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Pelvic inflammatory disease (PID) comprises a spectrum of infections
of the female upper reproductive tract. It is a common and serious
disease initiated by ascending infection from the cervix and vagina.
PID includes salpingitis, endometritis, myometritis, parametritis,
oophoritis, and tubo-ovarian abscess and may extend to produce pelvic
peritonitis and perihepatitis (Fitz-Hugh–Curtis syndrome). Worldwide,
it is difficult to estimate the incidence and prevalence of PID
due to difficulties experienced in access to care, lack of diagnostics
and laboratory facilities, and underfunding and overstretching of
public health services. Although no specific data are available
for PID incidence, the World Health Organization in 1999 (most recent
available data) estimated that 340 million new cases of curable
sexually transmitted infections occur annually throughout the world
in adults aged 15 to 49 years, most commonly in sub-Saharan Africa
and Southeast Asia. Women in resource-poor countries experience
an increased rate of complications and long-term sequelae. Worldwide,
sexually transmitted infections rank in the top five disease categories for
which adults seek care (http://www.who.org
and http://www.who.int/mediacentre/factsheets/fs110/en/). The
annual rate of PID in industrialized countries has been reported
to be as high as 10 to 20 per 1000 women of reproductive age, with
as many as 1 million cases estimated to occur per year in the U.S.
From 1995 to 2001, approximately 769,859 cases were reported in
the U.S. Of these, 91% were diagnosed in ambulatory care
settings.1,2 PID is the most common serious infection
in women aged 16 to 25 years. The increased risk in younger women
is attributed to the greater frequency of high-risk behaviors in
this group, including intercourse with multiple sexual partners,
less consistent condom use, increased coincident alcohol and drug
use, and delay or reduction in seeking care.3 An
increased rate of PID, approximately 2.3 times the rate seen in
white women overall, is reported in lower socioeconomic classes
in the U.S. This is attributed to early initiation of sexual activity,
relations with multiple sexual partners, and delay in seeking medical
care. Due to the subjective method of diagnosis of PID, racial and
socioeconomic biases may influence both how likely it is that this
diagnosis is assigned and which subjects are included in the large,
urban EDs and sexually transmitted disease clinics often utilized
as data collection sites for major studies. The numbers cited also
probably underestimate the true incidence of PID because of wide
variation in symptoms, relatively poor reliability of the clinical
diagnosis, and incomplete and nontimely conventional reporting methods.
Long-term sequelae, including tubal factor infertility, implantation
failure after in vitro fertilization, ectopic pregnancy, and chronic
pain, may occur in as many as 25% of patients, ultimately
affecting 11% of reproductive-aged women.4 Mortality
due to PID is estimated to occur in 0.29 patients per 100,000 cases
in women aged 15 to 44 years. The most common cause of death is
rupture of a tubo-ovarian abscess, and the mortality associated
with rupture remains at 5% to 10%, even with current
treatment methods. The annual direct ...