Original Contribution
Laboratory-confirmed gonorrhea and/or chlamydia rates in clinically diagnosed pelvic inflammatory disease and cervicitis

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Abstract

Objective

The aim of this study was to determine the rates of laboratory confirmed gonorrhea (GC) and chlamydia (CT) in emergency department (ED) patients with pelvic inflammatory disease (PID) and cervicitis who were diagnosed clinically and treated empirically. A secondary goal examines which clinical criteria were present in patients with PID testing positive for GC/CT.

Methods

We conducted a retrospective chart review of all ED patents diagnosed with PID or cervicitis during a 40-month period (January 2007–March 2010). Charts were reviewed for laboratory-confirmed GC or CT. For patients with positive GC or CT studies, the presence of key clinical criteria used in the diagnosis of PID was tallied.

Results

A total of 1469 patients were diagnosed with cervicitis and 343 with PID. Of these patients, 27 (1.8%) of 1469 and 15 (4.4%) of 343 were GC positive, and 136 (9.3%) of 1469 and 34 (10%) of 343 were CT positive. Twenty-six cervicitis (1.8%) and 9 PID (2.6%) patients were positive for both infections. One hundred eighty-nine cervicitis (13%) and 58 PID (17%) patients were positive for at least 1 sexually transmitted infection. Of the 58 patients with PID with laboratory-confirmed GC/CT, the following clinical criteria were present: abdominal pain, 58 of 58; abdominal tenderness, 50 of 58; cervical discharge, 47 of 58; cervical motion tenderness, 46 of 58; adnexal tenderness, 32 of 58; vaginal bleeding, 8 of 58; and fever, 2 of 58. Ultrasound was preformed in 27 (47%) of 58 GC/CT-positive patients with PID, with findings suggestive of PID in 12 (44%) of 27 ultrasounds. One hundred percent of abnormal ultrasounds were associated with positive GC and/or CT results.

Conclusion

There is a generally low prevalence of GC and CT in this patient population diagnosed with cervicitis or PID. There is a very low prevalence of coinfection.

Introduction

Pelvic inflammatory disease (PID) is an infection that starts in the vagina and ascends into the uterus, fallopian tubes, and potentially into the peritoneal cavity [1]. It is a polymicrobial process classically associated with a sexually transmitted infection such as Neisseria gonorrhea (GC) or Chlamydia trachomatis (CT). Prior studies have documented the rates of GC/CT recovered from tubo-ovarian abscesses at laparoscopy as high as 77% [2]. This association with GC/CT is reflected in the choice of antibiotics recommended by the Centers for Disease Control and Prevention (CDC) for empiric treatment of PID. Often, PID is preceded by an isolated cervicitis that can ascend into the upper genital tract during menstruation or douching [3], [4]. Currently, it is estimated that 750 000 American women experience acute PID each year, and 75 000 become infertile because of it [5]. A large portion of ectopic pregnancies are caused by fallopian tube scarring from prior PID. The literature describes primary epidemics of GC and CT, followed by secondary epidemics of PID. The term tertiary epidemic has been used to refer to the expected surge in ectopic pregnancies after the PID outbreak [6].

The CDC sets guidelines for the diagnosis of PID (Table 1) [7]. The classic doctrine in medical education stresses the need for a low threshold for diagnosing and treating PID. In general practice, a female with lower abdominal pain and tenderness on bimanual pelvic examination without an alternate explanation (appendicitis, diverticulitis, cystitis, etc) is often given a clinical diagnosis of PID. However, cervical motion, uterine, and adnexal tenderness are physical examination findings with a significant subjective component. The criterion standard for PID diagnosis is identification of purulent salpingitis on laparoscopy; however, this is a highly invasive and resource-intense procedure that is very infrequently performed in the modern era of medicine [8]. The challenge for the emergency physician lies in the fact that most of the diagnostic criteria are clinically based, subjective, or nonspecific. It is known that the clinical diagnosis of PID is imprecise [9].

Currently, polymerase chain reaction tests of cervical or vaginal samples are most commonly performed to evaluate GC or CT infection. Polymerase chain reaction–based tests are a form of nuclear acid amplification technology with sensitivities and negative predictive values of more than 95% for both GC and CT; however, the results are not immediately available (turnaround time is 2-3 days at many institutions) [10], [11]. This limits the utility of this diagnostic test for the emergency physician who is deciding on an empiric antibiotic treatment for an individual patient.

Determining if an individual patient has subjective physical examination findings that meet the CDC case definition of PID can be a challenge. Even when the CDC minimum criteria are met, the specificity for PID is only 22% [9]. Undertreatment of PID may yield a significant morbidity to the individual patient; however, false-positive diagnoses may contribute to antibiotic resistant organisms. In 2006, the CDC discontinued the recommendation for using quinolones in PID treatment, given the unacceptably high rates of quinolone resistant GC.

There have been no studies that have looked at the correlation between clinically diagnosed PID or cervicitis and positive laboratory studies for GC/CT in the emergency department (ED) population. Prior studies have examined the rate of positive culture results from laparoscopically drained tubo-ovarian abscesses; however, this is not very useful to the emergency physician at the bedside [12]. Our study attempts to add to the knowledge base by examining the rates of laboratory-confirmed GC/CT in patients clinically diagnosed with PID or cervicitis in an urban ED. Secondary goals are to determine which of the clinical criteria were present in the individuals diagnosed with PID who tested positive for GC/CT.

Section snippets

Methods

This study is a retrospective chart review. It was approved by our institutional review board. We identified as key variables the results of laboratory studies for GC/CT that were performed on patients clinically diagnosed with PID or cervicitis. Secondary variables that we studied included physical examination findings in these patients and results of radiographic and laboratory investigations.

This study was conducted in the ED of an academic, urban trauma center that hosts an emergency

Results

A total of 1469 patients were diagnosed with cervicitis, and 343 patients were diagnosed with PID. Of the patients with cervicitis, 1.8% (27/1469) were GC positive and 9.3% (136/1469) were CT positive. Patients diagnosed with PID had a 4.4% (15/343) rate of positive GC and 10% (34/343) rate for CT. Coinfection with both organisms was documented in 1.8% (26/1469) of the patients with cervicitis and 2.6% (9/343) of the patients with PID (see Fig. 1). For the 58 patients diagnosed with PID who

Discussion

Pelvic inflammatory disease is a serious infection that can lead to future infertility and ectopic pregnancy. Due to the complications that can arise from untreated infections, guidelines that encourage aggressive treatment for patients who present with signs and symptoms of PID have been established. Unfortunately, there is currently no physical examination finding or radiographic study with sufficiently high sensitivity to exclude this diagnosis. Although GC and CT are the most common

Conclusion

There is a generally low prevalence of GC and CT in this ED population diagnosed with cervicitis or PID. There is a very low prevalence of coinfection.

Acknowledgments

Health Partners Institute for Medical Education provided an internal grant of $2000 for this project.

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