Læknablaðið - 15.08.1995, Page 39

LÆKNABLAÐIÐ 1995; 81
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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. trcichomatis 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