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PID Evaluation and PID Evaluation and Clinical Health Clinical Health (PEACH) Study(PEACH) Study
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PEACH
Multi-center randomized clinical trial of 831 women followed 2-5
yrs through 10/00
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Study treatment
• Inpatient
2gr Cefoxitin IV
every 6 hours
100grs Doxiciclyne IV
Every 12 hours
• Outpatient
2gr Cefoxitin
1gr Probenecid
100 mg Doxiciclyne oral twice a day
1 shot
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Eligibility of patients into the studyInclusion(Must meet all of the following criteria)1. 37 years of age or younger2. Willing to participate3. Presenting with a history of pelvic discomfort for <30
days (this does not need to be the chief complain)4. Experiencing pelvic organ tenderness (uterine or adnexal
tenderness) on bilateral examination5. Leukorrhea and/or Mucopurulent Cervicitis and/or
untreated known + GC or CT
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Eligibility of patients into the study
Exclusion(Must not meet any of the following criteria)1. Currently pregnant by urine testing.2. Tubo-ovarian abscess. 3. Appendicitis, hemorrhagic ovarian cyst or
other condition requiring surgery by ultrasound or laparoscopy.
4. Nausea or vomiting after a trial of metocopramide
5. Antimicrobial therapy within the past 7 days
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Eligibility of patients into the study
Exclusion
6. Delivery, abortion or gynecology surgery with the past 30 days.
7. Prior hysterectomy or bilateral salipingectomy.
8. Allergy to penicillins, cephalosporins or tetracyclines.
9. Homeless.
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Outcomes
Primary
Involuntary infertility
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Others Outcomes
Short term:
• Time to clinical improvement
• Microbiologic cure on repeat cervical culture and endometrial biopsy
• Patient satisfaction with medical care
• Treatment adherence
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Others OutcomesLong term:
• Tubal occlusion in women with involuntary infertility
• Repeat episodes of PID
• Ectopic pregnancy
• Functional decline due to pelvic pain
• Quality of life
• Frequency of health service use and indirect PID-related cost, cost-utility analysis
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PID Evaluation and Clinical Health (PEACH) Study
Inpatient Outpatient p-value
Pregnancy
Infertility
Salpingo
Hysterectomy
Ectopic pregnancy
Tubal obstruction
Chronic pelvic pain (CPP)
Adjusted OR (95% CI)
172
71
41
7(1.7)
4
7
12
1.0
0.5
.11
1.
0.37
0.72
0.1
1.0
1.32
0
1.4
3
0.61
1.24
172
67
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Risk of Reproductive Outcomes Following Endometriosis and/or Upper Genital Tract Infection (UGTI) or No
Endometritis/No UGTI Among Women with Clinical PID
No Endometriosis/ No UGTI (n=258)
No Endometriosis and/or UGTI (n=156)
Crude OR 95%CI
Adjusted OR 95%CI
Outpatient N % N %
Pregnancy
Infertile
Recurrent PID
Chronic pelvic pain
103
50
50
112
40.2
17.87
19.5
44.48
142
53
46
98
40.8
16.4
13.2
29.5
1.0(0.7,1.4)
0.9(0.6,1.4)
0.6(0.4,1.0)
0.5(0.4.,0.7)
0.8(0.6,1.2)
1.0.(0.6,1.6)
0.6(0.4,0.9)
0.6(0.4.,0.9)
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Pregnancy rates-197 US and 1st Year Follow-up, PEACH Study
White Women
0
10
20
30
40
50
<= 19 20-24 25-39
US
PEACHEndometrisis and/orGTNOEndometrisis/UGTI
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Pregnancy rates-197 US and 1st Year Follow-up, PEACH Study
Black Women
0
10
20
30
40
50
<=19 20-24 25-39
US
PEACHEndometriosisand/or GTNoEndometriosis/UGTI
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PEACH 2 Specific Aims:• To continue the follow-up of women in the PEACH
study go as to better describe the rates of inability to achieve pregnancy, chronic pelvic pain, and recurrence after mild-to-moderate PID
• To develop and validate a clinical prediction rule(s) that identifies women after diagnosis of PID who are at high risk for: inability to achieve pregnancy, having chronic pelvic pain, or having recurrent disease
• To identify whether inpatient treatment is more effective than outpatient treatment in reducing the risk of sequelae among prognostic subset of women
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DAISY Project
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Women Not Counseled by Physician on Selected Health Behaviors in Past Year, 1991
5460 61
65
8083
0
10
20
30
40
50
60
70
80
90
Smoking Diet Eating PhysicalActivity
Alcohol Use Drug Use STDPrevention
Health Behavior
Pe
rce
nt
of
Wo
me
n A
ge
18
or
Old
er
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Recurrent Infection with C. Trachomatis by Age41.9
25.3
12.3
7
0
5
10
15
20
25
30
35
40
45
10-14 15-19 20-29 30-44
Age(Years)
Inci
den
ce o
f R
ecu
rren
t In
fect
ion
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Chlamydial Infection
Baseline testing
Home screeningEvery 6 mo * 2 yr
Return visitsEvery 6 mo * 2 yr
Number of screens completedNumber infectedProportion of infection treated
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Hormonal Contraception and the Recognition of Pelvic Inflammatory Disease
• RB Ness, LM Keder,
• DE Soper, AJ Amertegul,
• J Glack, H Wiesenfeld,
• PA Rice, JF Pelpert,
• A Karmbour-Shakir,
• SP Donegan
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Epidemiologic Data
• Oral Contraceptive use associated with 2* Increase prevalence of C. trachomatis.
• Oral contraceptive associated with protection against symptomatic PID.
• Salpingitis more mild among women using oral contraceptives.
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Subjects
Cases Controls
UnrecognizedPID
Endometritis RecognizedPID
Proportion of Hormonal Contraceptive Use
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Odds Ratios (95% CI) for Hormone Use vs. No Contraception or Barrier Contraception
Hormone vs. No Contraception
Hormone vs. Barrier
Any endometritis
5.0 (1.9,13.4)
(N=98)
2.6 (0.9,7.1)
(N=69)
A+C 4.7 (1.4,16.1)
(N=72)
3.1 (0.7,13.8)
(N=33)
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Independent Risk Factors for UGTI/Endometritis*
Endometritis without UGTI (OR(95% CI))
UGTI
(OR(95% CI))
Tenderness score >12
(OR(95% CI))
Oral Contraceptives+ 0.7(0.3-1.8) 2.2(0.9-5.0) 0.7(0.4-1.4)
progesterone* 1.7(0.8-3.8) 0.6(0.2-1.7) 0.9(0.4-1.8)
Other Barrier* 0.9(0.3-3.1) 2.6(0.8-8.2) 1.1(0.4-2.8)
Condom use+
<5/10 times 0.5(0.2-1.2) 2.5(0.9-7.1) 0.8(0.4-1.8)
6-9/10 times 1.6(0.3-1.6) 3.1(1.0-9.6) 1.1(0.5-2.4)
10/10 times 0.4(0.2-1.2) 1.2(0.3-4.2) 0.6(0/3-1.4)
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Gyn Infections
Follow-Through (GIFT) Study
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Douching Prevalence
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Bacterial Vaginosis (BV): What is it?
• A replacement of the normal vaginal flora (Lactobacillus) with a mixed flora of Gardnerella vaginalis, anaerobes, and Mycoplasma hominis
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Prospective Observational Study
1200 women enrolled from 5 clinical sites over 18 months
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Primary Objective
To compare the time to PID between women who are douching (at least
once / month on average) vs. women who are not.
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Prevention, prevention and prevention
• Douching cessation programs
• Self-testing for STDs
• Predictors of infertility among women with PID
• Will treating BV prevent PID?