Læknablaðið - 15.08.1995, Blaðsíða 39

Læknablaðið - 15.08.1995, Blaðsíða 39
LÆKNABLAÐIÐ 1995; 81 615 atypical or silent, and typical "textbook" PID has become a rare disease. Subsequently, there has been a dramatic drop in the incidence of inpatient PID in most developed countries. However, most studies of the diagnosis and treatment of PID have focused on inpatients with acute symptoms and severe disease. Such cases may represent only the tip of the iceberg of all upper genital tract infections. Concern about the problem of unrecognized PID has led to the most fundamental change in the recommendations for clinical diagnosis of PID. A set of simple, easily ascertained mini- mum clinical criteria (table I) should trigger antibiotic treatment for probable PID unless a competing diagnosis is certain. This is an im- portant change in practice guidelines, i.e. mov- ing away from laboratory- and laparoscopy- based diagnosis towards syndromic diagnosis. Concomitant use of risk assessment and syn- dromic diagnosis should increase sensitivity by decreasing the false negative rate. Although the more sensitive approach will result in some unnecessary antibiotic treatments, it will also lead to providing proper therapy earlier in the course of PID. Not just unrecognized PID but also delay of care is an important cause of impaired fertility, particularly in Chlamydial PID. C. trachomatis and immune surveillance Progress in understanding the pathogenesis of the long-term sequelae has come with better understanding of the immunopathogenesis of C. trachomatis infection. Persistence of chron- ic inflammation after proper therapy for Chla- mydial infection has been a puzzling phenom- enon in many clinical studies. For instance, persistent cervical inflammation, not ex- plained by relapse or reinfection, is often pre- sent several months after appropriate therapy in women with Chlamydial MPC. Similarly, not only adhesion formation and tubal occlu- sions but also persistent inflammation of the fallopian tubes in the absence of C. trachoma- tis is frequently seen during second look lapa- roscopy performed several months after the index episode. C. trachomatis is a strong im- munogen which stimulates both humoral and cell-mediated immune responses, and can in- duce immune system perturbations that may assist its own survival in the infected host. The Table I. Minimum criteria for clinical diagnosis of PID. Lower abdominal tenderness Bilateral adnexal tenderness Cervical motion tenderness No evidence of competing diagnosis (e.g., positive pregnancy test, acute appendicitis, etc.) ability of Chlamydia to convert from resting to replicating infectious forms within host cells may create difficulties in eliminating this mi- crobe. Besides subclinical infections, poor compliance with antibiotic therapy, inappro- priate therapy, and recurrent infections which are extremely common particularly among adolescents are other sources for repeat or prolonged antigenic stimulus increasing the risk for reproductive tract damage and long- term sequelae. The current theory is that chronic sequelae of Chlamydial infection are caused by delayed hypersensitivity (DHS) re- action to Chlamydial heat shock proteins (HSP), particularly the 57kD HSP. Treatment of Chlamydial infections Chlamydial infections are treatable with tet- racyclines or macrolides. Clindamycin and ofloxacin are also relatively effective against Chlamydiae. However, the clinical practice of treatment of Chlamydia in the Nordic coun- tries is highly variable because of the lack of official treatment guidelines. For instance, one study performed in Norway among general practitioners revealed that more than 50 differ- ent antibiotic regimens were used in the treat- ment of Chlamydial infections, and only less than half of the regimens were compatible with the current treatment guidelines of WHO or Center for Disease Control and Prevention (USA). Furthermore, up to one half of ade- quately treated patients develop another epi- sode of Chlamydial infection within two years suggesting poor counselling or poor efforts in contact tracing. New direction in the treatment of Chlamydial infections are towards more ef- fective and shorter treatments. Treatment of Chlamydial infections with one gram single dose of azithromycin clearly represent a major step forward. Socioeconomic evaluation — what does it mean? Socioeconomic evaluations (table II) are methods which can be used to assess the costs
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