Predictive value of clinical diagnostic codes for the CDC case definition of pelvic inflammatory disease (PID): implications for surveillance

BACKGROUND: Reporting of pelvic inflammatory disease (PID) from private providers could be incomplete because of time and staff constraints, lack of knowledge of reporting requirements and of case definitions. Reporting burden can be alleviated with the use of administrative data. GOAL: The goal of this study was to determine the validity of clinical diagnostic codes assigned in electronic medical records (EMR) for identifying PID and their use in enhancing surveillance. STUDY DESIGN: A random sample of 296 records with a PID International Classification of Diseases, 9th Revision (ICD-9), code (614.9) were reviewed to assess for the presence of the Centers for Disease Control and Prevention (CDC) criteria for the case definition of PID. We used the records meeting the CDC clinical case definition criteria as the reference standard to determine the sensitivity, specificity, and predictive values of various data elements. RESULTS: Used alone, the positive predictive value (PPV) of ICD-9 code 614.9 for a CDC case definition of PID was 18.1%. The PPV increased to 100% and 56% when the ICD-9 code visit was associated with a positive test for Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT), respectively. CONCLUSION: In this multispecialty group practice, a positive test for GC and CT coupled with ICD-9 code 614.9 could be used to enhance reporting of cases of PID.     

Incompleteness of reporting of laboratory-confirmed chlamydial infection by providers affiliated with a managed care organization, 1997-1999

BACKGROUND: Surveillance for sexually transmitted diseases (STDs) depends on the receipt of positive STD test results from laboratories or reports of STD diagnoses from clinicians to local or state health departments. GOAL: The goal of this study was to evaluate incompleteness of reporting of chlamydial infection in a large staff-model managed care organization (MCO) using laboratory data and provider-based reports. METHODS: All cases of chlamydial infection in 2 databases, one from the MCO during January 1997 through June 1999 and the other from the state STD registry, were compared by using a standard algorithm alone that included patient's name, sex, and date of specimen collection, and by using the standard algorithm together with the patient's medical record number. RESULTS: Of 833 cases of chlamydial infection in the MCO case database, 597 were matched to the cases in the state registry using the standard algorithm alone and 671 were matched using the standard algorithm together with the patient's medical record number. In addition, 89 cases of chlamydial infection in the state registry had been reported from the MCO during the same timeframe but were not matched to cases in the MCO case database by these algorithms. The estimated incompleteness of reporting ranged from 9% to 28% depending on matching algorithms used and the criteria used to define completeness. CONCLUSION: Based on this comparison of MCO data with the state STD registry data, the estimated incompleteness of reporting in a MCO depended on matching algorithms used and the criteria used to define completeness. Incompleteness of STD case reporting could be reduced if confidential electronic reporting methods and more complete case characteristic variables were used.     

Assessing neonatal herpes reporting in the United States, 2000-2005

OBJECTIVES: We describe neonatal herpes reporting and the number of cases reported in states with reporting requirements in the United States, 2000-2005. METHODS: A national assessment of neonatal herpes reporting practices was conducted using an e-mail and phone query. RESULTS: Neonatal herpes was a reportable condition in 9 states in the United States from 2000-2005: CT, MA, FL, OH, NE, LA, SD, DE, and WA. There was no standard surveillance case definition in 5 states and in 4 states there was no specific form for reporting neonatal herpes. Few cases were reported in any state (range, 0-13 cases per year). A total of 112 cases were reported in these 9 states over 5 years (2000-2004); the overall incidence rate was 4 cases/100,000 live births. CONCLUSIONS: Although reportable in some states, neonatal herpes is not currently a nationally reportable disease. As currently employed by individual states during this time frame, neonatal herpes reporting does not appear to be a reliable way to assess burden of disease. Development of a standard case definition and assessment of the best approaches for local and national neonatal herpes surveillance may improve performance of such reporting.     

Quality of life utilities for pelvic inflammatory disease health states

PURPOSE: Quality of life utilities for health states associated with pelvic inflammatory disease (PID) have been estimated but not directly measured. Utilities for PID could have important implications on the cost-effectiveness of interventions to prevent and manage this disease. METHODS: We obtained, in women with versus without a history of PID, visual analogue scale (VAS) and time-tradeoff (TTO) valuations for 5 PID-associated health states: ambulatory PID treatment, hospital PID treatment, ectopic pregnancy, chronic pelvic pain, and infertility. Subjects read brief scenarios describing the medical, functional, and social activity effects typically associated with each state, then gave valuations in the order above. RESULTS: Health state valuations were obtained from 56 women with and 150 women without a PID history. Subjects with a PID history had significantly lower mean valuations (P <0.05) on the VAS for ectopic pregnancy (0.55 vs. 0.63), pelvic pain (0.45 vs. 0.53), and infertility (0.53 vs. 0.66) but not on the TTO; VAS differences remained significant when controlling for demographic and childbearing characteristics. VAS and TTO valuations were similar in women with versus without a history of PID for the ambulatory and hospital PID treatment health states. CONCLUSION: PID has substantial impact on utility. In addition, some PID-related health states are valued less by women who have experienced PID, which could affect cost-effectiveness analyses of PID treatments when examined from the societal versus patient perspective.     

Health care access and follow-up of chlamydial and gonococcal infections identified in an emergency department

BACKGROUND: We examined 2 potentially important factors influencing successful treatment of Chlamydia trachomatis (Ct) and Neisseria gonorrhoeae (GC) infections identified in an emergency department (ED), health care coverage and reporting the ED as a primary source for health care. METHODS: Adult patients aged 18 to 35 years attending an urban ED were screened for Ct and GC. Patients testing positive were contacted by Disease Intervention Specialists and notified of their infection status. Analyses focus on infected patients for whom we have treatment and follow-up information. We used generalized linear models with log link and binomial error distribution to estimate risk ratios (RRs) and 95% confidence intervals (CI). RESULTS: Of 5537 patients screened in the ED, 348 (6.3%) tested positive for Ct, 143 (2.6%) tested positive for GC, and 43 (0.8%) tested positive for both. Overall, 20% of infected patients did not receive treatment. Among infected patients with no health care coverage 25% (n = 56) were untreated compared with 15% (n = 47) of patients reporting health care coverage (RR: 1.7, 95% CI: 1.2-2.3). Among patients reporting the ED as a primary source for health care 26% (n = 27) were untreated compared with the 18% (n = 77) reporting receiving health care from non-ED sources (RR: 1.4, 95% CI: 1.0-2.1). CONCLUSIONS: EDs often serve as primary care sites for difficult-to-reach populations. We were able to successfully locate and treat the greater part of ED-identified infections. However, one-fifth of infected patients did not receive treatment. ED-based screening programs can benefit from integration with local public health infrastructure to improve notification and treatment services.     

Universal screening or prophylactic treatment for Chlamydia trachomatis infection among women seeking induced abortions: which strategy is more cost-effective?

OBJECTIVE: The objective of this study was to evaluate the cost-effectiveness of universal screening and azithromycin-based prophylaxis against no intervention for Chlamydia trachomatis infection among women seeking induced abortions. METHODS: A decision tree was constructed to evaluate health effects of the program. Cost-effectiveness was estimated for universal screening and azithromycin-based prophylaxis against no intervention with a C. trachomatis test prevalence of 4.8%. RESULTS: Azithromycin-based prophylaxis produced higher cost but prevented 289 cases of pelvic inflammatory disease (PID) for a cost of 397 RMB (U.S. $48) per case of PID prevented over no intervention. Universal screening by polymerase chain reaction test prevented 253 cases of PID at a cost of 3,049 RMB (U.S. $372) per case of PID prevented over no intervention. Azithromycin-based prophylaxis prevented an additional 36 cases of PID, costing 18,239 RMB (US $2,224) less per case of PID prevented over universal screening. CONCLUSIONS: Azithromycin-based prophylaxis provided a cost savings over universal screening for chlamydial infection among women seeking induced abortion.     

Early syphilis in the United States identified in corrections facilities, 1999-2002

BACKGROUND: Corrections facilities offer public health practitioners an opportunity to gain access to large numbers of persons at risk for syphilis and other sexually transmitted diseases. GOALS: The goals of this study were to estimate the number of early syphilis cases (primary, secondary, early latent) identified from corrections facilities from 1999 to 2002 and to determine characteristics of persons likely to be identified with syphilis in corrections facilities. STUDY DESIGN: We determined the proportion of cases identified from corrections facilities for the entire United States using case reports by state health departments to the Centers for Disease Control and Prevention (CDC). We calculated the proportion of cases identified in corrections facilities in the 30 counties with the largest number of cases in 2002 and determined the male-to-female syphilis rate ratios. RESULTS: From 1999 to 2002, there were 63,293 cases of early syphilis reported to the CDC, of which 61,691 (97.5%) had a known source of report. Of these, 7725 (12.5%) noted corrections facilities as the source of information. Among men, 4747 (13.0%) cases were from corrections and in women 2974 (11.8%) of cases were. We found that counties with a higher proportion of cases from corrections facilities were likely to have lower male-to-female rate ratios (r = -0.66, P <0.001). CONCLUSIONS: A substantial proportion of early syphilis cases is identified from corrections facilities. Among counties with the largest number of cases, a higher proportion of syphilis cases was identified from corrections facilities in counties with higher rates of heterosexually transmitted syphilis.     

人工流产妇女衣原体普查和预防性治疗的成本效果分析

目的：评估人工流产妇女衣原体感染普查和阿奇霉素预防治疗的投入成本效果，确定不同并发症发生率对投入成本效果影响的敏感性。方法：建立决策树模型评价项目的效果，如预防衣原体感染的后遗症。在衣原体流行率为4．8％的基数上，从公共卫生角度评估普查和阿奇霉素预防治疗对无干预的成本效果。对后遗症和可预防性盆腔炎（PID）的发生率及贴现率进行了敏感性分析。结果：如感染率为4．8％，不干预将导致302例PID，并发症费用为296827元，阿奇霉素预防性治疗的费用为411525元，但可预防289例PID，与不干预相比，每预防1例PID需花费397元。应用PCR普查可预防253例PID，花费1018119元，与不干预相比，每预防1例PID需花费3049元。与普查相比，阿奇霉素预防治疗多预防36例PID，每多预防1例PID少花费18239元。结论：阿奇霉素预防治疗对人工流产妇女的衣原体感染具有成本效果。     

Prevalence and incidence of pelvic inflammatory disease in incarcerated adolescents

BACKGROUND: Few recent studies have determined the prevalence and incidence of pelvic inflammatory disease (PID) among adolescents. GOAL: The goal of this study was to determine these parameters among incarcerated youths. STUDY DESIGN: Both on admission and during incarceration, consecutive adolescents entering the Harris County, Texas, Juvenile Detention Center were evaluated for symptoms of PID. One of two experienced clinicians examined adolescents with possible PID. For the diagnosis of PID, we used the minimal criteria of the CDC. RESULTS: In sexually active heterosexual or bisexual adolescents (N = 313), the prevalence of PID at admission was 4.5%; during the first 31 days of incarceration, the incidence density of PID was 3.3 cases/100 person-months, and the cumulative incidence was 2.2%. The prevalence among these youths of chlamydial and/or gonorrheal infection, as determined by urine or cervical testing, was 24.9%. CONCLUSION: The high prevalence and incidence of PID underscore the need for effective programs to eradicate chlamydial and gonorrheal infections in high-risk youths.     

The cost effectiveness of gonorrhea screening in urban emergency departments

BACKGROUND: The prevalence of gonorrhea (GC) among adolescent and young women attending some urban emergency departments (EDs) ranges from 1% to 7%, but historically screening has not been logistically practical. GOAL: The primary goal of the study was to assess the cost effectiveness of GC screening in women ages 15 to 29, seeking care in urban EDs, using noninvasive or rapid point-of-care tests. STUDY: We developed a state-transition Markov model to compare the net lifetime health consequences, costs, and cost effectiveness of routine ED care (no screening for women without genitourinary symptoms) to GC screening using 1 of 5 detection methods: Gram-stained smears of endocervical swab specimens, urine-based nucleic acid amplification tests (NAATs), NAATs performed on endocervical swabs, rapid immunochromotographic strip test (RIS) performed on clinician-collected vaginal swabs, and RIS on patient-collected vaginal swabs. RESULTS: Screening women between 15 and 29 years of age using urine-based NAATs prevented 1247 cases of pelvic inflammatory disease (PID) and saved 177 US dollars per patient compared with no screening. Compared with urine-based NAAT, screening with RIS using clinician-obtained vaginal swabs prevented an additional 220 cases of PID and had an incremental cost effectiveness ratio of 6490 US dollars per quality-adjusted life year (QALY). Results were sensitive to assumptions about loss to follow-up, gonorrhea prevalence, and test costs. CONCLUSION: Screening females aged 15 to 29 for gonorrhea in some urban EDs will prevent substantial reproductive morbidity. Screening with rapid, point-of-care tests is cost effective compared with other well-accepted preventive interventions.     

Attendance by older patients at a genitourinary medicine clinic

OBJECTIVES: To determine how patients aged 50 and above had been referred to a department of genitourinary medicine (GUM), why they had attended, their sexual histories, and what diagnoses were made. To identify any special sexual health needs in this group of patients. METHODS: A case note review was undertaken of all patients aged 50 and over attending the Portsmouth GUM department over a 3 month period. RESULTS: There was a marked difference in reason for attendance between men and women in this older age group. Men were more likely to attend for a sexual health screen, often with minimal or no symptoms, following an extramarital or casual liaison. Women more commonly had symptoms causing difficulties with sexual intercourse with their regular partner. CONCLUSIONS: Older people present to GUM departments with a wide range of sexually associated problems. The diagnostic and management expertise available in GUM departments makes them ideal providers of sexual health care for this as well as younger age groups.     

The syphilis reactor grid: help or hindrance for syphilis surveillance?

BACKGROUND: Health departments use reactor grids (sex, age, and serologic test for syphilis [STS] titer criteria) to determine which persons to evaluate for untreated syphilis. GOAL: The goal of the study was to assess reactor grid performance in Chicago and reactor grid use nationally in 1999 to 2000. STUDY DESIGN: We reviewed Chicago health department records to identify characteristics of persons with a reactive STS excluded from evaluation by reactor grid criteria and syphilis cases not meeting evaluation criteria. We surveyed health departments regarding reactor grid use. RESULTS: Of persons with a reactive STS, 46% did not meet criteria for health department evaluation, including 62% of men, 29% of women, and 21% with titers > or =1:8. The reactor grid would have excluded 17% of primary syphilis cases. Overall, 82% of health departments use reactor grids. CONCLUSIONS: Reactor grids are widely used and may exclude persons with infectious syphilis from health department evaluation, especially men. The impact of reactor grid use on syphilis control and surveillance in the United States should be evaluated.     

Cost-effectiveness of five strategies for gonorrhea and chlamydia control among female and male emergency department patients

BACKGROUND: Previous studies have shown screening for gonorrhea and chlamydia to be cost-effective for limiting the sequelae of infection and the associated costs of management. GOAL: To evaluate the cost-effectiveness of enhanced screening for gonorrhea and chlamydia in an emergency department (ED) setting. STUDY DESIGN: Five strategies were compared with use of decision analysis for theoretical cohorts of 10,000 female and 10,000 male ED patients aged 18 years to 31 years: standard ED practice, three enhanced screening strategies, and mass treatment. Main outcome measures were untreated gonorrhea or chlamydia cases and their sequelae, transmission to a partner, congenital outcomes, and cost to prevent a case. This analysis, from the perspective of the healthcare sector, included medical case costs expressed in US dollars (1999), discounted at an annual rate of 3%. RESULTS: Mass treatment was the most cost-effective strategy among women and men. Of the screening strategies for women, universal screening combined with standard practice was the most cost-effective; it was used for treating 499 more cases of gonorrhea and chlamydia than was standard practice, saving $95.70 per case treated. Standard ED practice remained the most cost-effective strategy for men under a variety of circumstances. CONCLUSION: The authors recommend urine ligase chain reaction screening for gonorrhea and chlamydia in women aged 18 years to 31 years in the ED, in conjunction with standard ED practice, to decrease the occurrence of the sequelae and costs associated with infection.     

Surveillance systems for STIs in the European Union: facing a changing epidemiology

OBJECTIVES: To characterise the nature, content, and performance characteristics of existing national STI surveillance systems in the European Union (EU) and Norway, to facilitate collection of comparable surveillance data. METHODS: Cross sectional survey using a structured questionnaire. RESULTS: Case reporting from clinicians and/or laboratories is the mainstay of EU surveillance systems for bacterial STIs. Coverage of case reporting varies from less than 10% to over 75%, and lack of and/or heterogeneity in case definitions affect the relative specificity and sensitivity of reporting systems. Considerable variations also exist in STI care sites; the populations who use these services; and in partner notification practices, STI screening practices, and STI laboratory diagnostic tests employed, affecting the representativeness of reported data and the sensitivity of surveillance systems for detecting the true number of STI cases. CONCLUSIONS: The heterogeneity of current surveillance systems complicates direct comparison of STI incidence rates across Europe. Introduction of standardised case definitions for reporting, and increased coverage of mandatory reporting systems where necessary, are needed. Definition of standardised minimum datasets and use of sentinel and enhanced surveillance systems to supplement universal case/laboratory notification data, could improve our understanding of the distribution and determinants of STIs across Europe, and aid in the design of effective public health responses. In the context of the changing epidemiology of STIs, systems for detection and monitoring of localised outbreaks of acute bacterial STIs (syphilis and antimicrobial resistant gonorrhoea), as well as prevalence monitoring systems for frequently asymptomatic STIs (chlamydial infection and viral STIs), are also necessary.     

Control of Chlamydia trachomatis infections in female army recruits: cost-effective screening and treatment in training cohorts to prevent pelvic inflammatory disease.

CONTEXT: Chlamydia trachomatis genitourinary infections in females can lead to serious and costly sequelae. Programs such as basic (initial entry) military training with controlled points of entry offer an opportunity to screen large cohorts of women at risk for infection. OBJECTIVE: To assess the cost-effectiveness of three interventions for C. trachomatis infections in women beginning Army training: 1) screening using urine ligase chain reaction (LCR) by age, 2) unrestricted testing using urine LCR, and 3) universal antibiotic treatment with azithromycin. DESIGN: Cost-effectiveness analysis from a military perspective. SETTING AND PATIENTS: A hypothetical cohort of 10,000 women who intended to complete at least 2 years of military service was studied. Analysis was based on data from 13,204 female trainees screened for chlamydial infection at Fort Jackson, SC. OUTCOMES: Program and training costs, cost of illness averted, and pelvic inflammatory disease (PID) prevented were determined for a 1-year follow-up period. Using sensitivity analysis, outcomes over 2 years were studied. RESULTS: At a 9.2% prevalence, no screening resulted in $220,900 in training and sequelae costs and 276 cases of PID. Screening by age produced the lowest cost $217,600, over a 1-year period and prevented 222 cases of PID for a cost-savings of $15 per case of PID prevented. Universal testing prevented an additional 11 cases of PID at a cost of $226,400, or costing $800 per additional case of PID prevented over age-targeted screening. Universal treatment prevented an additional 32 cases of PID and cost $221,100, saving $167 per additional cases of PID prevented over universal screening. Over a 2-year period, universal treatment provided the highest cost-savings and prevented the most disease. CONCLUSION: Screening by age provided a cost-savings to the Army over a 1-year period. Other organizations accessing large cohorts of young women could also benefit, even in the short term, from implementation of an age-based chlamydial screening program. Universal testing or universal treatment may be warranted in which long-term societal goals, such as maximum reduction of PID, are relevant.     

The impact of urban community hospital surveillance for gonorrhoea on the infection rate and complications in the female. A progress report.

This study substantiates a previous report concerning the importance of the urban community hospital, particularly its emergency room, in the detection of gonorrhoea in women. Pelvic inflammatory disease (PID), a major complication of gonorrhoea in women, significantly declined during a nine-year surveillance and control programme in the Memphis-Shelby County area. This suggests that the programme may have prevented PID developing in women through the early detection and treatment of asymptomatic infections.     

The impact of urban community hospital surveillance for gonorrhoea on the infection rate and complications in the female. A progress report

This study substantiates a previous report concerning the importance of the urban community hospital, particularly its emergency room, in the detection of gonorrhoea in women. Pelvic inflammatory disease (PID), a major complication of gonorrhoea in women, significantly declined during a nine-year surveillance and control programme in the Memphis-Shelby County area. This suggests that the programme may have prevented PID developing in women through the early detection and treatment of asymptomatic infections.     

Improvement in the clinical cure rate of outpatient management of pelvic inflammatory disease following a change in therapy

OBJECTIVE: In the United Kingdom many genitourinary medicine clinics use oral doxycycline and metronidazole to treat pelvic inflammatory disease (PID). A retrospective case note review of PID treatment at our department in 2000 showed that the clinical cure rate (CCR) was only 55% with oral doxycycline and metronidazole for 2 weeks. We therefore added ceftriaxone 250 mg intramuscularly to the doxycycline and metronidazole for treating PID. We have repeated the review and compared the results with those from 2000. METHODS: All patients diagnosed as having PID between 1 July 2002 and 31 December 2002 were identified. These episodes were diagnosed on clinical presentations of pelvic pain, vaginal discharge or bleeding, and cervical motion tenderness on physical examination. The CCR was defined as patients who fully resolved their symptoms and signs during 2 week and 4 week follow up. The results were compared with those from 2000. RESULTS: Women receiving ceftriaxone, doxycycline, and metronidazole had a CCR of 72%. In 2000 the CCR for women receiving only doxycycline and metronidazole was 55%. There were only 8% non-responders in 2002 compared with 18% in 2000. Comparing CCR and non-response rate, in 2002 there was a significant improvement in cure rate, OR 3.01 (95% CI 1.28 to 7.47) p = 0.009. Using an intent to treat analysis and including the defaulters as treatment failures there was still a significant improvement in cure rate, OR 2.03 (95% CI 1.18 to 3.50) p = 0.009. CONCLUSIONS: The treatment of PID with ceftriaxone, doxycycline, and metronidazole gave a significantly higher CCR than doxycycline and metronidazole. Our experience would suggest that doxycycline and metronidazole alone is not a suitable regimen for treatment of PID in the United Kingdom.     

Prevalence and factors associated with gonorrhea and chlamydial infection in at-risk females presenting to an urban emergency department

BACKGROUND: Patients without a regular healthcare source are less likely to be tested, diagnosed, and treated effectively for sexually transmitted diseases (STDs). Emergency departments (EDs) are a major healthcare source for patients without health insurance or primary care providers. GOAL: This study evaluated the prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae in women aged 15 to 35 years presenting to a metropolitan ED with genitourinary or pregnancy-related complaints and the frequency with which patients were effectively treated for these infections during routine ED care. STUDY DESIGN: Women completed an interviewer-administered questionnaire and submitted urine for ligase chain reaction (LCR) testing for C trachomatis and N gonorrhoeae. RESULTS: The combined prevalence of gonorrhea and chlamydia was 16.4% (n = 62), and factors associated with infection included younger age and greater numbers of sex partners over 30 days. Problem-oriented care failed to detect infection in most cases, and 58% of infected women left the ED without effective therapy. Through a close working relationship with the local health department, we documented that 92% had received effective follow-up therapy. CONCLUSION: Continued efforts to refine and develop tools for the diagnosis and management of cervical infections for at-risk women seen in EDs are warranted.     

Comparison of acute and subclinical pelvic inflammatory disease

OBJECTIVE: The objective of this study was to compare the demographic, clinical, and microbiologic findings in women with subclinical pelvic inflammatory disease (PID) and women with acute PID. STUDY: A cross-sectional study was performed using cohorts from 2 separate studies of 1293 women at risk for PID. Most participants were recruited from emergency departments, sexually transmitted disease clinics, and family planning clinics in metropolitan centers. We compared demographic, clinical, and microbiologic findings among women with acute PID, women with subclinical PID, and women without endometritis (controls). Statistical analyses included chi-square for categorical variables, calculation of odds ratio and 95% confidence intervals, and polychotomous logistic regression when appropriate. RESULTS: Similar proportions of women with acute and subclinical PID tested positive for cervical Chlamydia trachomatis (odds ratio [OR], 1.1; 95% confidence interval, 0.6-2.0) and had bacterial vaginosis (OR, 0.7; 95% CI, 0.2-1.8). The rate of cervical Neisseria gonorrhoeae infection in women with subclinical PID was intermediate between the rates in women with acute PID and controls (21% vs. 49% vs. 7%, respectively, P <0.001, test for trend). Endometrial recovery of N. gonorrhoeae and C. trachomatis in women with subclinical PID was also seen at intermediate levels. Similar distributions of teenagers, women who smoked or used illicit drugs, and women engaging in sexual intercourse during menses were found in each group. Proportions of women with subclinical PID who were black and with lower education levels were intermediate between the proportions of these characteristics in women with acute PID and controls. CONCLUSION: Demographic and microbiologic characteristics of women with subclinical and acute PID are comparable. These findings suggest that the pathophysiological mechanisms of acute and subclinical PID are similar.