Meanwhile, focus on simple hygiene measures
Until confirmatory studies are reported, I propose that obstetricians avoid a rush to judgment and maintain their focus on simple measures to prevent horizontal transmission of CMV, such as:
- using CMV-negative blood products when transfusing pregnant women or fetuses
- encouraging expectant mothers to adopt safe sex practices
- encouraging expectant mothers to use careful handwashing techniques after handling infants’ diapers and toys.
Outpatient treatment of PID is effective, safe, and economical
Fertility and recurrence rates similar to inpatient therapy
Ness RB, Trautmann G, Richter HE, Randall H, Peipert JF, Nelson DB, et al. Effectiveness of treatment strategies of some women with pelvic inflammatory disease. Obstet Gynecol. 2005;106:573–580.
- Outpatient treatment is an effective and economically attractive alternative to inpatient therapy for women with mild to moderately severe pelvic inflammatory disease
Summary
Relatively inexpensive outpatient therapy for mild to moderately severe pelvic inflammatory disease (PID) proved effective and equivalent to inpatient treatment in key respects, in this long-term follow-up study.
Ness and colleagues describe 831 patients who had participated in a prospective, randomized, unblinded multicenter trial of outpatient versus inpatient treatment for mild-to-moderate PID.3 The patients were followed for a mean of 84 months (range 64–100 months).
- The inpatient treatment group received intravenous cefoxitin (2 grams every 6 hours) and either intravenous or oral doxycycline (100 mg twice daily) for at least 72 hours, followed by oral doxycycline (100 mg twice daily) to complete a 14-day course.
- The outpatient treatment group received a single 2-g intramuscular injection of cefoxitin plus a single 1-g oral dose of probenecid, followed by oral doxycycline (100 mg twice daily) for 14 days.
Equivalent outcomes
Outpatient treatment did not adversely affect subsequent fertility or increase the frequency of recurrent PID or chronic pelvic pain. The equivalence of outpatient compared with inpatient therapy extended to women of all races and to those with a history of PID; those colonized by Neisseria gonorrhoeae and/or Chlamydia trachomatis; and those with a high temperature, high white count, and high pelvic tenderness score.
Even in teenage women and women who had never had a live birth, outpatient and inpatient therapy were equivalent.
Risk of ectopic pregnancy was increased in outpatients (odds ratio 4.91); however, ectopic pregnancy was such a rare event that the 95% confidence interval was quite wide, ranging from 0.57 to 42.25.
Commentary
The initial encouraging results of the authors’ 2002 landmark Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) Randomized Trial3 led to this long-term follow-up study. In the women who were treated as described above, the short-term clinical outcomes and markers of micro-biologic improvement were similar in the outpatient and inpatient groups. After a mean follow-up of 35 months, pregnancy rates were essentially equal (42%) in both groups. Moreover, the groups did not differ significantly in risk of recurrent PID, chronic pelvic pain, or ectopic pregnancy.
Extended follow-up is reassuring
PID, a common and potentially serious illness, is the single most common predisposing factor for ectopic pregnancy and one of the principal causes of infertility and chronic pelvic pain. The direct and indirect expenses of PID are enormous, and the PEACH trial provides great reassurance that women who are not seriously ill can be safely, effectively, and inexpensively treated as outpatients.
The additional 4 years of follow-up reassures us that outpatient treatment did not adversely affect long-term outcome. Moreover, outpatient therapy was not less effective in women who initially appeared to be at higher risk for adverse sequelae: teens, African-Americans, women with a history of PID, and women colonized with N gonorrhoeae and/or C trachomatis.
Cost comparison
A 14-day prescription for doxycycline should cost less than $25. The single 2-g dose of cefoxitin, combined with the administration charge, should not exceed $100. If cefotetan (2 g) were substituted for cefoxitin (the 2 drugs should be therapeutically equivalent in this clinical situation), the cost would be even less. Conservatively, the charges for a single day in the hospital combined with charges for intravenous antibiotics would be at least $300 to $400.
Beyond the issue of expense are considerations of patient and physician convenience, ease of management, and conservation of scarce resources.
Recommendations
In carefully selected patients, outpatient treatment makes good sense, economically and clinically.
Whom to hospitalize
Patients judged to be seriously ill, particularly those in whom a tubo-ovarian abscess is suspected, should be treated in the hospital. Even with modern antibiotics and sophisticated intensive care, mortalities still occur in women with severe PID complicated by a ruptured abscess.