Hindawi Publishing Corporation
Infectious Diseases in Obstetrics and Gynecology
Volume 2012, Article ID 325108, 6 pages
theDiagnosis and Management of Pelvic
Inflammatory Disease:A Systematic Review
Bette Liu,1BasilDonovan,1,2Jane S.Hocking,3Janet Knox,1
Bronwyn Silver,1,4andRebecca Guy1
1The Kirby Institute, University of New South Wales, Sydney, NSW 2052, Australia
2Sydney Sexual Health Centre, Sydney Hospital, Sydney, NSW 2000, Australia
3Centre for Women’s Health, Gender and Society, Melbourne School of Population Health, University of Melbourne,
Melbourne, VIC 3010, Australia
4Menzies School of Health Research, Alice Springs, NT 0870, Australia
Correspondence should be addressed to Bette Liu, email@example.com
Received 14 May 2012; Accepted 19 July 2012
Academic Editor: Thomas Cherpes
Copyright © 2012 Bette Liu et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Background. Evidence suggests adherence to clinical guidelines for pelvic inflammatory disease (PID) diagnosis and management
is suboptimal. We systematically reviewed the literature for studies describing strategies to improve the adherence to PID clinical
to April 2012. Only studies with a control group were included. Results. An interrupted time-series study and two randomised
controlled trials (RCTs) were included. The interrupted time-series found that following a multifaceted patient and practitioner
intervention (practice protocol, provision of antibiotics on-site, written instructions for patients, and active followup), more
patients received the recommended antibiotics and attended for followup. One RCT found a patient video on PID self-care
did not improve medication compliance and followup. Another RCT found an abbreviated PID treatment guideline for health-
limited research on what strategies can improve practitioner and patient adherence to PID diagnosis and management guidelines.
Interventions that make managing PID more convenient, such as summary guidelines and provision of treatment on-site, appear
to lead to better adherence but further empirical evidence is necessary.
erate disease, can be difficult to diagnose as the symptoms
and signs are often nonspecific, and there is no gold standard
that confirms the diagnosis [1–4]. Because the consequences
of untreated PID may be severe, current clinical guidelines
recommend that practitioners have a high index of suspicion
for the diagnosis of PID and a low threshold for empirical
treatment [5–8]. Clinical guidelines outline the symptoms
and signs of PID and likely causative organisms in differ-
ent patient populations, appropriate diagnostic tests, and
empirical broad-spectrum antibiotics that are available and
appropriate, given local considerations regarding antibiotic
resistance and whether the PID was thought to be sexually
acquired, postpartum or postprocedural. Guidelines also
advise on outpatient or inpatient treatment, management
of sexual partners, and appropriate follow-up of patients to
assess the response to treatment.
Internationally, research suggests that the diagnosis and
management of PID could be improved. In a survey of 200
UK general practitioners, less than half were able to name
two symptoms and two signs of PID or correctly name
an antibiotic regimen , and a recent study of over 2000
women with PID seen in general practice found that only
34% were treated with recommended antibiotic regimens
2Infectious Diseases in Obstetrics and Gynecology
and 54% were tested for chlamydia . Audits of US
emergency department records have found that less than half
of the patients seen with a diagnosis of PID are prescribed
antibiotics according to the Centers for Disease Control and
Prevention guidelines [11–13]. An audit in an Australian
sexual health centre suggested substantial variation in PID
diagnoses between practitioners , and another audit
found that in a high chlamydia prevalence area, symptoms
and signs of PID were commonly recorded, but the majority
of women were not presumptively diagnosed with PID, nor
managed in accordance with the local guidelines .
Given there are current evidence-based clinical guide-
lines for the diagnosis and management of PID but sub-
stantial data suggesting poor adherence to these guidelines,
this paper aims to examine what strategies may improve
adherence to PID diagnosis and management guidelines.
This paper was undertaken according to the Preferred
Reporting Items for Systematic Reviews and Meta-Analyses
(PRISMA) guidelines .
2.1. Search Strategy. The electronic databases MEDLINE
and EMBASE (from January 2000 to April 2012) were
for relevant articles. The search terms and strategy used
comprised the following:
(i) “pelvic inflammatory disease” or “PID” or “salpingi-
tis” or “adnexitis”
(ii) “diagnosis” or “management.”
The reference lists obtained were limited to the English
language and humans. The titles of all articles were reviewed
and if relevant, the abstract examined. If the abstract
appeared to meet the inclusion criteria, the full text article
was obtained and was reviewed for inclusion.
2.2.InclusionCriteria. Weincluded allstudiesthatexamined
the effect of an intervention to improve practitioner or
patient adherence to diagnostic or management guidelines
2.3. Data Extraction. For each study the following data items
were extracted: study type, setting and population, number
nature of studies included in this paper varied substantially,
no attempt was made to combine the data in a meta-
analysis. Instead the studies are reviewed individually, and
their application to the improvement of PID diagnosis and
management is discussed.
The screening of studies is outlined in Figure 1. After
excluding duplicates, there were 2314 titles identified from
the electronic databases and of these, 203 abstracts were
reviewed. Eighteen full-text articles were obtained, and
2314 study titles
203 abstracts reviewed
18 full text articles
3 studies included
8 studies review articles with
no original data; 7 studies did
not include a control group
Figure 1: Screening of studies for inclusion in review.
of these, three studies met the inclusion criteria and are
outlined in Table 1 [17–19]. Of the full-text articles that
were excluded, eight were review articles rather than original
research and the other seven did not measure the effect of an
intervention to improve adherence.
The three included studies examined a variety of inter-
ventions aimed at the patient, the practitioner, or both. Two
studies were randomised controlled trials (RCTs) and one
was an interrupted time series study. All three studies were
conducted in the US between 2001 and 2008 and were aimed
at paediatric and adolescent populations, or practitioners
caring for these populations. The studies were based in
hospital and outpatient facilities; one was based at a single
hospital, the other two involved multiple centres (Table 1).
For the studies involving interventions with patients, the
populations were young (mean age 16 or 17 years) and
practitioners, they were practicing US paediatric emergency
3.1. Description of Individual Studies
3.1.1. Multifaceted Approach. The interrupted time-series
study by Trent et al.  aimed to assess if using a multi-
faceted approach in a single academic paediatric outpatient
setting improved the management of mild-to-moderate
PID. The intervention targeted both practitioners and their
patients. Practitioners were provided with a PID-treatment
algorithm, clinical practice guidelines, and training to follow
the PID care protocol. The patients were given the initial
of antibiotics to take home. They were also given written
discharge instructions and were followed by a telephone call
at 24–48 hours and at 2 weeks.
The intervention was evaluated by extraction of data
from administrative and medical records in the year prior
to the intervention and then compared to data recorded and
extracted over a nine-month period during the intervention.
Logs were used to record physician use of the clinical
practice guidelines and medications during the intervention
period. The medical records for 56 patients diagnosed with
PID and treated as an outpatient before the intervention
and 71 patients following the intervention were compared.
Patients diagnosed before and after the intervention were of
similar age and race, and had similar insurance status and
Infectious Diseases in Obstetrics and Gynecology3
Table 1: Summary of controlled studies to improve adherence to diagnosis and management guidelines for PID.
Study ID Study type Setting/YearTarget population
practitioner treatment algorithm
and practice guideline, full
14-day course of antibiotics for
patients and written discharge
follow-up at 24–48 hrs and 2
A single paediatric
in the US, 2001–2003
return for follow-up.
5 hospital emergency
clinics in a large urban
US centre, ∼2007
Members of the section
on Emergency Medicine
of the American
Academy of Paediatrics,
treatable PID in
6-minute video using health
belief model to acknowledge
barriers and benefits to PID
self-care in addition to
abstinence during the
14-day treatment period,
partner treatment, return
for 72-hour follow-up.
et al. 
Use of a PID-treatment summary
sheet versus the full CDC
Correct completion of a
multiple choice survey on
PID diagnosis, treatment
∗N is the total number of population including both intervention and control groups.
positivity rates for gonorrhoea and chlamydia. During the
post-intervention period, uptake of the intervention varied;
65% of practitioners used the clinical practice guidelines
and 52% distributed the patient information sheet; 88% of
patients received the 14-day course of antibiotics; 50% were
contactable by telephone within 24–48 hours and 38% were
contactable at 2 weeks.
Comparing the management of PID diagnosed in the
period before and after the intervention, testing for gonor-
rhoea and chlamydia were similarly high (98% before versus
100% after) but requesting wet-film microscopy of vaginal
discharge increased (3% versus 38%). The proportion of
patients receiving the recommended antibiotics increased
(95% CI 2.6–26.8); P < 0.001), and so did the proportion
who attended for follow-up within 72 hours (10% versus
43%, statistical test of significance not provided).
3.1.2. Randomised Controlled Trial of a Patient Educational
Video. Trent et al. subsequently conducted an RCT of an
educational video aimed at improving PID self-management
in adolescents diagnosed with mild-to-moderate PID .
The researchers recruited 126 adolescents who presented to
one of five clinical sites. All patients were managed using the
multifactorial approach described in Trent et al. , that
is, practitioners were given the PID treatment algorithm and
clinical practice guidelines, and the treatment site provided
patients with the full 14-day course of empirical antibiotics.
In addition to this routine management, the patients were
randomised to an intervention that involved watching a six-
minute video or the control group which did not have the
video. The video aimed to have patients better acknowledge
the barriers and benefits of PID self-care.
Interviews were conducted before and after the inter-
vention on all participants in order to compare baseline
characteristics and evaluate outcomes between the two
groups. The baseline interview included information on
sociodemographics, sexual, and reproductive history and the
follow-up interview was conducted following two weeks of
treatment to assess outcomes. The baseline characteristics of
the study population were similar between groups. None of
the outcomes examined at two-week follow-up, including
completing the course of antibiotics (intervention versus
control: 66% versus 66% resp., OR 0.99 (95% CI 0.38–
2.57)), follow-up visit within 72 hours (32% versus 16%,
OR 2.55 (95% CI 0.82–7.89)), abstention from intercourse
(78% versus 89%, OR 0.46 (95% CI 0.12–1.75)), partner
notification (88% versus 92%, OR 0.64 (95% CI 0.13–
3.10)), and partner treatment (71% versus 53%, OR 2.16
(95% CI 0.82–5.72)) was found to differ statistically in
the unadjusted analysis although the authors performed
became significant (OR 3.10 (95% CI 3.10 (1.03–9.39)).
3.1.3. Randomised Controlled Trial of an Abbreviated PID
Treatment Summary Sheet. Balamuth et al.  conducted
an RCT aimed at improving practitioner diagnosis and man-
agement of PID using an abbreviated PID treatment sum-
mary sheet versus the full 2006 Centres for Disease Control
and Prevention (CDC) Sexually Transmitted Disease man-
agement guidelines . The 237 recruited emergency pae-
diatricians were randomised to a either a weblink to the 2006
mary sheet that had been developed by the authors based on
the most salient points from the CDC guidelines. The inter-
vention was evaluated by a self-completed online multiple
4 Infectious Diseases in Obstetrics and Gynecology
choice survey assessing their diagnosis and treatment of PID.
The characteristics of practitioners were generally similar
between comparison groups. More practitioners reported
using the summary sheet than the weblink (79% versus
50% resp.). Significant differences were also found between
groups for the proportion of practitioners who chose the
correct antibiotics (summary sheet versus weblink: 97%
versus 61%, OR 19.4 (95% CI 6.6–76.9)) and who made
the correct follow-up recommendations (76% versus 32%,
OR 6.6 (95% CI 3.6–12.2)). The proportion making the
correct diagnosis (45% versus 50%, OR 0.82 (95% CI 0.49–
1.40)) and choosing the correct admission criteria (87%
versus 90%, OR 1.3 (95% CI 0.6–2.9)) did not differ between
4.1. Methodological Limitations. Two studies included in
this review were RCTs and therefore of a higher quality
for assessing interventions than the observational study.
However, all studies still had methodological issues that
limit their interpretation or generalisability. Overall the
studies were relatively small, and conducted on adolescent
patient groups in hospital or outpatient settings. Due to the
nature of the studies and the interventions, allocation of the
intervention was not concealed to either participants or the
Specifically, the RCT by Trent et al.  which did
not find any benefit to PID management with the video
intervention in the intention to treat analysis, was limited by
the loss to follow-up. The outcomes of interest assessed at
2-week follow-up were missing for 39% of participants. The
RCT by Balamuth was limited primarily by the hypothetical
nature of the study outcome and the generalisability of
the study findings. Rather than actual clinical diagnoses
of PID and treatment of real patients, the outcomes were
hypothetical responses to survey questions. Only 35% of
physicians invited to complete the study were included and it
is unknown if those who took part differed from those who
did not take part. Also, randomisation to the intervention
occurred before recruitment to the study (at the point of
email invitation), and while baseline characteristics of study
participants were similar between groups, smaller numbers
of study participants were allocated to the intervention
group than the control (109 versus 128). The 2006 study
by Trent found a significant difference in some outcomes
populations measured before and after the intervention that
could potentially bias the findings, could not be adequately
accounted for. Also, while the absolute numbers of PID
diagnoses made before and after the intervention (56 versus
rate of PID, the lack of denominators and hence underlying
rate of PID diagnosis at the study site meant that this
kind of interpretation was not possible. Similarly, as the
intervention was multifaceted, the contribution made by
various aspects of the intervention to the improved patient
antibiotic adherence and attendance at follow-up could not
4.2. Generalisability of Findings. In many settings the major-
ity of PID cases, especially mild-to-moderate disease, are
managed by general practitioners or primary care physicians
rather than in hospital settings by specialists . Therefore
applying the findings from these three small US studies to
of PID is difficult. While Balamuth found that abbreviated
summary PID clinical guidelines may improve practitioner
treatment of PID, such a strategy should be tested in clinical
settings with patients. Trent et al.’s earlier multifaceted
intervention to improve PID diagnosis and management
was an observational study rather than a trial. Therefore
while some components, such as the provision of the 14-day
course of antibiotics at presentation and written discharge
further study in a trial setting, and should consider issues
such as the socioeconomic status of the patient population
before being recommended for widespread implementation.
4.3. Future Directions of Research to Improve PID Diagnosis
and Management. While they were not included in this
paper because they did not assess improved compliance as
an outcome, some recent RCTs of antibiotics for PID have
compared simplified regimens such as once-daily dosing
using moxifloxacin instead of ofloxacin [22, 23] or once-
to more conventional treatments under the premise that
simplified regimens will result in greater patient adherence
to treatment . These studies have found that for uncom-
plicated PID management, the simplified regimens have had
similar or better clinical and microbial cure rates than the
conventional treatment, although none of these studies have
examined longer term sequelae. Also as PID, particularly
mild and moderate disease is recognised as being difficult
to diagnose due to the nonspecific symptoms and signs and
the range of possible differential diagnoses, there is a need
for noninvasive but specific diagnostic tests and clinical case
definitions to make the identification of PID simpler for
In Australia, as part of a trial of population screening
for chlamydia (http://www.accept.org.au/), an evaluation of
a PID education package delivered to general practitioners is
rials and a DVD on PID diagnosis and management. Practi-
tioner diagnosis rates, antibiotic treatments prescribed and
practitioner knowledge surveys measured before and after
the intervention will be used to assess the effectiveness of the
educational package. A recent review also found that health
practitioners may not follow clinical guidelines for a variety
of reasons including both knowledge and experience but also
beliefs and values . The review suggested that guidelines
should not only summarize evidence from clinical trials, but
also provide data on the cost-benefit and patient preferences
to make them more applicable to clinical practice.
This paper found that there is little research in the area
of improving practitioner and patient adherence to PID
Infectious Diseases in Obstetrics and Gynecology5
diagnosis and management guidelines. Only three studies
were identified, and because of the study settings and
limitations in their methodology, caution should be taken
in recommending their widespread application to clinical
practice. Based on the findings from this systematic review
we suggest that further studies, particularly in primary
care settings where diagnosis and management of PID has
been found to be suboptimal, should be conducted. Studies
that compare any one of the following interventions to
current practice should be investigated to determine if they
improve the diagnosis and management of PID: abbreviated
practitioner clinical management guidelines, provision of
the full course of antibiotic treatment to the patient at
presentation, simplified antibiotic regimens, and written
instructions for patients.
B. Liu, B. Donovan, J. S. Hocking, and R. Guy are supported
by research fellowships from the Australian National Health
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