1. Is a short course of azithromycin effective in the treatment of mild to moderate Pelvic Inflammatory Disease (PID) Gillian Dean 1, Jenny Whetham 1, Suneeta Soni 1, Louise Kerr 1, Linda Greene 2, Jonathan Ross 3, Caroline Sabin 4 1 Brighton & Sussex University Hospitals NHS Trust, Brighton; 2 Imperial College Healthcare NHS Trust; 3 University Hospitals Birmingham NHS Trust, Birmingham; 4 Research Department of Infection & Population Health, UCL

2. 2 Background Current first line treatment for PID requires 2 weeks of antibiotics Adherence to 2 weeks treatment in young population is challenging It has been estimated only 30-80% complete the full 14-day course 1,2 Mycoplasma genitalium is increasingly implicated in the pathogenesis of PID, but incidence in the UK is poorly understood Current first line treatment doesn’t cover M. genitalium 1.Dunbar-Jacob J et al. Adherence to oral therapies in PID. J Womens Health 2004; 13:285-91 2.Brookoff D. Compliance with doxycycline therapy for outpatient treatment of PID. South Med J. 1994 Nov; 87:1088-91

3. 3 Study Aims & Methods Open label, randomised controlled trial (RCT) Arm 2 Arm 1 5-days azithromycin (1g day 1, then 500mg od), metronidazole 400mg bd plus 1 dose of im ceftriaxone 14-days ofloxacin 400mg bd & metronidazole 400mg bd 56 tablets16 tablets, 1 injection Expected to take 18 months Initially planned over 2 sites: Brighton & Sheffield. Extended to a further 7 sites: Imperial College, Eastbourne & Hastings, Woolwich, St Georges, Birmingham, Homerton, Charing Cross

4. 4 Primary outcome Clinical efficacy at day 14-21 days Defined as 70% or greater reduction in tenderness compared with baseline Pain measured using the modified McCormack pain scale Incorporated adherence & tolerability 0= tenderness absent 2= tenderness resulting in altered facial 1= tenderness described by the patient but not expression or muscle tone manifested by changes in facial expression or muscle tone 3= tenderness causing observable, marked distress

5. 5 Study populations & sample size Randomised population: all patients regardless of whether the treatment was taken or they returned for a follow-up visit Per-protocol population: patients who returned for a day 14-21 visit in whom the primary outcome was assessed Required n=396 - 198 women in each arm (80% power, one sided alpha=5%) - to demonstrate non-inferiority of the short course (non-inferiority margin 10%) Definition of treatment ‘failure’ 1. <70% reduction in tenderness score at 14-21 days 2. requirement of treatment switch for side effects 3. failure to return for assessment at 14-21 days

6. 6 Secondary outcomes Tolerability (incidence of side effects in each group) Adherence (self report, residual pill count) Prevalence of causative organisms Identify mycoplasma anti-microbial resistance if present – Oral Presentation 31

7. 7 Inclusion / exclusion criteria Inclusion criteria Pelvic discomfort for < 30 days Adnexal tenderness Exclusion criteria Age < 16 years Severe PID requiring hospital admission Positive pregnancy test or breast feeding UTI (leucocytes AND nitrites) Intracellular gram negative diplococci on microscopy or contact of GC < 3/12 Antibiotics within the last 7 days Known allergy to antibiotic component Ultrasound scan showing other pathology History of epilepsy / severe depression

8. 8 Results Recruitment period: Nov 2011-Sep 2015 (46 months)* N=313 women recruited * (28 month extension)

9. 9 Ofloxacin 153 Azithromycin 160 Eligible McCormack score 107 Subsequently ineligible no score n=5 Rx discontinued <day 14-21 n=1 Withdrew consent n=0 Subsequently ineligible no score n=6 Rx discontinued <day 14-21 n=0 Withdrew consent n=1 LTFU at day 14-21 n= 24 Attended outside day 14-21 n=16 LTFU at day 14-21 n= 22 Attended outside day 14-21 n=11 Randomised Population n=313 Eligible McCormack score 120

10. 10 Per-Protocol Population n=227 Ofloxacin 153 Azithromycin 160 Eligible McCormack score 107 Subsequently ineligible no score n=5 Rx discontinued <day 14-21 n=1 Withdrew consent n=0 Subsequently ineligible no score n=6 Rx discontinued <day 14-21 n=0 Withdrew consent n=1 LTFU at day 14-21 n= 24 Attended outside day 14-21 n=16 LTFU at day 14-21 n= 22 Attended outside day 14-21 n=11 Randomised Population n=313 Eligible McCormack score 120

11. 11 Demographics Ofloxacin (n=153)Azithromycin (n=160) Age (years), median (range)25 (17-47)25 (16-52) Ethnicity, n (%) White UK/non UK/other Black African / other 114 (74.5) 20 (13.1) 124 (78.1) 23 (14.4) Previous PID, n (%) Yes No Unknown 45 (29.4) 97 (63.4) 11 (7.2) 45 (28.1) 109 (68.1) 6 (3.8) Previous chlamydia, n (%) Yes No Unknown 49 (32.0) 93 (60.8) 11 (7.2) 54 (33.8) 100 (62.5) 6 (3.8) No. sexual partners last 3/12 median (range) 1 (0-50)1 (1-130)

12. 12 Baseline symptoms Ofloxacin (n=153) N (%) Azithromycin (n=160) N (%) Lower abdominal pain147 (96.1)150 (93.8) Vaginal discharge99 (64.7)103 (64.4) Deep dyspareunia75 (49.0)91 (56.9) Intermenstrual bleeding41 (26.8)35 (21.9) Dysuria36 (23.5)40 (25.0) Post coital bleeding27 (17.7)38 (23.8)

13. 13 Baseline symptoms Ofloxacin (n=153) N (%) Azithromycin (n=160) N (%) Lower abdominal pain147 (96.1)150 (93.8) Vaginal discharge99 (64.7)103 (64.4) Deep dyspareunia75 (49.0)91 (56.9) Intermenstrual bleeding41 (26.8)35 (21.9) Dysuria36 (23.5)40 (25.0) Post coital bleeding27 (17.7)38 (23.8)

14. 14 Baseline symptoms Ofloxacin (n=153) N (%) Azithromycin (n=160) N (%) Lower abdominal pain147 (96.1)150 (93.8) Vaginal discharge99 (64.7)103 (64.4) Deep dyspareunia75 (49.0)91 (56.9) Intermenstrual bleeding41 (26.8)35 (21.9) Dysuria36 (23.5)40 (25.0) Post coital bleeding27 (17.7)38 (23.8)

15. 15 Baseline microscopy Ofloxacin (n=153) N (%) Azithromycin (n=160) N (%) Bacterial vaginosis45 (29.4)51 (31.9) Candida23 (15.0)18 (11.3) Cervical pus Present Absent 119 (77.8) 24 (15.7) 124 (77.5) 21 (13.1) Urine dip Nitrites Leucocytes 1 (0.7) 41 (26.8) 2 (1.3) 30 (18.8)

16. 16 Baseline microscopy Ofloxacin (n=153) N (%) Azithromycin (n=160) N (%) Bacterial vaginosis45 (29.4)51 (31.9) Candida23 (15.0)18 (11.3) Cervical pus Present Absent 119 (77.8) 24 (15.7) 124 (77.5) 21 (13.1) Urine dip Nitrites Leucocytes 1 (0.7) 41 (26.8) 2 (1.3) 30 (18.8)

17. 17 Primary end point Ofloxacin N (%) Azithromycin N (%) Difference in proportions 95% CI Randomised population 72/153 (47.1) 68/160 (42.5) -4.6%-15.6, 6.5%

18. 18 Primary end point Ofloxacin N (%) Azithromycin N (%) Difference in proportions 95% CI Randomised population 72/153 (47.1)68/160 (42.5) -4.6%-15.6, 6.5% Per protocol population 72/107 (67.3) 68/120 (56.7) -10.6%-23.2, 1.9%

19. 19 Primary end point Ofloxacin N (%) Azithromycin N (%) Difference in proportions 95% CI Randomised population 72/153 (47.1)68/160 (42.5) -4.6%-15.6, 6.5% Per protocol population 72/107 (67.3) 68/120 (56.7) -10.6%-23.2, 1.9%

20. 20 Adherence Missed dosesOfloxacin (n=117) N (%) Azithromycin (n=124) N (%) P value I did not miss a dose75 (64.1)113 (91.1) P=0.0001 I missed doses42 (35.9)11 (8.9) MetronidazoleOfloxacin (n=110) N (%) Azithromycin (n=113) N (%) P value Completed course76 (69.1)104 (92.0)n/a Completed at least 5 days107 (97.3)105 (92.9)P=0.23

21. 21 Tolerability Ofloxacin n=153 N (%) Azithromycin n=160 N (%) P value Nausea77 (50.3)80 (50.0)1.00 Vomiting23 (15.0)19 (11.9)0.51 Bloating52 (34.0)51 (31.9)0.78 Fatigue66 (43.1)56 (35.0)0.17 Dizziness55 (36.0)44 (27.5)0.14 Rash9 (5.9)17 (10.6)0.19 Diarrhoea37 (24.2)98 (61.3)0.0001

22. 22 Diarrhoea severity % 20 44 5 25 2 8 7 N=36N=97

23. 23 Microbiology Chlamydia trachomatis27 (9.6%) Neisseria gonorrhoeae1 (0.4%) Mycoplasma genitalium28 (9.7%) 10 patients co-infected with C. trachomatis & M. genitalium 1 patient co-infected with N. gonorrhoeae & M. genitalium MG resistance data – Oral Presentation 31

24. 24 Chlamydia trachomatis27 (9.6%) Neisseria gonorrhoeae1 (0.4%) Mycoplasma genitalium28 (9.7%) 10 patients co-infected with C. trachomatis & M. genitalium 1 patient co-infected with N. gonorrhoeae & M. genitalium MG resistance data – Oral Presentation 31 Microbiology

25. 25 Summary Study failed to demonstrate that a short-course of azithromycin was non- inferior to the standard longer course of ofloxacin Results were consistent both in the full randomised and per-protocol populations Although we did not formally test for inferiority, the results suggested that if anything, the short-course was likely to be inferior to the longer course Whilst adherence did appear to be better in those receiving short-course, diarrhoea rates were higher which may have contributed to the poorer outcomes in that group

26. 26 Difficulties encountered Low recruitment ̶↓PID rates nationally / internationally ̶expected contribution from gynae – no patients recruited despite heroic efforts Multi-site ̶funding for 2 sites (not multi-site), - support from Sponsor +++ ̶SIVs, R&D, pharmacy storage, RN availability ̶integration of sexual health & contraception / tendering All sites experienced poor retention rates (common in GU trials) ̶introduced £20 voucher (too late) Long recruitment period - multiple changes in personnel, maternity leaves Drug company supplying IMP unreliable ̶recruitment stopped on 3 occasions when company could not supply packs

27. 27 Conclusion Difficult to do multi-site GU studies in current political climate Difficult population to retain in study Similar rates of mycoplasma & chlamydia (80% no pathogen) Adherence better for short course… ….. but short course less well tolerated (diarrhoea ) The short course was likely to be inferior to the longer course

28. 28 Acknowledgments Trial co-ordinators: Marie Hyslop, Gemma Sugar, Amy Arbon, Jane Cox Brighton: Lou Kerr, Sarah Kirk, Marion Campbell Birmingham: Jonathan Ross, Jan Harding, Monika Okriak Imperial College Healthcare NHS Trust: Linda Greene, Wilbert Ayap St Georges: Phil Hay, Olonike Okolo Homerton: Iain Reeves, Sifiso Mguni Charing Cross: Michael Rayment, Kribashnie Nundlall Sheffield: Gill Dilke-Wing, Charlie Sayer Eastbourne & Hastings: Kazeem Aderogba, Harish Patel Woolwich: Judith Russell Leicester: Adrian Palfreeman Trial sponsors / BSUH R&D Department: Scott Harfield, Nicky Perry STBRU (PHE): Rachel Pitt, Sarah Alexander, Catherine Ison Advisory board: Janet Wilson, Jonathan Ross, Peter Greenhouse, Catherine Ison

29. 29 Alan Phillips: 2/3/1968 – 2/7/2016