Pelvic Inflammatory Disease: how partner notification and a joined-up approach enhances patient care

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It had been identified that there were less than satisfactory outcomes, in terms of follow up care of those patients who were diagnosed with PID through the Gynaecological teams, whether this be via A&E, the Gynaecological Assessment Unit or the Gynaecological Ward.
In terms of aetiology, pelvic inflammatory disease (PID) is usually the result of infection ascending from the endocervix causing endometritis, salpingitis, parametritis, oophhoritis,  tuboovarian abcess and or pelvic peritonitis.

Neisseria gonorrhoeae and Chlamydia trachomatis have been identified as causative agents but account for only a quarter of cases in the UK, whilst Gardnerella vaginalis, and other anerobes including Prevotella, Aptobium and Leptotrichia may also be implicated. Mycoplasma has also been associated with upper genital tract infection in women.^1,2

PID may be symptomatic or asymptomatic. Even when present, clinical symptoms and signs lack sensitivity and specifity –  the positive predictive value of a clinical diagnosis is 65-90 percent compared to laparoscopic diagnosis.³ If screening for gonorrhoea is not available then additional specific antibiotics effective against Neisseria gonorrhoea should be offered.

It is long been associated that delaying treatment of PID increases the associated long term sequelae such as ectoptic pregnancy, infertility and pelvic pain.⁴ Because of this, and equally from the lack of definitive diagnostic criteria, a low threshold for empiric treatment of PID is recommended.³

Re-infection with chlamydial and gonorrhoeal infection is common therefore stressing the importance of PN for the care of both the individual and their sexual partner.⁵

According to the BASHH guidelines, there were clear standards to be met in terms of the women who were referred to the GUM HAs. Current male partners of women with PID should be contacted and offered health advice and screening but as many cases of PID are not associated with gonorrhoea or chlamydia, broad spectrum empirical therapy should also be offered to partners e.g. azithromycin 1g as a single dose.

Further advice is that partners should be advised to abstain from intercourse until they and the index patient have completed the treatment course (this being either the two week course for the women or the seven day post azithromycin single dose for the partner.)
BASHH recommend that review at 72 hours is carried out, particularly for those with a moderate or severe clinical presentation.³ Also that further review two to four weeks after therapy may be useful to ensure:

• Adequate clinical response to treatment
• Compliance with oral antibiotics
• Screening and treatment of sexual contacts
• Awareness of the significance of PID

When a woman is diagnosed with PID, there is often much at stake in terms of both a physical but equally personal perspective and this is a point where HAs can step in at a point of management. There had previously been concerns that once discharged home, there was no clear documentation that the patient understood the need for relevant advice such as no sexual contact whilst on medication, compliance with the medication and the need for any sexual partners within the last six months to be notified and treated. There was also an expectation that the patient should be reviewed in a timely fashion i.e. two weeks after diagnosis either within the GUM Department or Gynaecology Out-Patients.

Therefore, all patients diagnosed with PID in the GUM Department are seen by a Health Advisor who establishes on the day of diagnosis, that the patient fully understands why the diagnosis has been made, what tests have been undertaken, the need for compliance with treatment – whatever the swab results; the need for sexual abstinence for the duration of both their and any partner’s treatment and the need for any other partners within the preceding six months to be treated as a contact of PID.

Once referred to as liaison HAs, the standard would be that the patient is contacted within 48 hours to ensure that the relevant advice is clear. Once this engagement is made, the HA can offer to contact the patient with their swab results i.e. gonorrhoea, chlamydia, Trichomonas vaginalis (TV), yeasts and hyphae (candida) and clue cells that would indicate bacterial vaginosis ( BV).

This contact is usually carried out in the form an initial phone call by the HAs and either a follow up review within the GUM clinic which is customary; within the Gynaecology Department or in a GP setting. This also allows for verification of the PN process and allows a gentle reminder for the patient to either act on this or take the opportunity for provider referral to be undertaken.

An annual audit is undertaken by the Liaison HAs and GUM Consultant using agreed standards and criteria and fed back to the Gynaecology team. A useful link has also been the agreed identification of a member of the ward nursing team to act as a promoter of the pathway and ensure that both nursing and medical staff are aware of the process.

Partner notification and the associated advice for the index patient clearly played a significant part in the success of patient management and for wider public health issues. It also encompasses other sexual health needs, including managing risk behaviour and ethical issues.³

PN has been an integral component of the challenge to control sexually transmitted infections (STIs) since the 1940’s and is an important part of managing such infections.⁶ The process involves identifying sexual partners, informing them of their potential exposure, ensuring treatment and or screening and providing advice and information to prevent further transmission treatment and or screening and providing advice and information to prevent further transmission.⁷

The National Institute for Health and Clinical Excellence is currently working on guidance around interventions to reduce the transmission of STIs, including PN. These are currently in draft form.

PN as a public health measure to reduce transmission of STIs is a cornerstone of STI control in most countries,⁸ and as Oakeshott et al. describe, is an essential component of the management of all STIs,⁹ because of the high chance of infection in sexual partners. However, the success of any PN strategy is conditional on its acceptability and feasibility to the patient and the healthcare professional, its level of compliance with relevant professional and legislative guidance and its cost – effectiveness.⁸

Tracing and notifying people who may have had contact with an STI is a complex and skilful activity⁵ and the task of establishing a strategy to inform sexual partners is not an easy one, but of vital importance as there are compelling reasons as well as good evidence that a successful outcome from the index patient and partners has a direct impact on wider public health issues and associated rates of infection.¹⁰

Various approaches may be utilised whilst bearing in mind that this is voluntary in the UK and individuals do not have to participate in this activity. Intensive approaches are unsurprisingly, correspondingly more effective.¹¹

A wide variety of factors can impede providers of PN. The associated stigma and anxiety around STIs can create challenges for the healthcare professional undertaking this in terms of engagement with the index or source patient and draw on input and time.
Gorbach et al. found that up to one third of patients failed to tell all their partners because of embarrassment or fears for their personal safety or reputation.¹² They also report that the least likely to be informed are casual and ex-partners, a fact supported by other studies.^10,13

PN aims to support patients with an STI such as PID, with the often difficult task of informing past or present partners who are likely to have no forewarning, of their possible exposure to infection and the need to access treatment. Bell and Potterat also describe further beneficial dimensions including ethics (duty to warn), disease control (case finding) and epidemiology (identifying factors associated with STI transmission).¹³

Discussions about partners and how they will access relevant services requires more than geographical instructions. There is often much more at stake in terms of future relationships whether it be closure, continuation with current partners or a review and agreement of an on – going relationship. There is often an issue of a “casual partner”, which equally requires sensitivity and a respectful approach if the HCP is to engage the trust of the index patient, promote safer sexual health and ultimately prevent the onward transmission of infection. In these cases other methods need to be employed.

There is clearly a theoretical rationale for contacting sexual partners of a person with a bacterial STI in that individuals with asymptomatic infection are identified and treated, thereby reducing morbidity and the duration of potential infectivity.

There is also a deeper level to consider. It is vital that PN strategies take a wider view and pay attention to more than individual case finding as there may well be individuals intentionally or unintentionally withholding information about sexual contacts.⁵ These missing individuals may be playing a key role in maintaining levels of infection.¹³

Patient referral involves the index patient inform partners themselves, or they may supply contact details to a healthcare worker in order to notify the partner without disclosing their identity – known as provider referral. When a longer time frame may be needed in order to aid the index patient for prepare to disclose to a partner, this is referred to as contract referral and may involve the setting of a time frame before the healthcare worker re-visits the issue. In a systematic review of PN strategies adopted, Matthews et al. found that there was moderately strong evidence that provider or contract referral increased the rate of partners attending for treatment and also that patient referral supported by verbal education together with a patient – centred counselling approach, improves the overall PN outcomes.¹⁴

There have been adjustments to ‘look back’ periods for STIs following the recent publication of the new BASHH statement on PN for STIs which are readily available online.³ However, as discussed it may well be more appropriate to refer to GUM in order to expedate the often drawn out process of follow up that this requires.

However, the look back interval for PID remains the same i.e. all contacts since and in the six months prior to the onset of symptoms. The six month look back interval for PID is given arbitrarily on the basis that Mycoplasma genitalium may cause disease in women and also be carried asymptomatically in men for an unknown period.^15,16 However further research is currently being undertaken in the author’s area of practice to examine this in more depth.

As Bell and Potterat note, the effectiveness of PN is commonly measured in terms of process rather than impact.¹³ In terms of the PID pathway, a database of all PID referrals from Gynaecology is maintained by the liaison HAs and regularly updated. This ensures for example that patients who have had difficulty notifying partners have the opportunity for further support and advice in achieving this.

A common misbelief or misunderstanding was that once the once it was confirmed that the women’s chlamydia gonorrhoea result was negative, they could stop treatment and there was no need for the partner to be treated as a contact.

From a purely anecdotal view there was a belief amongst male partners that they “would know if there was a problem” and that therefore they did not require any treatment or screening.^17,18

This belief presented challenges in terms of partner notification , particularly when male partners had witnessed their female partner being admitted with symptoms and a feeling that there may be some blame or fault. However, with careful, timely and well judged advice from the HA this was largely overcome.

There is no doubt that the agreed plan of follow up care requires time and energy re input from liaison health advisors – patients may prove elusive to follow up in terms of contact details, engagement with PN, as new rotations of medical staff rotate it requires further input and education in order to maintain awareness of the pathway and relevant proforma – including the need for consent from the patient to be contacted by the HA and establishing the correct and preferred method of contact.

PN interviews may employ a varied approach and therefore utilise different techniques to encourage patients to inform sexual partners, either themselves or via the health advisor once they feel comfortable in providing the necessary information and understand that there would be no compromise to their identity and associated confidentiality.

The recommendations in the PID guidelines may not be appropriate for use in all clinical situations. Decisions to follow these must be based on the professional judgement of the clinician and consideration of individual patient circumstances and available resources.

Health Advisors would certainly not claim to be the only Health Care Professionals capable of carrying out basic partner notification and would both encourage and support other colleagues to carry this out, particularly as there is an emphasis on patient directed PN. However, in terms of follow up and particularly where further input and careful negotiation is required, this on-going work  would indicate that an agreed pathway with clear methods of feedback provides the best outcomes for patient care, reduces the risk of onward and or re-infection and places the least demands on already pressurised gynaecology resources

Following the success of the PID referral pathway, the Liaison HAs have also set in place an agreed pathway whereby they are informed electronically via a daily email link from the Virology Department of any positive chlamydia diagnoses within the Trust and follow these up accordingly. As with the PID diagnoses, this contact is fed back to the relevant Obstetrician and Gynaecology Consultant including the final outcomes for documentation in the patient’s main medical records.

At its very best PN is a tool that holds potential to control infection. It can contribute to the control of PID by identifying and treating previously undiagnosed infection in the sexual contacts of known cases, thereby preventing reinfection of the index patient, or transmission to others.

A joined up approach between GUM and Gynaecology teams with agreed clear pathways and link key named staff can provide a robust, efficient and enhance the standard of care for women diagnosed with PID and therefore in turn address important public health issues. It is clear that successful negotiations that result from the partner or partners attending may protect the patient from re-exposure, both from complications of an untreated infection and furthermost, the community from onward transmission.

References

1. Cohen, C.R., Manhart, L.E., Bukusi, E.A., Astete, S., Brunham, R.C., Holmes, K.K. 2002. Association between mycoplasma genitalium and acute endometritus. Lancet 359, 765-766.
2. Simms, I., Eastick, K., Mallinson, H., Thomas, K., Gokhale, R., Hay, P., Herring, A., Rogers, P.A. Associations between Mycoplasma genitalium, Chlamydia trachomatis and pelvic inflammatory disease. Journal of Clinical Pathology. 2003. 56;616-618.
3. British HIV Association, British Association for Sexual Health and HIV and the Faculty of Sexual and Reproductive Healthcare. UK guidelines for the management of sexual and reproductive health (SRH) of people living with HIV infection. See: www.bashh.org/documents/1955 (last accessed 27 February 2012)
4. Ross, J. and McCarthy, G. 2011. UK National Guidelines for the Management of PID. Clinical effectiveness Group. British Association of Sexual Health and HIV.
5. Society of Sexual Health Advisers (SSHA). The Manual for Sexual Health Advisers.
6. Bell, G. and Brady, V. Monetary Incentives for sex workers. 2000. Letter to the Editor. International Journal of STI and AIDS. 11, 483-484.
7. Morton, R.S. and Kinghorn, G.R. Genitourinary chlamydial infection:a reappraisal and hypothesis. International Journal of STD and AIDS. 1 Dec.1999. Vol 10.No.12 765-775
8. Estcourt, C.S., Sutcliffe, L.J. andShackleton, T. 2009 Achieving successful partner notification: putting together the pieces of the puzzle. International Journal of STD and AIDS 20, 9:601-602.
9. Oakeshott, P., Kerry, S., Aghaizu, A. Atherton, H., Hay, S., Taylor-Robinson, D., Simms, I., Hay, P. Radomised controlled trial of screening for chlamydia trachomatis to prevent pelvic inflammatory disease:the POPI (prevention of pelvic infection) trial. BMJ 2010;340:c1642.
10. Trelle, S., Shang, A., Nartey, L., Cassell, J., Low, N. 2007. Improved effectiveness of partner notification for patients with sexually transmitted infections: systematic review. BMJ 334:734-41 doi:bmj 39079 460741 7C accessed 19/08/2012
11. Brewer, D.D. 2005 Case finding effectiveness of partner notification and cluster investigation for sexually transmitted diseases/HIV.  Sexually Transmitted Diseases 32,78-83.
12. Gorbach, P., Aral, S. and Cellum, C. 2000. To notify or not to notify: STD patients’ perspectives. Sexually Transmitted Diseases 27:193-200.
13. Bell, G. and Potterat, J. 2011 Notification for sexually transmitted infections in the  modern world: a practitioner perspective on challenges and opportunities. Sexually Transmitted Infection; 87:1134-1136
14. Matthews, C., Coetzee, N., Zwarenstein, M., Lombard, C. 2001. Strategies for partner notification for sexually transmitted diseases. Cochrane database systematic review.
15. Dave, S., Kerry, S.R., Oakeshott, P., Mcgregor, F., Cannon, E. Stephenson, J.M. 2012. Women’s Health Study of Mycoplasma genitalium: A feasibility study. St George’s University of London. UK CNWL Camden Provider Services, London , UK.
16. Ross, J.D.C., Brown, L., Saunders, L.P., Alexander, S. Mycoplasma genitalium in asymptomatic patients: implications for screening. Sex Transm Infect 2009; 85:436-7
17. Tolman, D.L., Stripe, M.I., Harman, T. 2003. Journal of Sex Research, 40:1
18. Yarmey, G. 1999. Sexual and reproductive  health: what about boys and men? BMJ 319:1315.

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