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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptNIH Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
JAMA Pediatr. Author manuscript; available in PMC Jul 3, 2013.
Published in final edited form as:
PMCID: PMC3700686
Are Emergency Departments Appropriately Treating Adolescent Pelvic Inflammatory Disease?
Monika Goyal, MD,1,2,3 Adam Hersh, MD, PhD,4 Xianqun Luan, MS,5 Russell Localio, MS, PhD,2,5 Maria Trent, MD, MPH,6 and Theoklis Zaoutis, MD, MSCE2,5
1Children’s National Medical Center, George Washington University
2Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania
3Leonard Davis Institute, University of Pennsylvania
4University of Utah
5Children’s Hospital of Philadelphia
6Johns Hopkins School of Medicine
Corresponding Author: Monika Goyal, MD, Children’s National Medical Center, 111 Michigan Avenue NW, Washington, DC 20010, (phone) 267-978-8171, (fax) 215-563-2899, monika.goyal217/at/
Of the almost 1 million annually diagnosed cases of pelvic inflammatory disease (PID), 20% occur among adolescents.1 Because reproductive health complaints are the most common reasons for emergency department (ED) visits among adolescent females, 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.
We conducted a retrospective cross-sectional analysis of the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2000–2009. This study was considered exempt from formal review by our institutional review board. The NHAMCS 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 14 and 21 years during 2000–2009 with the diagnosis of PID captured by the International Classification of Diseases (ICD-9) 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 methodology 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=0.01). The most common antibiotic regimen found among inappropriately treated patients was the combination of ceftriaxone and azithromycin (17.1%).
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 as 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, our study is the first to evaluate whether treatment adherence had changed since the dissemination of the CDC 2006 STD treatment guidelines. Even with the sizeable increase in the percent of patients who were treated appropriately from prior to 2006 to afterwards, over 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 utilizing the ED as a strategic setting to further understand these issues and change clinical practice.
The manuscript has not been published and is not being considered for publication elsewhere, in whole or part, in any language. Dr. Monika Goyal contributed to the conception; study design, data acquisition, analysis, and interpretation; and drafting of the manuscript. Dr. Monika 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. Dr. Adam Hersh contributed to study design; interpretation of data; and provided critical manuscript revisions. Xianqun Luan contributed to data acquisition, analysis, and interpretation. Dr. Russell Localio contributed to study design; data analysis and interpretation of data. Dr. Maria Trent contributed to study design; interpretation of data; and provided critical manuscript revisions. Dr. Theoklis Zaoutis contributed to study conception and design; interpretation of data; and provided critical manuscript revisions. Each author provided approval for the final submitted manuscript.
Our funding source included NIH K23 HD070910 (MKG) and Children's Hospital of Philadelphia, Department of Pediatrics (MKG). 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. Dr. Monika 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.
None of the authors have any conflicts of interest or disclosures.
1. Centers for Disease Control and Prevention, Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. Pelvic Inlammatory Disease (PID): CDC Fact Sheet.
2. National Center for Health Statistics. Ambulatory health care data: NAMCS and NHAMCS descriptions. [Accessed May 7, 2012];
3. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2006. MMWR. 2006;55 (No. RR-11).
4. 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 Mar;43(3):333–338. [PubMed]
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6. 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 Apr;38(4):299–305. [PubMed]