Chlamydia trachomatis and Mycoplasma genitalium prevalence and associated factors among women presenting to a pregnancy termination and contraception clinic, 2009-2019.

BACKGROUND: Risk of pelvic inflammatory disease associated with Chlamydia trachomatis and Mycoplasma genitalium is increased after termination of pregnancy (TOP) and may be increased after insertion of intrauterine devices (IUDs). Screening prior to these procedures is recommended only for C. trachomatis. We examined C. trachomatis and M. genitalium prevalence and associated factors among women presenting to a pregnancy termination and contraception service over 10 years. METHODS: Retrospective analysis of clinical data collected from 17 573 women aged 15-45 years in 2009-2019 and for 266 M. genitalium positive women tested for macrolide resistance-associated mutations in 2016-2019. RESULTS: C. trachomatis and M. genitalium prevalence was 3.7% and 3.4%, respectively. In multivariable analyses, shared risk factors were younger age (p<0.001, for both C. trachomatis and M. genitalium), socioeconomic disadvantage (p=0.045 and p=0.008, respectively) and coinfection (p<0.001, for both sexually transmitted infections), with 10.1% of C. trachomatis positive women also positive for M. genitalium. Additional risk factors were earlier year of visit (p=0.001) for C. trachomatis and for M. genitalium residing outside a major city (p=0.013). The proportion of M. genitalium infections tested between 2016 and 2019 with macrolide resistance-associated mutations was 32.7%. CONCLUSIONS: Given the high level of antimicrobial resistance and the prevalence of coinfection, testing C. trachomatis positive women for M. genitalium could be considered in this setting to prevent further spread of resistant infections. Further research is required into the causal link between M. genitalium and pelvic inflammatory disease in women undergoing TOP and IUD insertion.

Screening for Chlamydial and Gonococcal Infections: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force.

Importance: The 2014 US Preventive Services Task Force (USPSTF) recommendation statement supported the effectiveness of screening for chlamydia and gonorrhea in asymptomatic, sexually active women 24 years or younger and in older women at increased risk for infection, although evidence for screening in men was insufficient. Objective: To update the 2014 USPSTF review on screening for chlamydial and gonococcal infection in adults and adolescents, including those who are pregnant. Data Sources: Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Ovid MEDLINE (January 1, 2014, through May 28, 2020) with surveillance through May 21, 2021. Study Selection: Randomized clinical trials and observational studies of screening effectiveness, accuracy of risk stratification and alternative screening methods, accuracy of tests, and screening harms. Data Extraction and Synthesis: One investigator abstracted data; a second checked accuracy. Two investigators independently assessed study quality. Main Outcomes and Measures: Complications of infection; infection transmission or acquisition; diagnostic accuracy of anatomical site-specific testing and collection methods; screening harms. Results: Twenty-seven studies were included (N = 179 515). Chlamydia screening compared with no screening was significantly associated with reduced risk of pelvic inflammatory disease (PID) in 2 of 4 trials and with reduced hospital-diagnosed PID (0.24% vs 0.38%); relative risk, 0.6 [95% CI, 0.4-1.0]), but not clinic-diagnosed PID or epididymitis, in the largest trial. In studies of risk prediction instruments in asymptomatic women, age younger than 22 years demonstrated comparable accuracy to extensive criteria. Sensitivity of chlamydial testing was similar at endocervical (89%-100%) and self- and clinician-collected vaginal (90%-100%) sites for women and at meatal (100%), urethral (99%), and rectal (92%) sites for men but lower at pharyngeal sites (69.2%) for men who have sex with men. Sensitivity of gonococcal testing was 89% or greater for all anatomical samples. False-positive and false-negative testing rates were low across anatomical sites and collection methods. Conclusions and Relevance: Screening for chlamydial infection was significantly associated with a lower risk of PID in young women. Risk prediction criteria demonstrated limited accuracy beyond age. Testing for asymptomatic chlamydial and gonococcal infections was highly accurate at most anatomical sites, including urine and self-collected specimens. Effectiveness of screening in men and during pregnancy, optimal screening intervals, and adverse effects of screening require further evaluation.

Screening for Chlamydia and Gonorrhea: US Preventive Services Task Force Recommendation Statement.

Importance: Chlamydia and gonorrhea are among the most common sexually transmitted infections in the US. Infection rates are highest among adolescents and young adults of both sexes. Chlamydial and gonococcal infections in women are usually asymptomatic and may lead to pelvic inflammatory disease and its associated complications. Newborns of pregnant persons with untreated infection may develop neonatal chlamydial pneumonia or gonococcal or chlamydial ophthalmia. Infection in men may lead to urethritis and epididymitis. Both types of infection can increase risk of acquiring or transmitting HIV. Objective: To update its 2014 recommendation, the US Preventive Services Task Force (USPSTF) commissioned a systematic review to evaluate the benefits and harms of screening for chlamydia and gonorrhea in sexually active adolescents and adults, including pregnant persons. Population: Asymptomatic, sexually active adolescents and adults, including pregnant persons. Evidence Assessment: The USPSTF concludes with moderate certainty that screening for chlamydia in all sexually active women 24 years or younger and in women 25 years or older who are at increased risk for infection has moderate net benefit. The USPSTF concludes with moderate certainty that screening for gonorrhea in all sexually active women 24 years or younger and in women 25 years or older who are at increased risk for infection has moderate net benefit. The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for chlamydia and gonorrhea in men. Recommendation: The USPSTF recommends screening for chlamydia in all sexually active women 24 years or younger and in women 25 years or older who are at increased risk for infection. (B recommendation) The USPSTF recommends screening for gonorrhea in all sexually active women 24 years or younger and in women 25 years or older who are at increased risk for infection. (B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for chlamydia and gonorrhea in men. (I statement).

Preclinical Testing of Vaccines and Therapeutics for Gonorrhea in Female Mouse Models of Lower and Upper Reproductive Tract Infection.

Murine models of Neisseria gonorrhoeae lower reproductive tract infection are valuable systems for studying N. gonorrhoeae adaptation to the female host and immune responses to infection. These models have also accelerated preclinical testing of candidate therapeutic and prophylactic products against gonorrhea. However, because N. gonorrhoeae infection is restricted to the murine cervicovaginal region, there is a need for an in vivo system for translational work on N. gonorrhoeae pelvic inflammatory disease (PID). Here we discuss the need for well-characterized preclinical upper reproductive tract infection models for developing candidate products against N. gonorrhoeae PID, and report a refinement of the gonorrhea mouse model that supports sustained upper reproductive tract infection. To establish this new model for vaccine testing, we also tested the licensed meningococcal 4CMenB vaccine, which cross-protects against murine N. gonorrhoeae lower reproductive tract infection, for efficacy against N. gonorrhoeae in the endometrium and oviducts following transcervical or vaginal challenge.

Where to go to in chlamydia control? From infection control towards infectious disease control.

OBJECTIVES: The clinical and public health relevance of widespread case finding by testing for asymptomatic chlamydia infections is under debate. We wanted to explore future directions for chlamydia control and generate insights that might guide for evidence-based strategies. In particular, we wanted to know the extent to which we should pursue testing for asymptomatic infections at both genital and extragenital sites. METHODS: We synthesised findings from published literature and from discussions among national and international chlamydia experts during an invitational workshop. We described changing perceptions in chlamydia control to inform the development of recommendations for future avenues for chlamydia control in the Netherlands. RESULTS: Despite implementing a range of interventions to control chlamydia, there is no practice-based evidence that population prevalence can be reduced by screening programmes or widespread opportunistic testing. There is limited evidence about the beneficial effect of testing on pelvic inflammatory disease prevention. The risk of tubal factor infertility resulting from chlamydia infection is low and evidence on the preventable fraction remains uncertain. Overdiagnosis and overtreatment with antibiotics for self-limiting and non-viable infections have contributed to antimicrobial resistance in other pathogens and may affect oral, anal and genital microbiota. These changing insights could affect the outcome of previous cost-effectiveness analysis. CONCLUSION: The balance between benefits and harms of widespread testing to detect asymptomatic chlamydia infections is changing. The opinion of our expert group deviates from the existing paradigm of 'test and treat' and suggests that future strategies should reduce, rather than expand, the role of widespread testing for asymptomatic chlamydia infections.

New best practice guidance for general practice to reduce chlamydia-associated reproductive complications in women.

BACKGROUND: Chlamydia is the most commonly diagnosed bacterial sexually transmissible infection (STI) in Australia, with most infections diagnosed and managed in general practice. Often asymptomatic, left untreated it can cause serious reproductive complications in women. There is now global recognition of the importance of enhanced chlamydia case management to reduce the risk of repeat infection and minimise harms of pelvic inflammatory disease (PID). OBJECTIVE: The aim of this article is to provide evidence-based information and resources to help general practitioners engage in partner management and retesting as part of routine STI care, in accordance with Australia's Fourth National Sexually Transmissible Infections Strategy: 2018-2022, and to provide up-to-date evidence about anorectal chlamydia and other emerging concerns in women. DISCUSSION: Evidence-based information and strategies for partner management and retesting the index case are provided in this article, in addition to information regarding the detection of PID, screening and treatment of anorectal chlamydia, antimicrobial resistance, and testing and treatment in pregnancy.

[Prevention of postoperative or associated of care pelvic inflammatory diseases. Is there a need for antibiotic prophylaxis for first trimester surgical-induced abortion to prevent pelvic inflammatory diseases? CNGOF good practice points]. / Prévention des infections génitales hautes postopératoires ou associées aux soins. Faut-il proposer une antibioprophylaxie lors des interruptions volontaires de grossesse chirurgicales pour prévenir les infections génitales hautes ? Conseils de bonne pratique du CNGOF.

Antibiotic prophylaxis is not recommended during surgical induced abortions. Systematic screening for Chlamydia trachomatis and Neisseria gonorrheae infection by polymerase chain reaction (PCR) on a vaginal sample is recommended before any surgical abortion. Moreover, the bacteriological result should be available before the abortion so that antibiotic treatment effective against the identified bacteria, if any, can be proposed before the procedure. The absence of bacteriological result on the day of the abortion must not, however, delay the procedure. If screening is positive for a sexually transmitted infection (STI), and the bacteriological result is only available after the abortion, it is recommended that antibiotic treatment start as soon as possible. The first-line antibiotic treatment is ceftriaxone 500mg in a single dose by the intramuscular route for N. gonorrheae, doxycycline 200mg per day orally for 7 days for C. trachomatis and azithromycin 500mg the first day (D1) then 250mg per day from D2 to D4 orally if Mycoplasma genitalium is detected by multiplex PCR. In case of positive screening, antibiotic treatment of the woman's partner(s) is recommended, adapted to the STI agent(s).

Pelvic Inflammatory Disease: Diagnosis, Management, and Prevention.

Pelvic inflammatory disease (PID) is an infection of the upper genital tract occurring predominantly in sexually active young women. Chlamydia trachomatis and Neisseria gonorrhoeae are common causes; however, other cervical, enteric, bacterial vaginosis-associated, and respiratory pathogens, including Mycobacterium tuberculosis, may be involved. PID can be acute, chronic, or subclinical and is often underdiagnosed. Untreated PID can lead to chronic pelvic pain, infertility, ectopic pregnancy, and intra-abdominal infections. The diagnosis is made primarily on clinical suspicion, and empiric treatment is recommended in sexually active young women or women at risk for sexually transmitted infections who have unexplained lower abdominal or pelvic pain and cervical motion, uterine, or adnexal tenderness on examination. Mild to moderate disease can be treated in an outpatient setting with a single intramuscular injection of a recommended cephalosporin followed by oral doxycycline for 14 days. Additionally, metronidazole is recommended for 14 days in the setting of bacterial vaginosis, trichomoniasis, or recent uterine instrumentation. Hospitalization for parenteral antibiotics is recommended in patients who are pregnant or severely ill, in whom outpatient treatment has failed, those with tubo-ovarian abscess, or if surgical emergencies cannot be excluded. Treatment does not change in patients with intrauterine devices or those with HIV. Sex partner treatment is recommended; expedited partner treatment is recommended where legal. Prevention of PID includes screening for C. trachomatis and N. gonorrhoeae in all women younger than 25 years and those who are at risk or pregnant, plus intensive behavioral counseling for all adolescents and adults at increased risk of sexually transmitted infections.

[Prevention of postoperative or associated of care pelvic inflammatory diseases: CNGOF and SPILF Pelvic Inflammatory Diseases Guidelines]. / Prévention des infections génitales hautes postopératoires ou associées aux soins. RPC infections génitales hautes CNGOF et SPILF.

Numerous prophylactic antibiotic regimens (PBR) have been evaluated particularly in surgical abortion, hysterosalpingography or caesarean section, but few randomized comparative trials are available. Recommendations for PBR should take into account, expected and demonstrated benefits that reduce the risk of surgical site infection, but also the impact on the microbiota, the risk of bacterial resistance selection, and the overall cost to the community. In addition, antibiotic prophylaxis is not the only one factor to reduce the risk of surgical site infection, such as preventive measures and good hygiene practices.

[Follow-up and counselling after pelvic inflammatory disease: CNGOF and SPILF Pelvic Inflammatory Diseases Guidelines]. / Suivi et conseils après infection génitale haute. RPC infections génitales hautes CNGOF et SPILF.

OBJECTIVES: To determine the procedures for follow-up and counselling of patients after pelvic inflammatory disease (PID). METHODS: A search in the Cochrane database, PubMed, and Google was performed using keywords related to follow-up and PID to identify reports published between 1990 and 2018. All studies published in French and English relevant to the areas of focus were included. A level of evidence (LE) based on the quality of the data available was applied for each area of focus and used for the guidelines. RESULTS: The rate of recurrent PID is 15 to 21%. They are related to a recurrent sexually transmitted infection (STI) in 20 to 34% of cases. Recurrence PID increase the risk of infertility and chronic pelvic pain (LE2). Follow-up is recommended after PID (grade C). The rate of patients lost to follow-up is around 40%. Follow-up is improved by personalized text message reminders (grade B). Vaginal sampling for detection of N. gonorrhoeae, C. trachomatis, (and M. genitalium) by nucleic acid amplification techniques is recommended 3 to 6 months after treatment of PID associated with STI to rule out possible reinfections (grade C). The use of condoms after PID associated with STI is recommended to reduce the risk of recurrences (grade C). The systematic use of contraceptive pills after PID is not recommended to prevent subsequent infertility and chronic pelvic pain. Vaginal sampling for microbiological diagnosis is recommended before the insertion of an intrauterine device (grade B). The risk of ectopic pregnancy is high in these women and must be kept in mind. CONCLUSION: Patient counselling and microbiological testing after PID decrease the risk of STI and thus the recurrence of PID.

Compliance with national guidelines for antibiotic prophylaxis prescription with a surgical abortion: Results of the Mya study.

PURPOSE: Performing an antibiotic prophylaxis (ATBP) with a surgical abortion (SA) is recommended in numerous countries, including France where the CNGOF has issued guidelines. There is little data regarding the actual application of these guidelines in clinical practice. The aim of this study was to evaluate the practice of ATBP with SA and to assess the degree of compliance with the national guidelines. METHODS: This longitudinal, prospective, multicenter, non-interventional study was undertaken between December 2013 and July 2014 with the objective of assessing the modalities of prescription of ATBP under real-life conditions in the setting of SA, and to compare it with the national guidelines. RESULTS: A total of 542 pregnant patients agreed to participate and were included by 36 French hospitals. Of these 36 active centers, 18 (50%) systematically prescribed an ATBP, while 10 (27.8%) prescribed an ATBP depending on the risks for the patient. Of these 542 patients, 263 (48.5%) received an ATBP prescription, 274 (50.6%) did not receive such a prescription. The prescribed ATBP was metronidazole (88/263 (33.5%)), azythromycin (76/263 (28.9%)), or doxycycline (44/263 (16.7%)). In total, 208/263 (79.1%) of the patients received an ATBP. Finally, three factors were identified as independent contributors that influence the prescription of an ATBP: the prescribed cervix preparation, the type of center, and the number of surgical abortions per year in the center over 500/year. CONCLUSION: Only half of the patients who undergo an SA receive a prescription for ATBP. Of the prescribed antibiotics, 80% correspond with the recommended ones.

Biological feasibility and importance of a gonorrhea vaccine for global public health.

There is a growing public health interest in controlling sexually transmitted infections (STIs) through vaccination due to increasing recognition of the global disease burden of STIs and the role of STIs in women's reproductive health, adverse pregnancy outcomes, and the health and well-being of neonates. Neisseria gonorrhoeae has historically challenged vaccine development through the expression of phase and antigenically variable surface molecules and its capacity to cause repeated infections without inducing protective immunity. An estimated 78 million new N. gonorrhoeae infections occur annually and the greatest disease burden is carried by low- and middle-income countries (LMIC). Current control measures are clearly inadequate and threatened by the rapid emergence of antibiotic resistance. The gonococcus now holds the status of "super-bug" as there is currently no single reliable monotherapy for empirical treatment of gonorrhea. The problem of antibiotic resistance has elevated treatment costs and necessitated the establishment of large surveillance programs to track the spread of resistant strains. Here we review the need for a gonorrhea vaccine with respect to global disease burden and related socioeconomic and treatment costs, with an emphasis on the impact of gonorrhea on women and newborns. We also highlight the challenge of estimating the impact of a gonorrhea vaccine due to the need for more data on the burden of gonococcal pelvic inflammatory disease and related sequelae and of gonorrhea-associated adverse pregnancy outcomes and the problem of empirical diagnosis and treatment of STIs in LMIC. There is also a lack of clinical and basic science research in the area of gonococcal/chlamydia coinfection, which occurs in a high percentage of individuals with gonorrhea and should be considered when testing the efficacy of gonorrhea vaccines. Finally, we review recent research that suggests a gonorrhea vaccine is feasible and discuss challenges and research gaps in gonorrhea vaccine development.

The effect of antibiotic prophylaxis for acute pelvic inflammatory disease after hysterosalpingography: a retrospective cohort study.

AIMS: Concerns about acute pelvic inflammatory disease (PID) after hysterosalpingography (HSG) have been raised since 1980. However, the effectiveness of prophylactic antibiotics remains unclear. This study investigated the effect of antibiotic prophylaxis in women undergoing HSG. METHODS: Women undergoing HSG between 2000 and 2012 were screened from the Taiwan National Health Insurance Research Database for eligibility. The prophylactic cohort included patients using any antibiotics of 1st-generation cephalosporins, doxycycline, clindamycin, and metronidazole, within 7 days before HSG (n = 3257). Patients not using any antibiotics were registered as the non-prophylactic cohort (n = 4662). An unconditional logistic regression model was applied to calculate the odds ratio (OR) and 95% confidence interval (CI) of acute PID after HSG associated with prophylactic antibiotics. RESULTS: The cumulative incidences of acute PID after HSG were 0.46% and 1.42% in the prophylactic and non-prophylactic cohorts, respectively. Prophylactic patients had a significantly reduced estimated relative risk of acute PID compared with non-prophylactic patients (adjusted OR = 0.33, 95% CI = 0.19-0.58; p = .001). Doxycycline users had the lowest adjusted OR of 0.20 (95% CI = 0.04-0.81; p = .02), followed by users of 1st-generation cephalosporins (adjusted OR = 0.35, 95% CI = 0.18-0.68; p = .002). Multivariate sub-group analysis verified this protective effect for almost all sub-groups of prophylactic patients. CONCLUSIONS: Antibiotic prophylaxis is associated with a decreased estimated relative risk of acute PID in HSG patients. Doxycycline and 1st-generation cephalosporins may be effective prophylactic regimens for HSG.

Cost-effectiveness of microscopy of urethral smears for asymptomatic Mycoplasma genitalium urethritis in men in England.

The objective was to determine whether or not the limited use of urethral microscopy to diagnose asymptomatic and symptomatic non-chlamydial, non-gonococcal urethritis (NCNGU) in men is a cost-effective strategy to avert pelvic inflammatory disease (PID), ectopic pregnancy or infertility in female partners. Outputs from a transmission dynamic model of NCNGU in a population of 16-30 year olds in England simulating the number of consultations, PID cases and patients treated over time amongst others, were used along with secondary data to undertake a cost-effectiveness analysis carried out from a health care provider perspective. The main outcome measure was cost per case of PID averted. A secondary outcome measure was cost per major outcome averted, where a major outcome is a case of symptomatic PID, ectopic pregnancy, or infertility. Offering a limited number of asymptomatic men urethral microscopy was more effective than the current practice of no microscopy in terms of reducing the number of cases of PID with an incremental cost-effectiveness ratio of £15,700, meaning that an investment of £15,800 is required to avert one case of PID. For major outcomes averted, offering some asymptomatic men urethral microscopy was again found to be more effective than no microscopy, but here an investment of £49,900 is required to avert one major outcome. Testing asymptomatic men for NCNGU in a small number of genitourinary medicine settings in England is not cost-effective, and thus by maintaining the current practice of not offering this patient group microscopy, this continues to make savings for the health care provider.

Early screening for Chlamydia trachomatis in young women for primary prevention of pelvic inflammatory disease (i-Predict): study protocol for a randomised controlled trial.

BACKGROUND: Genital infection with Chlamydia trachomatis (Ct) is the most common bacterial sexually transmitted infection, especially among young women. Mostly asymptomatic, it can lead, if untreated, to pelvic inflammatory disease (PID), tubal factor infertility and ectopic pregnancy. Recent data suggest that Ct infections are not controlled in France and in Europe. The effectiveness of a systematic strategy for Ct screening in under-25 women remains controversial. The main objective of the i-Predict trial (Prevention of Diseases Induced by Chlamydia trachomatis) is to determine whether early screening and treatment of 18- to-24-year-old women for genital Ct infection reduces the incidence of PID over 24 months. METHODS/DESIGN: This is a randomised prevention trial including 4000 eighteen- to twenty-four-year-old sexually active female students enrolled at five universities. The participants will provide a self-collected vaginal swab sample and fill in an electronic questionnaire at baseline and at 6, 12 and 18 months after recruitment. Vaginal swabs in the intervention arm will be analysed immediately for Ct positivity, and participants will be referred for treatment if they have a positive test result. Vaginal swabs from the control arm will be analysed at the end of the study. All visits to general practitioners, gynaecologists or gynaecology emergency departments for pelvic pain or other gynaecological symptoms will be recorded to evaluate the incidence of PID, and all participants will attend a final visit in a hospital gynaecology department. The primary endpoint measure will be the incidence of PID over 24 months. The outcome status (confirmed, probable or no PID) will be assessed by two independent experts blinded to group assignment and Ct status. DISCUSSION: This trial is expected to largely contribute to the development of recommendations for Ct screening in young women in France to prevent PID and related complications. It is part of a comprehensive approach to gathering data to facilitate decision-making regarding optimal strategies for Ct infection control. The control group of this randomised trial, following current recommendations, will allow better documentation of the natural history of Ct infection, a prerequisite to evaluating the impact of Ct screening. Characterisation of host immunogenetics will also allow identification of women at risk for complications. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02904811 . Registered on September 14, 2016. World Health Organisation International Clinical Trials Registry, NCT02904811. AOM, 15-0063 and P150950. Registered on September 26, 2016. A completed Standard Protocol Items : Recommendations for International Trials (SPIRIT) Checklist is available in additional file 1.

Improving Adolescent Pelvic Inflammatory Disease Follow-up From the Emergency Department: Randomized Controlled Trial With Text Messages.

STUDY OBJECTIVE: Centers for Disease Control and Prevention guidelines recommend follow-up within 72 hours of diagnosis of pelvic inflammatory disease because patients with inadequate treatment are at increased risk of acute and chronic complications. Follow-up rates in adolescents after diagnosis range between 10% and 16%. The primary objective is to assess the effect of text message reminders to adolescent patients receiving a diagnosis of pelvic inflammatory disease on obtaining follow-up care within 72 hours of emergency department (ED) discharge. METHODS: This was a single-blinded randomized controlled trial of adolescents receiving a diagnosis of pelvic inflammatory disease in the ED. Patients received standard discharge instructions or standard discharge instructions plus text message reminders. Patients in the text message group received daily, tailored text messages for 4 days, with a reminder to schedule and attend primary care provider follow-up. The primary outcome was follow-up within 72 hours of ED discharge. RESULTS: Ninety-five patients (48 standard; 47 text message) were randomized. Three patients were excluded, leaving 92 patients (46 standard; 46 text message) for analysis. Baseline characteristics were similar between treatment groups. Follow-up was 15.2% in the standard group and 43.5% in the text message group. Patients receiving text message reminders were more likely to follow up compared with the standard group (relative risk 2.9; 95% confidence interval [CI] 1.4 to 5.7). The absolute efficacy difference was 28.3% (95% CI 9.5% to 46.9%), yielding number needed to treat of 4 (95% CI 2.2 to 9.5). CONCLUSION: Personalized text message reminders were efficacious in improving follow-up for adolescents after ED diagnosis of pelvic inflammatory disease.

Which sexually active young female students are most at risk of pelvic inflammatory disease? A prospective study.

OBJECTIVE: To identify risk factors for pelvic inflammatory disease (PID) in female students. METHODS: We performed a prospective study set in 11 universities and 9 further education colleges in London. In 2004-2006, 2529 sexually experienced, multiethnic, female students, mean age 20.8 years, provided self-taken vaginal samples and completed questionnaires at recruitment to the Prevention of Pelvic Infection chlamydia screening trial. After 12 months, they were followed up by questionnaire backed by medical record search and assessed for PID by blinded genitourinary medicine physicians. RESULTS: Of 2004 (79%) participants who reported numbers of sexual partners during follow-up, 32 (1.6%, 95% CI 1.1% to 2.2%) were diagnosed with PID. The strongest predictor of PID was baseline Chlamydia trachomatis (relative risk (RR) 5.7, 95% CI 2.6 to 15.6). After adjustment for baseline C. trachomatis, significant predictors of PID were ≥2 sexual partners or a new sexual partner during follow-up (RR 4.0, 95% CI 1.8 to 8.5; RR 2.8, 95% CI 1.3 to 6.3), age <20 years (RR 3.3, 95% CI 1.5 to 7.0), recruitment from a further education college rather than a university (RR 2.6, 95% CI 1.3 to 5.3) and history at baseline of vaginal discharge (RR 2.7, 95% CI 1.2 to 5.8) or pelvic pain (RR 4.1, 95% CI 2.0 to 8.3) in the previous six months. Bacterial vaginosis and Mycoplasma genitalium infection were no longer significantly associated with PID after adjustment for baseline C. trachomatis. CONCLUSIONS: Multiple or new partners in the last 12 months, age <20 years and attending a further education college rather than a university were risk factors for PID after adjustment for baseline C. trachomatis infection. Sexual health education and screening programmes could be targeted at these high-risk groups. TRIAL REGISTRATION NUMBER: (ClinicalTrials.gov NCT00115388).