A Perfect Storm of Noncompliance: Chlamydia Trachomatis Infection and Progressive Pelvic Inflammatory Disease in an Adolescent Patient

Introduction: Adolescents are at risk for poor adherence to pelvic inflammatory disease (PID) treatment and adverse reproductive health outcomes. We report a case of Chlamydia trachomatis and progressive PID in an adolescent with a complex social situation.

Case Description: A 15-year-old female presented to clinic with nausea and mild abdominal pain; Chlamydia trachomatis urine NAAT was positive. Upon follow-up she was afebrile but had adnexal, uterine and cervical motion tenderness. Urine pregnancy test, HIV and syphilis testing were negative. She disclosed her sexual activity but not her chlamydia diagnosis to her mother, who disallowed contraception. She was given medroxyprogesterone confidentially, IM ceftriaxone and sent home with metronidazole and doxycycline; expedited partner therapy prescription was provided. Ten days later, she admitted taking only 2 doses of antibiotics. She was taken out of her mother’s custody after a physical altercation and placed in a short-term residential program where she refused antibiotics. Four days later she was admitted to the hospital after development of vaginal bleeding and severe abdominal pain without fever; ultrasound revealed endometritis and cystitis with likely infected pelvic free fluid. She was treated with an alternative azithromycin regimen as she refused compliance otherwise. She demonstrated complete lack of concern or understanding of the risks behind untreated PID despite multiple provider discussions. Upon discharge she remained in her placement program for two weeks during which time she completed azithromycin only under threat of removal of privileges.

Discussion: (1) Multiple challenges may exist in ensuring an adolescent’s compliance with an outpatient regimen for PID. (2) There is insufficient evidence to guide best practice strategies for PID in this group due to low enrollment of early and middle adolescents in national trials. (3) Alternative PID regimens may be necessary to ensure compliance and successful treatment in this population.