% of women with acute PID. The most common anaerobic bacteria found are Bacteroides, Peptostrep- tococcus, and Peptococcus species, whereas the most common facultative bacteria are Gardnerella vaginalis, Streptococcus species, Escherichia coil and Haemophilus influenzae. The syndrome bacterial vaginosis (BV) has also been suggested as an antecedent to lower-genital-tract infection that leads to polymicrobial acute PID (8); the organisms involved in BV are similar to the nongonococcal, nonchlamydial bacteria frequently isolated from the upper-genital-tract of women with acute PID.

B. Pathogenesis

PID is believed to result from direct canalicular spread of organisms from the endocervix to the endometrial and fallopian tube mucosa (9). Both N. gonorrhoeae and C. trachomatis commonly cause endocervicitis. Between 10% and 40% of women not treated for gonococcal or chlamydial cervicitis apparently develop clinical symptoms of acute PID (11,12). Even higher percentages of ascending infection are detected if endometrial biopsies are used to diagnose subclinical endometritis. Noncanalicular spread of cervical infections has also been observed, possibly extending via parametrial lymphatics (9).

At least four factors could contribute to the ascent of these bacteria and/or be associated with the pathogenesis of upper-genital- tract infection. First, uterine instrumentation (e.g., the insertion of an intrauterine device {IUD}) facilitates upward spread of vaginal and cervical bacteria. Second, the hormonal changes during menses, as well as menstruation itself, leads to cervical alterations that may result in loss of a mechanical barrier preventing ascent (13). Also, the bacteriostatic effect of cervical mucus is lowest at the onset of menses. Third, retrograde menstruation may favor ascent to the tubes and peritoneum. Finally, individual organisms may have potential virulence factors associated with the pathogenesis of acute chlamydial and gonococcal PID (9,14).

III. MAGNITUDE OF THE PROBLEM OF PID

  1. Epidemiology

    In the 1980s, millions of women in the United States were

afflicted with symptomatic PID. From 1979 through 1988, an annual mean of 276,100 women were hospitalized for PID, with approximately 182,000 of these hospitalizations attributed to acute PID and the remainder to chronic PID (1). During the same period, women with acute PID made an annual mean of approximately 1.2 million visits to private physicians' offices; approximately 420,000 of these representing a woman's initial visit for PID. However, comparable data on the number of women seen in public clinics, emergency rooms, and hospital outpatient departments in this 10-year period are not available.

Sexually active women in younger age groups have higher rates of hospitalization for acute PID but lower rates of hospitalization for chronic PID. Data regarding office visits for PID show the age distribution to be similar to that of hospitalizations for acute PID. Women of other than white race have higher average annual hospitaliza- tion rates than white women for both acute and chronic PID. Similarly, rates of office visits for PID are slightly higher for women of other than white race (1). For acute PID, hospitalization rates are higher for women who are single, separated, or divorced than for women who are married or widowed. For both acute and chronic PID, average annual hospitalization rates are highest in the South and lowest in the Northeast, with intermediate rates in the Midwest and West.

Overall, hospitalization rates for acute PID declined in the 1980s, although office-visit rates appear to have remained unchanged (1). Hospitalization rates decreased 36% from 1979 to 1988, from 3.5 to 2.2 hospitalizations per 1,000 women (Figure_1). Although hospitalization rates decreased for all age groups, a relatively smaller decrease among 15- to 19-year olds (10%) compared with a 40% decrease for the 20- to 24-year age group resulted in the younger age group's having the highest hospitalization rate in 1987-1988, even without adjusting for the proportion of sexually active women. Finally, hospitalization rates for women of both racial groups decreased similarly over the decade, and hospitalization rates declined in all four geographic regions.

B. Financial Impact

PID and its consequences represent a substantial economic burden. For 1990, the total cost of PID has been estimated to exceed $4.2 billion, with approximately $2.7 billion for direct expenditures for medical services (2). Annually, women make an estimated 2.5 million outpatient visits to both public and private providers for treatment for PID. More than 275,000 women are hospitalized annually for PID, with over 100,000 surgical procedures performed. In addition to these sizeable direct medical costs, indirect costs are estimated to have exceeded $1.5 billion in 1990 because of lost wages and the lost value of household management.

Overall, private insurance covers approximately 41% of PID direct costs, public sources (e.g., Medicaid) 30%, health maintenance organizations/preferred provider organizations (HMO/PPO) 18%, and self payment 11% (2). Among women ages 19 years and younger, however, public sources (36%), followed by private insurance (32%), covers most PID-associated direct costs.

Projections of PID costs show that by the year 2000, the total annual cost of PID will exceed $9 billion, assuming no change in PID incidence, and a constant rate of medical inflation (8.1%) (2) (Figure_2). If the incidence of PID increases by 1%/year over the 10-year period, total costs (direct and indirect) are projected to exceed $10 billion in the year 2000 (Figure_2). With a 1%/year decrease in the rate, total costs of $8.4 billion are projected. If a more substantial decrease (10%) in the rate of PID/year occurred, total costs could decline to approximately $3.2 billion.

IV. RISK ASSESSMENT

Identifying factors associated with increased risk of PID can help in both prevention and management of PID. Men and women without genital infections who are not engaged in high-risk sex practices can be encouraged to maintain healthy behaviors; those without infection who do acknowledge high-risk behaviors can be targeted for more intensive education and counseling. For women suspected of having PID, information about risk indicators should help clinicians in diagnosing PID when more definitive diagnostic capability, such as laparoscopy, is not readily available. However, diagnosis should not be based solely on knowledge about a suspected risk factor. Many women perceived to be at increased risk because of the presence of a risk indicator will not have PID, and many women who do not fit a typical risk profile will have PID.

  1. Demographic and Social Indicators of Risk

    Age, socioeconomic status, marital status, and rural/urban

residence have been correlated with risk of PID (15) (Table_1). Age is inversely related to PID rates and directly correlated with PID sequelae, (e.g., tubal damage and infertility) (4). Sexually experienced teenagers are three times more likely to be diagnosed as having PID than are 25- to 29-year-old women (16). Both biological and behavioral characteristics of adolescents may account for these differences (17).

Low levels of education, unemployment, and low income as measures of socioeconomic status have been associated with increased risk of PID (15). However, the extent of the relationship between lower- genital-tract infection and socioeconomic status is not known. Data on marital status indicate that women who never married and women who are divorced or separated are at increased risk of PID (15). Finally, urban residence is often suggested to be associated with increased risk of PID, but no studies have compared PID rates among urban and rural populations.

B. Individual Behavior and Practices

  1. Sexual behavior. Although STD-related PID results from having sex with someone with an STD, the precise role of sexual behavior in the development of PID remains unclear. Several dimensions of sexual behavior, however, have been associated with increased risk of PID. These include young age at first sexual intercourse, multiple sex partners (18), high frequency of sexual intercourse (19), and increased rate of acquiring new partners within the previous 30 days (20).

  2. Contraceptive practice. Contraceptive choice affects risk of PID as well as risk of STD and tubal infertility (Table_1). Because of complex interrelationships, precise etiologic associations are difficult to unravel.

    1. Barrier methods.

      When properly used, mechanical and chemical barriers decrease the risk of STD, PID, and tubal infertility. Current barrier methods and devices include condoms, diaphragms, and vaginal spermicides.

      Condoms, when used consistently and correctly throughout sexual activity, compared with nonuse and incorrect use, appear highly effective for reducing risk of acquisition and transmission of the STD that causes PID (27,22), leading to decreased risk of hospitalization for PID (23), tubal pregnancy (24), and tubal infertility (25). Latex condoms offer greater protection against agents that cause STD -- particularly viruses -- than natural-membrane condoms (26).

      Vaginal spermicides also appear to decrease a woman's risk of acquiring bacterial STD, particularly cervical infection with C. trachomatis and N. gonorrhoeae (27,28). Use of a diaphragm appears to decrease a woman's risk for PID (23) and tubal infertility (25), although its precise mechanical protective effect against PID has not been determined because most women use a spermicide with a diaphragm. Finally, the combination of spermicide and diaphragm, as well as other combinations of barrier methods, may further decrease risk of STD and PID (29).

    2. Oral contraceptives.

      Current data on use of oral contraception (OC) and risk of lower- and upper-genital-tract infection and sequelae are inconsistent. Women who use OC have an increased risk of C. trachomatis infection of the cervix (30), but lower risk of symptomatic, clinically overt PID (37,32). No substantial increase or decrease in risk of tubal infertility occurs among women using OC (25). Because of the questions raised by these findings, the risk of PID and its sequelae attributable to C. trachomatis among women using OC is undetermined. OC may reduce the risk of PID that is not attributable to C. trachomatis.

    3. Intrauterine devices.

      Women who use intrauterine devices (IUDs) are probably at increased risk of PID that may not be STD-related. Most of this increased risk occurs in the first months after insertion of an IUD. Lower risks of PID have been reported with the current generation of IUDs than with types used in earlier years.

  3. Health-care-seeking behavior. Health-care-seeking behavior of both men and women influences the risk of lower- and upper-genital-tract infection. Prompt evaluation, compliance with management instructions, and referral of sex partners are likely to decrease the risk of PID (33).

  4. Other risk variables. Vaginal douching, menses, cigarette smoking, and substance abuse have also been suggested as variables influencing the risk of PID. Data from several reports suggest that women with acute PID are more likely to have a history of douching than women without PID (20,34). Current data, however, do not provide sufficient information to determine whether positive associations are attributable to characteristics of the women who douche, or to douching itself. Consequently, no conclusion can be reached regarding the precise relationship between douching and PID.

    Women with chlamydial and/or gonococcal salpingitis have experienced onset of symptoms substantially more often within 7 days of onset of menses than at other times in the menstrual cycle (13). For nonchlamydial, nongonococcal salpingitis, the reverse relationship has been found. In two studies examining the effect of cigarette smoking on relative risk of having PID, women who were current smokers had a twofold increased relative risk of PID (18,35). A dose-response relationship was observed in one study (35) but not in the other (18). Finally, alcohol and illicit drug use, particularly that involving cocaine, have been associated with gonorrhea and PID (20,36).

Provider Behavior and Practices

Clinicians can help reduce the risk for PID and its sequelae. Timely diagnosis and appropriate treatment of lower-genital-tract chlamydial and gonococcal infection among both men and women can reduce the risk of adverse consequences among infected individuals and can reduce the risk of further transmission to others. Also, practitioners can influence men's and women's risk of infection by providing effective counseling about their sexual behavior, health- care-seeking behavior, and contraceptive practice, and by convincing them to comply with management instructions. Finally, by ensuring timely and effective treatment of patients' sex partners, practitioners can reduce risk of reinfection. Moreover, because the partners' infections may be asymptomatic, interviewing and treating these persons will help reduce further transmission of infection in the community and may facilitate identifying other infected persons.

V. PREVENTION

Preventing PID and its sequelae can take place on three levels -- primary, secondary, and tertiary prevention (37). Primary prevention involves avoiding acquisition of sexually transmitted infections. Secondary prevention involves preventing a lower-genital-tract infection from ascending to the upper-genital-tract. Tertiary prevention involves preventing upper-genital-tract infection from leading to tubal dysfunction/obstruction and functional or structural damage to other abdominal/pelvic organs. At each of these levels of prevention, communities, individuals, and health-care providers can play a role (Table_2 and Table_3).

  1. Recommended Strategies for Communities

    Community support is essential if STD-prevention activities are to

succeed. Community-based approaches to STD/PID prevention should be aimed at providing a) information, b) motivation, and c) skills to consumers and providers. In addition, communities have a respon- sibility to provide supportive services for prevention programs.

A vital element of any community strategy for prevention of PID is a community STD-control program to prevent lower-genital-tract chlamydial and gonococcal infection. Such programs are important in reducing both symptomatic and asymptomatic PID. The components of an STD-control program have been described in a variety of recent publications (38). Several of these components (counseling, disease detection, and treatment) are covered in the patient-management sections of this document. Other community activities specific to preventing PID are discussed below.

  1. Community health promotion and education. Broadly defined, the term health promotion encompasses five strategic areas: a) advocacy for public policy that recommends safer sex practices, b) providing environments conducive to safer sexual behaviors, c) strengthening community action, d) promoting healthy personal skills (by providing information, education, and counseling), and e) orienting health services toward meeting all health needs. Health promotion thus involves health education directed to society as a whole and to the individual. Homes, schools, religious settings, and media are essential aspects of community health education.

    1. Health promotion messages to prevent STD/PID should be ingrained early in life. School education strategies that increase students' knowledge of the full spectrum of STD (including PID) have been upgraded. Prototype human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) and STD curriculum materials for both students and teachers in grades 6 through 12 have been widely disseminated. These curricula use self- instruction formats and emphasize behavioral skill building (39). Further, availability of school-based clinics can reinforce safer behaviors by providing individual counseling and on-site services to anyone with symptoms.

    2. Mass media need to be used more frequently and effectively by health professionals for health promotion and prevention of STD, including PID. Awareness of HIV/AIDS is widespread largely because of the attention given these problems by the media. Teenagers are a special audience for the broadcast media; they spend an average of 23 hours a week listening to the radio or watching television (40,41). Public-service announcements, which increasingly are used to encourage condom use in high-risk settings and to publicize hotline numbers for further questions, need to be aired more widely. These messages should build on the tools of the modern mass-media campaign

      • including relevance to target audiences and the use of sports and entertainment personalities respected by target audiences.

    3. Collaboration between relevant organizations should be developed, and joint ventures between public and private entities should be encouraged at the community level. Community-based organizations are qualified to assist in prevention activities, because many of them represent or provide services to at-risk groups who are more difficult to reach through traditional STD/PID prevention channels. Relevant organizations may operate through a variety of settings, including schools, workplaces, health-care systems, religious settings, and clubs.

  2. Appropriate clinical services. High-quality clinical care that is available and accessible to persons with STD should be developed and maintained. The final common pathway for preventing both lower- and upper-genital-tract infections is the provision of effective clinical STD services, including laboratory support (42). Communities have the ultimate responsibility for ensuring access to medical care.

    In the United States, public STD clinics have encountered a dual problem -- an increasing demand for clinical attention to the wider STD spectrum (e.g., counseling and testing for HIV, Pap-smear screening, and drug and family- planning counseling) and decreasing resources (e.g., experienced personnel, adequate space, new funds for expanded screening) with which to address the demand. Other clinical settings, (e.g., family-planning clinics and emergency rooms in public hospitals) are also facing this dilemma. Therefore, fewer patients with STD are being evaluated and treated promptly. For example, among STD clinics in areas with the highest syphilis rates, during 1989 nearly 75% reported longer patient-waiting times and a greater number of STD patients turned away than in 1988 (CDC, unpublished data).

  3. Partner notification. Partner notification implies a public health process that informs persons directly exposed to an STD of their status so they may be evaluated and treated. Sex partners of patients with chlamydial and gonorrheal infection need to be identified for appropriate treatment. Male partners of women with PID have infection rates ranging up to 53% for chlamydial infections and 41% for gonorrhea (43; CDC, unpublished data) although the role of partner notification in directly preventing PID remains unclear. Partners can be notified in one of two ways -- patient referral or provider referral.

    1. Patient referral actively involves the patient in the disease-control effort, is relatively inexpensive, is acceptable to many patients, and reserves limited staff time for targeted provider referral. Potential shortcomings of patient-referral methods, however, include limited effectiveness with noncompliant patients and difficulty in evaluating outcomes associated with these methods.

    2. Provider referral (i.e., contact tracing by the public health staff) is labor intensive, time consuming, and expensive; therefore, provider referral frequently concentrates on high-yield cases or on persons from high-risk "core" environments (44). Despite the initial costs, provider referral can be cost beneficial because of its greater yield of infected persons, and because these persons may be high- frequency transmitters of STD (45).

  4. Training of health-care providers. Training in controlling STD problems is essential if the medical community is to support control programs. However, in the United States, medical schools have been slow to respond to the increasing magnitude of the STD problem. In 1985, only one in five medical schools provided even one-half its students with STD clinical training (CDC, unpublished data).

    Physicians interested in STD will need to complement their traditional diagnostic and therapeutic skills with training in behavioral science. Skills such as those required to obtain an appropriate and complete sex history, including details about sex practices and partners, must be taught. To facilitate these efforts, STD prevention and training centers have been established throughout the United States as collaborative efforts among selected local health departments, selected local academic institutions, and CDC (46).

  5. Detecting asymptomatic STD. Routine screening for chlamydial and gonococcal infection is indicated for selected groups and settings (47-49). Early detection of lower-genital-tract infection is crucial in preventing PID. Many infected women have no recognized symptoms (and often neither do their sex partners). To make the most effective use of resources, targeted screening for chlamydial infection and gonorrhea is recommended in a) adolescent-health and family-planning clinics serving high percentages of young persons, b) high-prevalence groups such as commercial sex workers and illicit drug users, and c) facilities in which high levels of STD might be expected (e.g., jails, emergency rooms).

Recommended Strategies for Individuals

Because of the importance of personal health behaviors, individuals must assume an active role in self-protection (Table_2). Most of these recommendations are based only on expert opinions since few prevention strategies for individuals have been appropriately evaluated.

  1. Maintain healthy sexual behavior. Specific sexual behaviors that decrease the risk of having sex with an infected person can be adopted. These include postponing sexual debut and limiting the number of sex partners (37,50,51). Knowledge of the infection status of one's sex partner is also important. Inquiring about sex and substance-using history should be a routine part of the dating ritual. Avoiding sex with persons from known high- risk groups or persons about whom little is known will lower the risk of exposure to STD. Sex with persons who exhibit signs and symptoms suggestive of STD should especially be avoided, even though they may be "steady" partners.

  2. Use barrier methods. Mechanical and chemical barriers are important tools for personal prophylaxis for STD/PID. These include condoms, diaphragms, and vaginal spermicides. Because proper use of such barriers protects against acquisition and transmission of some STD, their use should be encouraged for STD prevention among individuals at risk, even if contraception is not needed.

  3. Adopt appropriate health-care-seeking behavior. Prevention of PID includes early detection and effective treatment of C. trachomatis and N. gonorrhoeae infection among men and women. Thus, a patient's health-care-seeking behavior influences the natural history of infection. A prompt response to symptoms of chlamydial or gonococcal infection can probably reduce the risk of PID (11) and community levels of infection. Likewise, compliance with such recommendations as taking medications as directed, returning for follow-up evaluation, and abstaining from sex during treatment will influence the course of current infections as well as subsequent ones.

  4. Influence sex partners to be evaluated. Patients can facilitate proper medical evaluation and treatment of their sex partners. Appropriate treatment of sex partners will prevent reinfection, prevent complications affecting that partner, and reduce further spread of disease in communities.

Recommended Strategies for Health-Care Providers

Providers should play a leading role in preventing PID and its sequelae (Table_3). Therefore, clinicians must assume a greater responsibility for such primary prevention activities as counseling, patient education, and community awareness, in addition to their traditional role of diagnosing illness and treating patients (49). Providing effective preventive care to patients at risk for STD involves the following five recommendations.

  1. Maintain up-to-date knowledge. about the prevention and control of STD/PID. Achieving this critical objective will require establishing an accurate and complete clinical base of information about STD and then keeping informed of changes in a timely fashion. Providers can successfully meet the challenge of preventing PID through effective patient education/counseling, timely diagnosis, and appropriate treatment if they have current, relevant knowledge and information.

  2. Provide appropriate preventive services. This respon- sibility entails screening for chlamydial and gonococcal infection and providing treatment as recommended (47-49) for persons with STD/PID. Targeted screening for chlamydial infection and gonorrhea is recommended for high-prevalence groups and for use in facilities in which high levels of STD might be expected. For any patients with symptoms or signs consistent with a cervical infection, clinicians should consider treatment even before culture results are received. Because populations with high rates of STD and PID are also at risk for HIV infection, HIV counseling and testing services should be offered.

    Selective prophylactic (preventive or epidemiologic) treatment also has a major role in STD prevention strategies. On the basis of epidemiologic indications, antibiotics can be administered to high-risk patients when chlamydial infection or gonorrhea is considered likely. This approach interrupts the chain of transmission in the community and reduces the likelihood of ascending genital infection that might occur between the time of testing and treatment. It also ensures treatment for infected individuals who have false-negative laboratory results, and guarantees treatment for those who might not return when notified of positive results. For example, tetra- cycline is given concurrently with penicillin to patients with confirmed gonococcal infection, since a relatively high proportion are also likely to be coinfected with C. trachomatis (12,52).

  3. Provide appropriate medical management for illness. Early and adequate treatment of patients and their sex partners lowers the risk of adverse consequences among patients and prevents further spread of bacterial STD. Comprehensive guidelines for treating PID and other STD are available and should be consistently applied (47,48).

  4. Provide risk-reduction counseling. Risk-reduction counseling to prevent acquisition or transmission of STD should be a standard part of STD clinical care, whether provided in public STD clinics, other public health facilities, or private physicians' offices. Patients with an STD who are seen in any clinical setting are, by definition, a high-risk group; because of their own or their partners' behavior, they are most in need of counseling.

    Risk-reduction counseling seeks to change unsafe sex behaviors (Table_1). Patients need to understand the importance of knowing the risk behaviors of their partners and to avoid those partners at high risk. They need to know which practices reduce the potential risk of infection (e.g,, mutual masturbation) and which practices carry the highest risk of infection (e.g., receptive anal/vaginal intercourse). They should be introduced to the social skills essential to negotiating such behaviors as condom use with their partners (53). Counselors should be nonjudgmental in discussing potential life-style changes. Unrealistic recommendations will either be ignored or will lead to only short-term changes. Counseling messages should be comprehensible, acceptable, and accessible to patients.

  5. Ensure evaluation of sex partners. Sex partners of patients with chlamydial and gonococcal infection should be evaluated promptly and treated appropriately. Patients have not been adequately treated for these infections until their partners are similarly treated.

    Treating sex partners is crucial in preventing reinfection; for many women who become reinfected, reinfections can be traced to the persons who were the sources of the original infection (33,45). Moreover, because a woman's infection may be asymptomatic, identifying female sex partners of men with chlamydial or gonococcal infection may prevent development of PID as well as further transmission of infection.

Recommended Strategies for Adolescents

Adolescents are highly vulnerable to acquiring STD and their complications because of biological and behavioral factors. Therefore, within the context of broader community and health-provider prevention efforts, special attention should be given to adolescents. Such a focus should include the activities described below.

  1. Education and counseling tailored for adolescents. All adolescents should be educated about their risks of acquiring an STD and its relation to PID. Adolescents often fail to recognize the dangers of high-risk sex behaviors and do not seek medical advice about such behavior. Age-appropriate and developmentally appropriate counseling strategies are needed.

    To provide adolescents with directed educational messages, careful risk assessment is also needed. A history of STD or PID is a valuable risk marker identifying young women at risk of having PID. In addition, clinicians should specifically inquire about the circumstances under which new sex partners were acquired.

  2. STD evaluation and treatment. Any health-care program that serves adolescents should either provide STD evaluation and treatment or should be able to refer teenagers rapidly to a facility that offers such care. Routine screening for chlamydial infection and gonorrhea should be encouraged for all sexually active female teenagers who have pelvic examinations. Sexually active males should also be encouraged to be tested for STD. School-based clinics can provide effective, convenient STD clinical services for sexually active adolescents.

  3. Encouraging use of barrier contraceptives. Clinicians should inquire about an adolescent's willingness to use condoms or other barrier contraceptives. Use of barrier contraceptives by sexually active teenagers is frequently inconsistent. Selective condom use with sex partners who teenagers perceive to be high risk (e.g., new or anonymous partners) may not be adequate to prevent transmission of STD. Regular, consistent use of condoms should be strongly encouraged for all sexually active teenagers.

    Early and effective intervention for adolescents will reduce their likelihood of acquiring STD and, consequently, should diminish PID and other complications of STD.

DIAGNOSIS

Clinical diagnosis of PID is difficult because of the wide variation in symptoms and signs among women with this condition. Many women with PID may exhibit subtle, vague, or mild symptoms that are not readily recognized as PID. This situation interferes with timely diagnosis, inhibits effective treatment, and contributes to inflam- matory sequelae in the upper-reproductive tract. Laparoscopy can be used to obtain a more accurate diagnosis of salpingitis and a more complete bacteriologic diagnosis. However, this diagnostic tool is often neither readily available for acute cases nor easily justified when symptoms and signs are mild and/or vague. Moreover, laparoscopy will not detect endometritis and may not detect subtle inflammation of fallopian tubes. Consequently, the diagnosis of PID is often based on clinical findings supplemented with results of cultures or non-culture tests of samples obtained from the endocervix.

The clinical diagnosis of PID is imprecise. In published studies, when compared with laparoscopy as the standard, a clinical diagnosis of symptomatic PID has a predictive value positive of approximately two-thirds. No single historical, physical, or laboratory finding is both sensitive and specific for the diagnosis of PID (i.e., can be used both to detect all cases of PID and to exclude all women without PID) (54). Combinations of diagnostic findings, which improve either sensitivity (detect more women who have PID) or specificity (exclude more women who do not have PID), have done so only at the expense of the other (i.e., requiring two or more findings will exclude more women without PID, but will also reduce the number of patients with PID who are detected).

Current evidence indicates that many episodes of PID are unrecog- nized. Although some women may have truly asymptomatic ("silent") PID, others go undiagnosed because they or their health-care providers fail to recognize the implications of mild or nonspecific symptoms and/or signs. Because of the potential for damage to the reproductive health of women by even these apparently mild cases of PID, a "low threshold for diagnosis" of PID is recommended. The following recommendations for diagnosing PID are intended to help clinicians both recognize when PID should be suspected and gain additional information to increase their diagnostic certainty.

Treatment for PID should be instituted on the basis of these minimum clinical criteria for pelvic inflammation in the absence of competing diagnoses (e.g., positive pregnancy test, acute appendicitis).

Minimum Criteria for Clinical Diagnosis of PID

  • Lower abdominal tenderness

  • Bilateral adnexal tenderness

  • Cervical motion tenderness

Among women with severe clinical signs, more elaborate diagnostic evaluation is warranted because incorrect diagnosis and management may cause unnecessary morbidity. Thus, additional criteria should be used to increase the specificity of diagnosis. Routine criteria are those that are simple to assess; elaborate criteria are more definitive but are more expensive and often invasive.

Additional Criteria Useful in Diagnosing PID

Routine Elaborate

  • Oral temperature >38.3 C -- Histopathologic evidence

  • Abnormal cervical or vaginal on endometrial biopsy discharge -- Tubo-ovarian abscess on

  • Elevated erythrocyte sonography sedimentation rate and/or -- Laparoscopy C-reactive protein

  • Culture or non-culture evidence of cervical infection with N. gonorrhoeae or C. trachomatis

    Although not necessary to justify initial treatment decisions,

bacteriologic diagnosis is helpful. It provides diagnostic confir- mation (thereby improving management and reinforcing the need to treat sex partners) and serves as baseline for test-of-cure cultures.

Tests Recommended for All Suspected Cases of PID

  • Cervical cultures for N. gonorrhoeae

  • Cervical culture or non-culture test for C. trachomatis

OTHER IMPORTANT DIAGNOSTIC CONSIDERATIONS

The diagnostic approach outlined above reflects a growing concern that PID is often not diagnosed, especially among women with mild or atypical clinical signs. Although correcting this situation is a high public health priority, three qualifications regarding this more sensitive diagnostic approach must be noted.

First, the use of highly sensitive PID diagnostic criteria means that many women who do not have PID will be misdiagnosed and treated for PID (low specificity). Patients and their sex partners often have strong emotional reactions when faced with the implications of a diagnosis of STD. The health-care provider must, therefore, inform a patient of a diagnosis of PID carefully. Both the uncertainty of the diagnosis and the value of empiric treatment must be explained clearly.

Second, careful follow-up is necessary. If no clinical improvement has occurred at 48-72 hours, alternate diagnoses (e.g., appendicitis, endometriosis, ruptured ovarian cyst, or adnexal torsion) should be reconsidered. Use of alternate or additional antimicrobial therapy should also be considered.

Third, use of even these minimum clinical criteria may exclude some women with PID. Clinicians should not withhold therapy from a woman in whom they suspect PID because of failure to meet these criteria.

VII. TREATMENT

  1. Patient Education

    The clinician's role as a health educator is central to effective

management. Practitioners should explain to women the nature of their disease and should encourage them to comply with therapy and prevention recommendations. Specifically, practitioners should:

  • Emphasize the need for taking all the medication, regardless of symptoms.

  • Review contraindications and potential side effects.

  • Identify and discuss potential compliance problems.

  • Review the medical purpose of follow-up evaluation.

  • Emphasize the need to avoid sex until treatment is completed.

  • Emphasize the need to refer sex partners for evaluation and treatment (55). When medical-care messages are clear, explicit, relevant, and

rigorously delivered by providers, patients are likely to comply (56). Reinforcement of these messages can be achieved by providing written information. Information on written materials for patient distribution can be obtained from CDC or local and state health departments. **

B. Management of Sex Partners

Treatment for sex partners of women with PID is imperative. The management of women with PID should be considered inadequate unless their sex partners have been appropriately evaluated and treated. Failure to manage her sex partner(s) effectively places a woman at risk for recurring infection and related complications. Moreover, untreated sex partners often unknowingly transmit STD in a community because of asymptomatic infection.

In clinical settings in which only women are seen, special arrangements should be made to provide care for male sex partners of women with PID. When this is not feasible, clinicians should ensure that sex partners are referred for appropriate evaluation and treatment. After evaluation, sex partners should be empirically treated with regimens effective against C. trachomatis and N. gonorrhoeae infections (48).

C. Hospitalization

The efficacy of outpatient management for preventing late sequelae remains uncertain. A single intramuscular (IM) injection of cefoxitin or ceftriaxone, even in conjunction with oral doxycycline for 10-14 days, will provide less complete antimicrobial coverage for a shorter duration than regimens recommended for inpatients. Theoretically, outpatient management could, therefore, reduce the likelihood of successful eradication of upper-genital-tract pathogens and potentially increase the likelihood of late sequelae. Currently, no data are available to adequately assess the risks, benefits, and costs of inpatient versus outpatient treatment for PID.

As for all serious intra-abdominal infections, hospitalization should be considered whenever possible, and is particularly recommended in the following situations:

  • The diagnosis is uncertain.

  • Surgical emergencies such as appendicitis and ectopic pregnancy cannot be excluded.

  • A pelvic abscess is suspected.

  • The patient is pregnant.

  • The patient is an adolescent (adolescent patients' compliance with therapy is unpredictable, and the long-term sequelae of PID may be particularly severe for members of this group).

  • Severe illness precludes outpatient management.

  • The patient is unable to tolerate an outpatient regimen.

  • The patient has failed to respond to outpatient therapy.

  • Clinical follow-up within 72 hours of starting antibiotic treatment cannot be arranged. Many experts recommend that all patients with PID be hospitalized

so that treatment with parenteral antibiotics can be initiated.

D. Treatment Regimens

Although several antimicrobial regimens have been proven highly effective in achieving clinical cure, no single therapeutic regimen of choice exists for persons with PID (57), unlike treatment for many specific sexually transmitted organisms (48). PID is a complex syndrome that encompasses a broad spectrum of inflammatory diseases (e.g., endometritis, salpingitis, and tubo-ovarian abscess) that may be caused by a variety of organisms.

Guidelines for the treatment of patients with PID, therefore, have been designed to provide flexibility in therapeutic choices. PID therapy regimens are designed to provide broad-spectrum coverage of likely etiologic pathogens. In addition to considering microbial etiology, selection criteria for a treatment regimen should also include institutional availability, cost-control efforts, patient acceptance, and regional differences in antimicrobial susceptibility.

The treatment regimens that follow are recommendations, and the specific antibiotics named are examples. Treatments used for persons with PID will continue to be broad spectrum until more definitive studies are performed. Any regimen used, however, should cover C. trachomatis, N. gonorrhoeae, anaerobes, gram-negative rods, and streptococci.

  1. Inpatient treatment One of the following:

    Recommended Regimen A

    Cefoxitin 2 g intravenously (IV) every 6 hours or cefotetan *** IV 2 g every 12 hours

    plus Doxycycline 100 mg orally or IV every 12 hours.

    The above regimen is given for at least 48 hours after the patient clinically improves. After discharge from hospital, doxycycline 100 mg orally 2 times a day should be continued for a total of 10-14 days.

    Recommended Regimen B

    Clindamycin IV 900 mg every 8 hours

    plus Gentamicin loading dose IV or IM (2 mg/kg of body weight) followed by a maintenance dose (1.5 mg/kg) every 8 hours.

    The above regimen is given for at least 48 hours after the patient improves. After discharge from hospital, doxycycline 100 mg orally 2 times a day should be continued for 10-14 days total. Continuation of clindamycin 450 mg orally 4 times a day for 10-14 days may be considered as an alternative.

    Continuation of medication after hospital discharge is important, particularly for the treatment of persons who may have C. trachomatis infection. Clindamycin has more complete anaerobic coverage than doxycycline. Although preliminary data suggest that clindamycin is effective against C. trachomatis infection, doxycycline remains the treatment of choice for patients with chlamydial disease. Thus, when C. trachomatis is strongly suspected as an etiologic agent, doxycycline is the preferred alternative. In such instances, doxycycline therapy may be started while the patient is hospitalized if initiating therapy before hospital discharge is likely to improve the patient's compliance.

Rationale

Clinicians have extensive experience with both the cefoxitin/ doxycycline and clindamycin/aminoglycoside combinations. Each of these regimens provides broad coverage against polymicrobial infection and has been shown in numerous studies to be highly effective in achieving clinical cures. However, data are lacking on the efficacy of these regimens, as well as other regimens, in preventing late sequelae. Cefotetan has properties similar to those of cefoxitin and requires less frequent dosing. Clinical data are limited on other third- generation cephalosporins (ceftizoxime, cefotaxime, ceftriaxone), to replace cefoxitin or cefotetan, although many authorities believe they are effective. Doxycycline administered orally has bioavailability similar to that of the IV formulation and may be given if normal gastrointestinal function is present.

Experimental studies suggest that aminoglycosides may not be optimal treatment for patients who have gram-negative organisms within abscesses, but clinical studies suggest that they are highly effective in treating persons for abscesses when administered in combination with clindamycin. Short courses of aminoglycosides are given to healthy young women when serum-level monitoring is usually not required.

2. Outpatient Management

Recommended regimen

Cefoxitin 2 g IM plus probenecid, 1 g orally, concurrently or ceftriaxone 250 mg IM or equivalent cephalosporin

plus Doxycycline 100 mg orally 2 times a day for 10-14 days or

Tetracycline 500 mg orally 4 times a day for 10-14 days.

Alternative Regimen for Patients Who Do Not Tolerate Doxycycline/tetracycline ****

Substitute erythromycin 500 mg orally 4 times a day for 10-14 days. ****

Rationale

These empiric regimens provide broad-spectrum coverage against the common etiologic agents of PID. Notably, these regimens were particularly designed to treat persons with chlamydial and gonococcal infections; few data are available on the efficacy of these regimens for treating persons with PID, particularly nonchlamydial/nongonococcal PID. Parenteral B-lactam antibiotics are recommended in all cases. The cephalosporins are effective in treating persons with gram- negative organisms, including enteric rods, anaerobic organisms, and gonococci. Although decreased susceptibility of gonococci to cefoxitin has recently been noted, clinically evident treatment failure has not been a problem. Patients who do not respond to therapy within 72 hours should be hospitalized for parenteral therapy. Doxycycline provides definitive therapy for chlamydial infections. Patients treated on an outpatient basis need to be monitored closely and reevaluated in 72 hours.

E. Management of HIV-Infected Women Although the precise etiologic relation between HIV infection and the risk of PID is uncharacterized -- since HIV infection is sexually transmitted and PID is often caused by sexually transmitted pathogens -- these two conditions often coexist (58.59). The management of coexistent HIV infection and PID is becoming an increasingly important concern. Differences in the clinical manifestations of PID among HIV-infected women have not been clearly described. However, PID among women immunocompromised for any reason may be more clinically severe and more refractory to medical management than PID among women with normal host defenses. It is reasonable to expect, therefore, that those HIV-infected women who are immunocompromised may be at increased risk for a complicated clinical course. In one study, HIV-infected women with PID were less likely than HIV-negative women with PID to have an elevated white-blood-cell count, but were more likely to have tubo-ovarian abscesses and to require operative intervention (60). HIV-infected women who develop PID should be followed closely with early hospitalization and IV therapy with a recommended antibiotic regimen, if possible.

VIII. SURVEILLANCE

Currently, data for surveillance of PID are derived primarily from surveys of reproductive-age women, hospital discharges, or visits to physicians. Although these surveys offer important national estimates of the number of PID diagnoses, information at the local level is necessary to determine the magnitude and nature of PID in a particular community, to plan prevention activities based on local needs, and to evaluate the success of control strategies.

At all levels, PID surveillance is affected by four main constraints:

  • PID is difficult to diagnose accurately.

  • PID has a broad clinical spectrum that includes acute, silent, and atypical PID, the PID residual syndrome (chronic PID), and postpartum/postabortal PID.

  • PID is diagnosed in a wide variety of clinical settings.

  • Microbiology test results are needed to determine the etiology of PID. Because of these problems and the likelihood that they will not be

quickly resolved, universal communicable disease reporting is unlikely to be a suitable model for PID surveillance.

The objectives of PID surveillance at the national, state, and local levels are to provide quantitative estimates of disease occurrence, to determine secular trends, to target intervention resources, and to evaluate control efforts (61).

RECOMMENDATIONS

  • State and local health departments are encouraged to initiate PID surveillance in selected local areas. Whenever possible, PID surveillance should be conducted using community sentinel surveillance sites. In such a system, a group of health-care providers (e.g., hospitals, emergency rooms, public clinics, private physician offices, and student health centers) that are representative of health-care in the community are recruited to serve as sentinels of disease occurrence.

Disease reporting can be ongoing or systematically episodic (e.g., reporting could occur for 6 weeks of every year). Ideally, to determine the disease burden of PID in a community, sentinel practitioners and sites should be selected in a way that permits the total number of PID cases in the community to be estimated. However, this type of estimation requires a detailed sampling scheme that is difficult to apply in most community settings. An alternative to a community-based surveillance system would be to use as a sentinel site a health-maintenance organization or other health-care provider that serves a well-characterized population. In other settings, in which population-based estimates are not possible, sentinel sites may still be useful for monitoring trends.

  • National surveys should continue to be used for obtaining estimates of the number of PID diagnoses. These surveys include the National Disease and Therapeutic Index (a survey of office- based practitioners) and three surveys from CDC's National Center for Health Statistics: a) the National Hospital Discharge Survey, b) the National Survey of Family Growth, c) the National Ambulatory Medical Care Survey. The usefulness of these surveys for surveillance of PID could be improved by standardizing the case definition for PID, by reporting microbiology test results for detected cases, and by including cases of PID from a wide variety of clinical settings to make the sample more representative.

  • The surveillance case definition for PID should be simple. It must also be consistent over time and among different surveillance settings and systems. A surveillance case definition that is easy for health-care providers to use, such as the clinical definition recommended in these guidelines, might be appropriate for use in sentinel sites or for national surveys. If used in either setting, the sensitivity and specificity of such a definition should be periodically assessed.

  • PID surveillance systems should be structured so that PID diagnoses can be linked with microbiology test results (i.e., positive or negative results of testing for C. trachomatis, N. gonorrhoeae, and other potential etiologic agents) whenever possible.

  • Estimates of the number of PID cases and trends in PID should be compared with the estimated number of cases and trends of genital C. trachomatis and N. gonorrhoeae infection in the same population whenever possible.

  • PID surveillance systems should be evaluated periodically according to the surveillance principles described in the document Guidelines for Evaluating Surveillance Systems (61,62), which can be obtained from CDC. *****

    • Pelvic inflammatory disease refers to the clinical syndrome among women resulting from infection involving the uterus, fallopian tubes, ovaries, peritoneal surfaces and/or contiguous structures. Most PID results from ascending spread of microorganisms from the vagina and endocervix to these upper-genital sites. Because PID encompasses a wide variety of pathologic processes and many etiologic agents, it has a broad clinical spectrum that includes a) acute PID, b) silent PID, c) atypical PID, d) the PID residual syndrome or chronic PID, and e) postpartum/postabortal PID. Individual cases of PID can also be more specifically defined by a)the site(s) of disease (i.e., endomyometritis, salpingitis, salpingo-oophoritis); and b) the etiologic agent(s) involved (e.g., those that cause chlamydial endometritis, gonococcal salpingitis, nonchlamydial/nongonococcal salpingo-oophoritis).

    ** Information Services, Center for Prevention Services, Centers

for Disease Control, E06, Atlanta, Georgia 30333. Telephone (404) 639-1819.

*** Other cephalosporins such as ceftizoxime, cefotaxime, and

ceftriaxone, which provide adequate gonococcal, other gram- negative aerobic, and anaerobic coverage, may be utilized in appropriate doses.

**** No data available on this regimen.

***** Information Services, Center for Prevention Services, Centers

for Disease Control (E06), Atlanta, Georgia 30333. Telephone (404) 639-1819.

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TABLE 1. Health outcomes affected (15)
===================================================================================
                                                 Progression of disease
                                       ------------------------------------------
                                       Acquisition   Development   Development of
Risk Variable                            of STD         of PID      PID sequelae
---------------------------------------------------------------------------------
Demographic and social indicators

  Age                                      +              +              -
  Socioeconomic status                     +              +              .
  Marital status                           +              +              .
  Residence, rural or urban                +              .              .

Individual behavior and practices

  Sexual behavior
    Number of partners                     +              .              .
    Age at first sexual intercourse        +              .              .
    Frequency of sexual intercourse        +              .              .
    Rate of acquiring new partners         +              .              .

  Contraceptive practice
    Barrier                                -              -              -
    Hormonal                               +              -              .
    Intrauterine device                    .              +              +

  Health-care behavior
    Evaluation of symptoms                 +              +              +
    Compliance with treatment
      instructions                         +              +              +
    Partner notification                   +              +              +

  Others
    Douching                               .              +              .
    Smoking                                +              +              .
    Substance abuse                        +              .              .
    Menstrual cycle                        +              +              .
---------------------------------------------------------------------------------
Key: (+) increased risk; (-) decreased risk; (.) no association reported.
===================================================================================

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Table_2
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TABLE 2. Recommendations for individuals to prevent STD/PID (37)
=================================================================================================
                                                                                Quality of
General                                                                     evidence supporting
preventive                                                                   effectiveness of
measures             Specific Recommendations                                 intervention *
-----------------------------------------------------------------------------------------------
Maintain healthy     Postpone intitiation of sexual intercourse until              III
  sexual behavior    at least 2-3 years following menarche

                     Limit number of sex partners                                   II

                     Avoid "casual" sex and sex with high-risk partners            III

                     Question potential sex partners about STD and                 III
                     inspect their genitals for lesions or discharge

                     Avoid sex with infected persons                               III

                     Abstain from sex if STD symptoms appear                       III

Use barrier          Use condoms, diaphragms, and/or vaginal                        II
  methods            spermicides for protection against STD,
                     even if contraception is not needed.

                     Use condoms consistently and correctly                         II
                     throughout all sex

Adopt healthy        Seek medical evaluation promptly after having                 III
  medical-care-      unprotected sex (intercourse without a condom)
  seeking behavior   with someone who is suspected of having an STD

                     Seek medical care immediately when                            III
                     genital lesions or discharge appear

                     Seek routine check-ups for STD if in non-mutually             III
                     monogamous relationship(s), even if symptoms
                     are not present

Comply with          Take all medications as directed, regardless                   I
  management         of symptoms
  instructions
                     Return for follow-up evaluation as instructed                 III

                     Abstain from sex until symptoms disappear                     III
                     and appropriate treatment is completed

Ensure examination   When diagnosed as having an STD, notify                       III
  of sex partners    all sex partners in need of medical assessment.

                     If preferred, assist health providers in identifying          III
                     sex partners
-----------------------------------------------------------------------------------------------
Key:  I: Evidence obtained from at least one properly randomized controlled trial; II: Evidence
obtained from well-designed cohort or case-control analytic studies; III: Opinions of respected
authorities based on clinical experience, descriptive studies, or reports of expert committees.
* Source: U.S. Preventive Services Task Force.
=================================================================================================

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Table_3
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TABLE 3. Recommendations for health providers to prevent STD/PID (37)
============================================================================================
General preventive measures          Specific recommendations
------------------------------------------------------------------------------------------
Maintain up-to-date knowledge        Develop an accurate base of information on the
  about the prevention and           diagnosis, treatment, and prevention of STD/PID
  management of STD/PID
                                     Complete continuing education courses periodically
                                     to update knowledge on STD/PID prevention and
                                     management

Provide effective patient            Educate patients about STD/PID and their
  education and counseling           potential complications

                                     Encourage individuals to maintain healthy sexual
                                     behavior, use barrier methods, and adopt healthy
                                     medical-care-seeking behavior

Provide appropriate preventive       Screen patients for chlamydial and gonococcal
  medicine services                  infection routinely when indicated

                                     Provide epidemiologic treatment for STD/PID
                                     when appropriate

Provide appropriate medical          Diagnose STD/PID promptly
  management for illness
                                     Treat STD/PID promptly and with effective antibiotics

                                     Encourage patients to comply with management
                                     instructions

Ensure examination                   Encourage infected patients to refer all sex
  of sex partners                    partners in need of medical assessment

                                     Evaluate and treat sex partners appropriately

Report all STD to appropriate
  health authorities
------------------------------------------------------------------------------------------
============================================================================================

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