Recurrent PID, Subsequent STI, andReproductive Health Outcomes:Findings from the PID Evaluation andClinical Health (PEACH) Study
Maria Trent, MD, MPH
Debra Bass, MS
Roberta Ness, MD, MPH
Catherine Haggerty, PhD, MPH
Funding: Centers for Disease Control and Prevention: K01DP001128-02;
Agency for Healthcare Research and Quality Development: HS08358-05
Disclosures
•I have no relevant financial relationships withthe manufacturer(s) of any commercialproduct(s) and/or providers (s) of commercialservices discussed in this CME activity.
•I do not intend to discuss off-label use ofproducts in this presentation
Background
•PID is a common reproductive health disorder
• Associated with significant reproductive morbidity:
– Tubal infertility
–Ectopic pregnancy
–Chronic pelvic pain (CPP)
•Risk estimates of morbidity based on Scandinaviancohort of PID inpatients enrolled 1960 -1984
– Subsequent shifts in the biological organisms causing PID
–Management shifted to outpatient setting
•Re-analysis of the impact of recurrent PID and STIswarranted
Objective
•To examine the risk of longitudinal adverseoutcomes associated with recurrent STIs andPID among urban American women with mild-moderate PID
•To determine the potential impact ofadolescence on the observed longitudinaloutcomes
Methods
•Secondary data analysis
•PID Evaluation and Clinical Health(PEACH)Study
–Women 14-38 years with mild-moderate PID
–Urban Settings in United States
–Randomized to inpatient/outpatient treatment
–Baseline interview & gynecologic exam(endometrial biopsies, STI testing)
–Visits at 5 and 30 days
–Telephone interview quarterly x 84 months
PEACH
831 Women 14-38 years Mild-Moderate PID
Randomized to Inpatient/ Outpatient Arms
Main PEACH Analysis
No Difference in Outcomesby group
Re-Analysis based onRecurrent PID/STI
AdolescentSub-Analysis(≤19 yrs)
N=209
Approach to Analysis
Methods
•Data evaluated using bivariate & multipleregression analyses
•Analysis approved by Johns Hopkins IRB
Selected Demographics
Baseline Measure
% (N)
Race/Ethnicity
Black
White
Hispanic
Native American/Alaskan Native
74.5% (621)
16.0% (133)
6.1% (51)
3.1% (26)
Insurance Status
Uninsured
Private
Public
43.8% (364)
13.8% (115)
33.5% ( 278)
Regular Access to Care
65% (539)
Ever Pregnant
75.2% (625)
Prior history of PID
37.4% (311)
New Sexual Partner
9.3% (78)
Any Contraceptive use past 4 weeks
61.0% (508)
84-Month Reproductive HealthOutcomes
Subsequent STI & Reproductive HealthOutcomes: All Women
SubsequentSTI
(N = 195)
NoSubsequentSTI
(N = 596)
OR (95% CI)
Adjusted OR(95% CI)*
Pregnancy**
124 (63.6)
330 (55.4)
1.4 (1.0 – 2.0)
1.0 (0.7 – 1.5)
Live Birth*
91 (46.7)
239 (40.1)
1.3 (.09 – 1.8)
1.0 (0.7 – 1.4)
Infertility
41 (21.0)
104 (17.4)
1.3 (0.8 – 1.9)
1.4 (0.9 – 2.2)
Chronic pelvicpain
105 (53.8)
218 (37.7)
1.9 (1.4 – 2.7)
2.3 (1.6 – 3.2)
Outcomes by Recurrent PID Status:ALL Women
Recurrent PID
(N = 168)
No RecurrentPID
(N = 621)
OR (95% CI)
Adjusted OR(95% CI)*
Pregnancy**
95 (56.5)
356 (57.3)
1.0 (0.7 – 1.4)
1.0 (0.6 – 1.4)
Live Birth*
61 (36.3)
270 (43.5)
0.7 (0.5 – 1.1)
0.7 (0.5 – 1.0)
Infertility
44 (26.2)
104 (16.7)
1.8 (1.2 – 2.6)
1.8 (1.2 – 2.8)
Chronic pelvicpain
115 (68.5)
213 (35.3)
4.0 (2.8 – 5.7)
4.2 (2.8 – 6.2)
Subsequent STI & Reproductive HealthOutcomes: Adolescent
SubsequentSTI
(N = 195)
NoSubsequentSTI
(N = 596)
OR (95% CI)
Adjusted OR(95% CI)*
Pregnancy**
124 (63.6)
330 (55.4)
1.4 (1.0 – 2.0)
1.0 (0.7 – 1.5)
Live Birth*
91 (46.7)
239 (40.1)
1.3 (.09 – 1.8)
1.0 (0.7 – 1.4)
Infertility
41 (21.0)
104 (17.4)
1.3 (0.8 – 1.9)
1.4 (0.9 – 2.2)
Chronic pelvicpain
105 (53.8)
218 (37.7)
1.9 (1.4 – 2.7)
2.3 (1.6 – 3.2)
Outcomes by Recurrent PID Status:Adolescents
Recurrent PID
(N = 50)
No RecurrentPID
(N =149)
OR (95% CI)
Adjusted OR(95% CI)*
Pregnancy**
34 (68.0)
108 (72.5)
0.8 (0.4 – 1.6)
1.1 (0.5 – 2.2)
Live Birth
22 (44.0)
80 (53.7)
0.7 (0.4 – 1.3)
0.9 (0.4 – 1.7)
Infertility
13 (26.0)
23 (15.4)
1.9 (0.9 – 4.2)
1.9 (0.8 – 4.4)
Chronic pelvicpain
34 (68.0)
44 (30.1)
4.9 (2.5 – 9.8)
5.0 (2.3 – 10.6)
Conclusions
•Women with recurrent PID are more likely to reportinfertility and CPP at 84 months
•Substantiates the relationship between recurrent PIDand adverse
–Modern microbiology
–Outpatient and inpatient care approaches
•Highlights CPP as a major adverse outcome andrecurrent lower genital tract infection (STI) as a keycontributor
• Supports to the concept of tertiary prevention
–Upper genital tract disease = smaller, well defined publichealth
–Adolescents are also an important sub-target
Limitations
•Limited Generalizability
–Demographics
–Trial Participation
•Contraception
•Clinical Criteria for PID
–Endometrial biopsies
–Mimics clinical practice
•Self-Reported Longitudinal Outcomes
–Supported by medical record review
Implications
•Young women with a history of PID are aclearly defined target group for public healthintervention.
•Acute PID should prompt linkage of affectedpatients to tailored STI risk-reduction servicesto prevent the adverse outcomes associatedwith PID