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Importance: Chlamydia and gonorrhea are among the most common sexually transmitted infections in the US. Infection rates are highest among adolescents and young adults of both sexes. Chlamydial and gonococcal infections in women are usually asymptomatic and may lead to pelvic inflammatory disease and its associated complications. Newborns of pregnant persons with untreated infection may develop neonatal chlamydial pneumonia or gonococcal or chlamydial ophthalmia. Infection in men may lead to urethritis and epididymitis. Both types of infection can increase risk of acquiring or transmitting HIV., Objective: To update its 2014 recommendation, the US Preventive Services Task Force (USPSTF) commissioned a systematic review to evaluate the benefits and harms of screening for chlamydia and gonorrhea in sexually active adolescents and adults, including pregnant persons., Population: Asymptomatic, sexually active adolescents and adults, including pregnant persons., Evidence Assessment: The USPSTF concludes with moderate certainty that screening for chlamydia in all sexually active women 24 years or younger and in women 25 years or older who are at increased risk for infection has moderate net benefit. The USPSTF concludes with moderate certainty that screening for gonorrhea in all sexually active women 24 years or younger and in women 25 years or older who are at increased risk for infection has moderate net benefit. The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for chlamydia and gonorrhea in men., Recommendation: The USPSTF recommends screening for chlamydia in all sexually active women 24 years or younger and in women 25 years or older who are at increased risk for infection. (B recommendation) The USPSTF recommends screening for gonorrhea in all sexually active women 24 years or younger and in women 25 years or older who are at increased risk for infection. (B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for chlamydia and gonorrhea in men. (I statement).

Importance: The 2014 US Preventive Services Task Force (USPSTF) recommendation statement supported the effectiveness of screening for chlamydia and gonorrhea in asymptomatic, sexually active women 24 years or younger and in older women at increased risk for infection, although evidence for screening in men was insufficient., Objective: To update the 2014 USPSTF review on screening for chlamydial and gonococcal infection in adults and adolescents, including those who are pregnant., Data Sources: Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Ovid MEDLINE (January 1, 2014, through May 28, 2020) with surveillance through May 21, 2021., Study Selection: Randomized clinical trials and observational studies of screening effectiveness, accuracy of risk stratification and alternative screening methods, accuracy of tests, and screening harms., Data Extraction and Synthesis: One investigator abstracted data; a second checked accuracy. Two investigators independently assessed study quality., Main Outcomes and Measures: Complications of infection; infection transmission or acquisition; diagnostic accuracy of anatomical site-specific testing and collection methods; screening harms., Results: Twenty-seven studies were included (N = 179 515). Chlamydia screening compared with no screening was significantly associated with reduced risk of pelvic inflammatory disease (PID) in 2 of 4 trials and with reduced hospital-diagnosed PID (0.24% vs 0.38%); relative risk, 0.6 [95% CI, 0.4-1.0]), but not clinic-diagnosed PID or epididymitis, in the largest trial. In studies of risk prediction instruments in asymptomatic women, age younger than 22 years demonstrated comparable accuracy to extensive criteria. Sensitivity of chlamydial testing was similar at endocervical (89%-100%) and self- and clinician-collected vaginal (90%-100%) sites for women and at meatal (100%), urethral (99%), and rectal (92%) sites for men but lower at pharyngeal sites (69.2%) for men who have sex with men. Sensitivity of gonococcal testing was 89% or greater for all anatomical samples. False-positive and false-negative testing rates were low across anatomical sites and collection methods., Conclusions and Relevance: Screening for chlamydial infection was significantly associated with a lower risk of PID in young women. Risk prediction criteria demonstrated limited accuracy beyond age. Testing for asymptomatic chlamydial and gonococcal infections was highly accurate at most anatomical sites, including urine and self-collected specimens. Effectiveness of screening in men and during pregnancy, optimal screening intervals, and adverse effects of screening require further evaluation.

Objective: To determine the most cost-effective method of screening for chlamydia and gonorrhea to prevent pelvic inflammatory disease (PID) in asymptomatic sexually active adolescent females., Design: Cost-effectiveness decision analysis comparing pelvic examination with cervical screening (the current national standard) with a model of urine screening with ligase chain reaction testing for Chlamydia trachomatis and Neisseria gonorrhoeae., Methods: Four strategies using decision analysis were compared for a potential cohort of 100000 asymptomatic sexually active young women: (1) pelvic examination screening in 100%; (2) urine screening in 100%; (3) actual predicted pelvic examination screening in 70%; and (4) actual predicted urine screening in 90%. Assumptions and costs were generated from published sources., Main Outcome Measures: Cases of PID prevented per year and cost to prevent a case of PID., Results: A total of 1750 cases of PID would be predicted to occur per year with no screening. Strategy 1 would prevent the most cases of PID (1283) at a mean cost of $10230. Strategy 2 would prevent 1215 cases of PID at a mean cost of $5093. The marginal cost to prevent an additional case of PID by strategy 1 is $101454. Strategy 3 would prevent 898 cases of PID and 1093 cases of PID would be prevented with urine screening in strategy 4., Conclusion: Urine-based ligase chain reaction screening is the most cost-effective strategy to detect chlamydial and gonococcal genital infection in asymptomatic sexually active adolescent females and, owing to ease of implementation, the most likely to prevent the greatest number of cases of PID.

Effective strategies for preventing pelvic inflammatory disease (PID) are crucial to protect women from adverse reproductive consequences and to avoid substantial economic losses. To identify current PID prevention options and assess their efficacy, we conducted a literature search and examined relevant data in published reports. We organized our review by level of participation (ie, individuals, providers, and communities) and prevention (ie, primary, secondary, and tertiary). For individuals, several prevention strategies related to personal protection appear promising, but few have been appropriately evaluated. For providers of health care, five prevention measures are recommended, including such primary prevention activities as counseling and patient education in addition to the usual diagnosis and treatment. Specific evidence supporting the efficacy of these provider practices, however, is limited. For communities, maintaining comprehensive sexually transmitted disease control strategies to prevent lower genital tract chlamydial and gonococcal infection is most important in reducing both symptomatic and asymptomatic PID. We provide specific recommendations for preventing PID and outline research needs.

To assess the risk for pelvic inflammatory disease (PID), a practitioner must evaluate the likelihood that a woman has PID or will be exposed to a sexually transmitted disease causing PID. Successful risk assessment depends on accurate information about variables influencing risk of PID. To determine the current state of knowledge about PID risk variables, we examined data in published reports. Data on each risk variable were scrutinized to discern which link(s) in the PID risk chain it affects (acquisition of a sexually transmitted disease, development of PID, or development of PID sequelae) and whether it is a risk marker or a risk factor. Most PID risk variables, particularly sexual behaviors, are associated with acquisition of a sexually transmitted disease, rather than development of PID itself. With the exception of age, demographic and social indicators of risk appear to be risk markers, while contraceptive practices appear more often to be risk factors than risk markers. Additional data are needed for most PID risk variables confidently to categorize them as risk factors. Enough information is available, however, to begin assessing risk for PID, so that appropriate counseling can ensue and timely diagnosis can be made.

The protective effect of barrier-method contraception against pelvic inflammatory disease (PID) was examined by analyzing data from the Women's Health Study, a large multicenter case-control study. We compared the contraceptive methods used by 645 women hospitalized for initial episodes of PID with the contraceptive methods used by 2,509 control subjects reporting no history of PID. The risk of hospitalization for PID in women currently using barrier methods relative to women using all other methods and to women using no method of contraception was 0.6 (95% confidence limits, 0.5 to 0.9) for both comparisons. This protective effect was observed for both chemical and mechanical barrier methods, although it was not statistically significant for the former. The prevention of PID and its sequelae is one of the most important noncontraceptive benefits of barrier methods of contraception.

Management of pelvic inflammatory disease (PID) and decisions about contraception are being influenced by reports that oral contraceptives decrease the risk of PID. To evaluate the validity of this association, we have examined published epidemiologic evidence and reviewed relevant information from other disciplines. Current information does not permit the generalization that oral contraceptives protect against all forms of PID. Most studies conducted (1) have been limited to hospitalized women, who represent less than 25% of all PID cases and are likely to have relatively severe forms of the disease, and (2) have failed to distinguish between gonococcal and nongonococcal PID. While oral contraceptives may provide some protection against gonococcal PID, no basis exists for assuming similar protection is provided against chlamydial PID. In fact, epidemiologic and biologic evidence suggests that infection with Chlamydia trachomatis, the leading cause of nongonococcal PID, is enhanced by oral contraceptives. We judge the conclusion that oral contraceptives protect against all PID to be premature, and urge caution in its application in health policy and clinical decisions.