Diagnosis of pelvic inflammatory disease predicts high risk and high rate of further infection in teenagers

Nov 3 2008

A study among Baltimore inner-city teenage girls treated for pelvic inflammatory disease shows they are highly vulnerable to subsequent sexually transmitted infections (STI) - sometimes within a few weeks or months of their treatment.

Results of the research by Johns Hopkins Children's Center investigators, reported in the November issue of Archives of Pediatric and Adolescent Medicine, suggest that treating pelvic inflammatory disease (PID) "with a prescription and a brochure" is simply not enough to change behavior and prevent future infections, according to lead investigator Maria Trent, M.D., M.P.H., a pediatrician and adolescent medicine specialist at Hopkins Children's.

Repeat infections can increase a teenager's risk for chronic pelvic pain, ectopic pregnancies and infertility.

"Because our findings show that PID is not a single isolated incident, doctors should look for ways to change behaviors in these girls and not just treat the acute clinical episode," said Trent. "We are talking counseling, we are talking strict follow-up and, most importantly, we need to develop new strategies that actually work."

While cautioning that the study was limited to Baltimore City girls, the researchers say teenage girls across the country's urban areas likely face similar problems linked to inner-city life and practice behaviors that put them at high risk for repeat STIs.

In the four-year study of 110 girls ages 15 to 21 and diagnosed with PID, 80 girls returned for follow-up during the 48-month study period. Under the Hopkins protocol, those with confirmed diagnosis of PID are given a course of free medication and asked to return within 72 hours and advised to follow up again at three and again in six months with a primary-care provider.

Of the 80, 27(34 percent) were diagnosed with at least one subsequent sexually transmitted infection over a six-month period. Of the 27, eight (30 percent) had two or more STIs in the six-month period.

Getting girls to come back is challenging, researchers say. An earlier study by the Hopkins Children's group found that only 38 percent of girls diagnosed with PID could be reached, and of these only 43 percent returned for follow-up care.

The best - and narrow - window of opportunity to counsel girls, researchers say, may be at the time of diagnosis or when they return for the repeat screening in 72 hours. This counseling, moreover, must be more thorough, not just admonitions to practice safe sex or not to have sex at all.

"What we think we need is individually tailored counseling by a clinical provider that is done after an in-depth interview with each patient to determine what aspects of her behavior put her at risk and must change," Trent says.

Researchers are currently testing a pilot program that involves showing an educational video to teenage girls coming to the ED with PID. The Hopkins team also plans to test the value of house calls to patients by a nurse within 72 hours of diagnosis.

Funding for this research came from the Thomas Wilson Sanitarium Foundation for the Children of Baltimore City, the Robert Wood Johnson Foundation and the Centers for Disease Control and Prevention.

Other investigators in the study: Jonathan Ellen, M.D.; Shang-en Chung, M.Sc.; Lynette Forrest, all of Hopkins.