Prognosis Predictors of Pelvic Inflammatory Disease among the Hospitalized Patients

Introduction: Serious reproductive health consequences linked to pelvic inflammatory disease (PID) include infertility and ectopic pregnancy. Thus, it is important to identify patients likely to have a poor prognosis in choosing the best initial treatment. The aim of our study was to identify the valuable prognosis predictors of PID among the hospitalized patients and determined cut off values of quantitative independent prognosis predictors. Material and methods: Hospital records for women hospitalized with PID were retrospectively examined. The PID patients were divided into two sub-groups according to their clinical outcome. Prognostic factors were evaluated by T-test, χ2-test, and logistic regression analysis. The cut-off values of age, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and ESR combined with CRP were calculated by receiver-operator curve analysis. Results: Independent prognosis predictors of PID were advanced age (OR=1.031, 95% CI=1.002-1.062; P=0.036), elevated ESR (OR=1.029, 95% CI=1.013-1.046; P<0.001), increased CRP (OR=1.096, 95% CI=1.0271.169; P=0.006), and presence of endometriosis (OR=5.700, 95% CI=1.123-28.943; P=0.025). The cut-off values of age, ESR, CRP, and ESR combined with CRP were 35 years, 30.5 mm/hr, 7.0 mg/dL, and 25 mm/hr and 6.5 mg/ dL respectively. Conclusions: The initial treatment of patients who are elderly, and/or who have endometriosis, elevated ESR, or increased CRP should be carefully decided. Evaluation of ESR together with CRP is recommended to gain a more accurate prediction of disease outcome. Page 2 of 5 Citation: Lee MH, Hwang JY, Back JW, Kong DS, Lee GH, et al. (2016) Prognosis Predictors of Pelvic Inflammatory Disease among the Hospitalized Patients. Gynecol Obstet (Sunnyvale) 6: 366. doi:10.4172/2161-0932.1000366 Volume 6 • Issue 3 • 1000366 Gynecol Obstet (Sunnyvale) ISSN: 2161-0932 Gynecology, an open access journal the favorable clinical course group and 162 (58.1%) were in the poor clinical course group. Using T-test and χ2-test, mean age, platelet count, ESR, CRP, presence of endometriosis, and rate of IUD use were higher in the poor clinical course group than in the favorable clinical course group. There were no significant differences between the groups in terms of MPV level and rate of previous intrauterine surgery (Table 1). Independent prognosis predictors of PID were advanced age (OR=1.031, 95% CI=1.002-1.062; P=0.036), elevated ESR (OR=1.029, 95% CI=1.013-1.046; P<0.001), increased CRP (OR=1.096, 95% CI=1.027-1.169; P=0.006), and presence of endometriosis (OR=5.700, 95% CI=1.123-28.943; P=0.025). Platelet count and IUD use were not independent prognosis predictors (Table 2). A ROC curve was constructed and used to select cut-off values for the occurrence of poor prognosis. The area under the curve (AUC) for age was 0.63 and the cut-off value was 35 years of age, yielding a sensitivity of 51.9% and specificity of 66.7% (Figure 1A). For ESR, the AUC was 0.78 and the cut-off value was 30.5 mm/hr, yielding a sensitivity of 75.2% and specificity of 72.2% (Figure 1B). For CRP, AUC was 0.77 and the cut-off value was 7.0 mg/dL, yielding a sensitivity of 79.5% and specificity of 46.9% (Figure 1C). For ESR combined with CRP, AUC was 0.79 and the cut-off value was 25 mm/hr and 6.5 mg/ dL, respectively, yielding a sensitivity of 81.5% and specificity of 73.5% (Figure 1D). Discussion The present study was a comprehensive analysis of the effect of multiple variables on the poor prognosis of PID. Advanced age, elevated ESR, increased CRP, and presence of endometriosis were independent prognosis predictors of PID. Patient age was previously implicated as a potential prognosis predictor of PID [4]. Age was also reported as an independent factor predictive of TOA in acute PID, with an age exceeding 35 years old a benchmark that strongly correlated with an increase in the risk for PID surgery as a result of failed conservative treatment [6,7]. The present pregnancy, and admission diagnosis of tubo-ovarian abscess (TOA) on admission. Following exclusions, 279 women were studied. When conducted, combination therapy comprised triple antibiotic therapy with metronidazole, aminoglycoside, and cephalosporin. Patients received these antibiotics until clinical symptoms and signs improved. The PID patients were divided into two sub-groups according to their clinical outcome. The median duration of hospitalization for all cases was 7 days. One group comprised 117 patients discharged within 7 days and only given a conservative treatment (favorable clinical course group). The other group comprised 162 patients who needed hospitalization for more than 7 days and/or diagnosed with pyosalpinx or TOA after being hospitalized on day 2 (poor clinical course group). There were 267 cases of uncomplicated PID and 12 cases of complicated PID suspected as pyosalpinx or TOA after the second day of hospitalization. The patients with complicated PID were included in the poor clinical course group. Factors used for prediction of prognosis were obtained on admission. Patients diagnosed before admission or upon entry with endometriosis were included. Intrauterine operations included embryo transfer (ET), intrauterine insemination (IUI), dilatation and curettage (D&C), and hysteroscopy (HSC). These were categorized into one group because all involved insertion of instruments into the uterine cavity through the cervix. The subdivisions for intrauterine operation (favorable/poor clinical course) were ET (0/0), IUI (0/0), D and C (28/56), and HSC (19/21). The results obtained were statistically analyzed with the Statistical Package for Social Sciences software program (SPSS, Chicago IL, USA). T-and χ2-tests were used for data analysis as appropriate. Binary logistic regression analysis was performed to reveal the independent prognosis predictors of PID. A P-value<0.05 was considered statistically significant. The cut-off values for age, ESR, CRP, and ESR combined with CRP were calculated by the receiver-operator curve (ROC) analysis. Results Among the 279 females diagnosed with PID, 117 (41.9%) were in Factors Favorable clinical course group (n=117) Poor clinical course group (n=162) 95% CI P-value Age 30.47 ± 9.07 35.42 ± 11.01 2.578-7.322 <0.001 MPV 7.52 ± 0.88 7.60 ± 0.78 -0.392 NS Platelet count 300910 ± 90470 334320 ± 123238 6.967-59.846 0.01 ESR 23.03 ± 21.65 47.20 ± 27.26 18.400-29.944 <0.001 CRP 3.37 ± 4.91 8.50 ± 6.74 3.755-6.501 <0.001 Intrauterine surgery 47(40.2%) 77(47.5%) -1.933 NS Endometriosis 2(1.7%) 13(8.0%) 0.040-0.216 0.029 IUD use 10(8.5%) 31(19.1%) 0.044-0.251 0.016 Values are given as a mean standard deviation or number (percentage). CI: Confidence Interval; MPV: Mean Platelet Volume; ESR: Erythrocyte Sedimentation Rate; CRP: C-Reactive Protein; IUD: Intrauterine Device; NS: Non-Significant; PID: Pelvic Inflammatory Disease Table 1: T-test and χ2-test of factors related to the clinical course of PID. Factors Odds ratio 95% CI P-value Age 1.031 1.002-1.062 0.036 Platelet count 0.998-1.004 NS ESR 1.029 1.013-1.046 <0.001 CRP 1.096 1.027-1.169 0.006 Endometriosis 5.700 1.123-28.943 0.025 IUD use 0.788-4.469 NS CI: Confidence Interval; ESR: Erythrocyte Sedimentation Rate; CRP: C-Reactive Protein; IUD: Intrauterine Device; NS: Non-Significant; PID: Pelvic Inflammatory Disease Table 2: Multivariate analysis of factors related to the clinical course of PID. Page 3 of 5 Citation: Lee MH, Hwang JY, Back JW, Kong DS, Lee GH, et al. (2016) Prognosis Predictors of Pelvic Inflammatory Disease among the Hospitalized Patients. Gynecol Obstet (Sunnyvale) 6: 366. doi:10.4172/2161-0932.1000366 Volume 6 • Issue 3 • 1000366 Gynecol Obstet (Sunnyvale) ISSN: 2161-0932 Gynecology, an open access journal data corroborate advanced age as an independent prognosis predictor of PID, with a cut-off value of 35 years. Possible explanations for age as an influence in a poor clinical outcome in women with PID are inherent weakness or vulnerability of the subjects, a tendency not to seek medical help at an advanced age, and delayed diagnosis due to a reduced suspicion of PID among gynaecologists [4]. PID patients over 35 years of age require careful initial management. The consensus is that ESR and CRP are related with poor prognosis in PID and that these factors reflect PID severity. In a previous study, ESR with CRP levels were useful for assessing the severity of acute PID [8]. Another study concluded that ESR>50 mm/h was the best predictor of TOA and prolonged hospital stay in PID patients [5]. Our study findings echo these observations and add to the weight of evidence of an association between ESR and CRP and poor clinical course. ROC analysis indicated an ESR and CRP cut-off value of 30.5 mm/hr and 7.0 mg/dL, respectively (ESR: sensitivity of 75.2% and specificity of 72.2%, CRP: sensitivity of 79.5% and specificity of 46.9%). Furthermore, the cut-off value of ESR combined with CRP was >25 mm/hr and >6.5 mg/ dL, a sensitivity of 81.5% and specificity of 73.5%. The cut-off value of ESR combined with CRP was more predictive than the separate cut-off A 1.0