29 - Gynecological Infections / PID Flashcards
What type of Gynecological Infection?
Fever + tenderness
more diffuse across abdominal region
Sicker / often require IV ABx
Often associated w/ surgical procedures such as:
Hysteroctomy
PELVIC CELLULITIS
Surgical Site Infection
Surgical site is contamintated w/ vaginal flora:
B-Strep / E-Coli / Anaerobes (Prevotella / G. Vaginalis)
Pelvic Inflammatory Disease
PID
CRITERIA FOR INPATIENT TREATMENT
Surgical Emergency can NOT be ruled out
PREGNANCY
Lack of Clinical response to ABX
>72 hours
Unable to tolerate outpatient management
VERY SICK = high fever + NVD
Presence of ABSCESS
What type of Gynecological Infection?
Spread of Infection –> DEEP into ABDOMINAL TISSUE
Late Complication
Antibiotics +/- Surgical Drainage
Often associated w/ surgical procedures such as:
Hysteroctomy
PELVIC CELLULITIS
Surgical Site Infection
Surgical site is contamintated w/ vaginal flora:
B-Strep / E-Coli / Anaerobes (Prevotella / G. Vaginalis)
Gynecological / Fetal Friendly Antibiotics
What does this ABx Cover?
Doxycycline
Doxycycline
CHLAMYDIA
NOT FOR PREGNANCY
Bacteria Found in
IAIS
Intra-Amniotic Infectious Syndrome = Chorioamniotis
- *IASA**
- *IntraPartum** -> involve contamination of amniotic fluid w/ vaginal flora
B-Strep** + **E.COLI
Anaerobes:
Mycoplasma + Prevotella
- *PELVIC INFLAMMATORY DISEASE**
- *PID**
RISK FACTORS
Similar Risk factors to STD’s
Younger Females 20s
Multiple Sex Partners
Substance Abuse
Lower Socioeconomic Status
Douching
Bacterial Vaginosis
What type of Gynecological Infection?
Infxn @ surgical Margins
Discharge w/ lower abdominal pain
Often associated w/ surgical procedures such as:
Hysteroctomy
VAGINAL CUFF CELLULITIS
Surgical Site Infection
Surgical site is contamintated w/ vaginal flora:
B-Strep / E-Coli / Anaerobes (Prevotella / G. Vaginalis)
- *Vaginal Flora Bacteria**
- potentially infectious*
B-Streptococci
E. Coli
Anaerobes - PPBM
Peptostreptococcus spp.
Prevotella
Bacteroids
Mycoplasma
Gynecological / Fetal Friendly Antibiotics
What does this ABx Cover?
Cephalosporins
Cefoxitin / Ceftriaxone / Cefotetan
Cephalosporins
Cefoxitin / Ceftriaxone / Cefotetan
GONORRHEA (GC)
no chlamydia
- avoid QUINOLONES & CEFIXIME*
- due to RESISTANCE*
Gynecological / Fetal Friendly Antibiotics
What does this ABx Cover?
Clindamycin
Clindamycin
+Gram POS+
Streptococcus
ANAEROBES
Peptostreptococcus / Prevotella / Bacteroides / Mycoplasma
+ G. Vaginalis
Bacterial Vaginosis
DIAGNOSIS
CLUE CELLS** + **Gray-White Discharge
Clue Cells:
Coccobacillary Cells (G. VAGINALIS) adhered to Vaginal Epithelum
pH > 4.5
“whiff test” was used before + KOH
Gynecological / Fetal Friendly Antibiotics
What does this ABx Cover?
- *B-Lactams + Inhibitor**
- *Augmentin / Amp-Sub / Pip-Tazo**
- *B-Lactams + Inhibitor**
- *Augmentin / Zosyn / Pip-Tazo**
-GRAM NEG-
E. Coli
+Gram POS+
Streptococcus
ANAEROBES
Peptostreptococcus / Prevotella / Bacteroides / Mycoplasma
+ G. Vaginalis
Bacteria Found in:
PELVIC INFLAMMATORY DISEASE = PID
PID
C. TRACHOMATIS** + **N. GONORRHEAE
plus normal
E. Coli + Strep
Severe Cases ADD ANAEROBES
avoid Quinolones in those suspected of N. gonorrheae
due to resistance
Intrapartum IAIS
Intra-Amniotic Infectious Syndrome
AKA: Chorioamnionitis
Diagnosis / Signs
IMPRECISE DIAGNOSIS:
FEVER (>100.4*) + >2 of below
Maternal/Fetal TACHYcardia
↑WBC >15k
FOUL-smelling amniotic fluid
Uterine Tenderness
Amniotic Fluid + Fetal Membranes
infected due to vaginal organisms ASCENDING –> intrauterine cavity
after membrane rupture - Preterm Labor <37 weeks
Causes dysfunctional labor = Oxytocin or C-section
Pelvic Inflammatory Disease
PID
INPATIENT TREATMENT
Criteria:
PREGNANCY - Surgery
SEVERE ILLNESS
ABSCESS
No Abx Response > 72 hours
14 DAYS
Cefotetan IV** + **Doxycycline IV -> followed by Doxy PO
OR
CeFOXitin IV** + **Doxy IV –> Doxy PO
OR
Clindamycin IV** + **Gentamicin IV** –> **Doxy** or **Clinda PO
OR
Ampicillin/Sulbactam IV** + **Doxy** –> **Doxy Po
Bacteria Found in
ENDOMYOMETRITIS
- *Endomyometritis**
- *IntraPartum** -> involve contamination of amniotic fluid w/ vaginal flora
Same as IASA:
B - Strep** + **E. Coli
PLUS
ANAEROBES
Peptostreptococcus / Prevotella / Bacteroids / Mycoplasma
Pelvic Inflammatory Disease
PID
Outpatient Treatment
14 DAYS
- *CeFOXitin** 2mg IM x1 + Probenecid 1g PO x1
- *Doxycycline** 100mg PO BID
OR
CeftTRIaxone 250mg IM x1 + Doxycycline 100mg PO BID
- *PELVIC INFLAMMATORY DISEASE**
- *PID**
Diagnostic Criteria
often VAGUE presentation** –> **no SINGLE symptom specific
Suggested to Treat:
Sexually Active + Pelvic/ab pain + Discharge
Minimum criteria > 1:
Cervical Motion** / **Uterine** / **Adnexal
TENDERNESS
Additional Criteria:
Oral Temp > 101 / Discharge / WBC >10k
ESR > 15 / ↑CRP
Gynecological / Fetal Friendly Antibiotics
What does this ABx Cover?
Flagyl
Flagyl
ANAEROBES
Peptostreptococcus / Prevotella / Bacteroides / Mycoplasma
+ G. Vaginalis
Gynecological / Fetal Friendly Antibiotics
What does this ABx Cover?
Azithromycin
Azithromycin
CHLAMYDIA
could be used for prgnancy > Doxycycline
avoid QUINOLONES & CEFIXIME
due to RESISTANCE
TREATMENT
PCN ALLERGY
Surgical Site Infection:
Vaginal Cuff Cellulitis
Infxn @ surgical margins / Discharge+lower abdominal Pain
Vaginal Cuff Cellulitis
ORAL ABx
CIPRO 500mg BID** + **FLAGYL 500mg BID
instead of Augmentin 875 BID ONLY
Gynecological / Fetal Friendly Antibiotics
What does this ABx Cover?
Gentamicin
Gentamicin
-GRAM NEG-
E. Coli
Surgical Site Infections:
Cuff Celulitis / Pelvic Cellulitis / Pelvic Abscess
RISK FACTORS
- NOT using PREOPERATIVE PREP*
- *Chlorhexidine or Providone Iodine**
NOT using SYSTEMIC ABx
around time surgery is started
Blood Loss > 500mL** or **Blood Transfusion
Prolonged Surgery >140min
STAPLES > Sutures
sutures are @ lower risk for infxn
TREATMENT
Surgical Site Infection:
Pelvic Cellulitis
patient is more sick vs cuff cellulitis
deeper tissue infxn
Pelvic Cellulitis
Hospitilization + IV TREATMENT until patient FEBRILE (24-48hrs)
complete regimen OUTPATIENT
14 DAY TREATMENT
Augmentin 875 BID
- PCN ALLERGY:*
- *CIPRO 500mg BID_ + _FLAGYL 500mg BID**
- *ENDOMYOMETRITTIS**
- *Postpartum infxn of the uterus**
Diagnosis / Risk Factors
Risk Factors:
- *DURATION of LABOR** or RUPTURE of membranes
- *Bacterial Vaginosis**
- *# of Vaginal Exams**
- *Internal Fetal Monitoring**
POSTpartum Endometritis:
- *C-Section** or Rupture of membranes after labor = strong predictor
- *Inoculation**
Bacteria found in:
Bacterial Vaginosis
Bacterial Vaginosis
Caused by:
↓Lactobacillus - keeps flora in check, stops anaerobe growth
Then:
Vaginal Anaerobes PREDOMINATE
G. VAGINALLIS / prevotella / Bacterdes / Peptostrep
Treat with:
- *Flagyl** or Clindamycin
- exception to 14 day treatment –> could be 3/5/7 days*
Bacterial Vaginosis
RISK FACTORS
- not considered an STD*
- *alteration of normal vaginal flora –> preterm birth**
Risk Factors
SMOKING / DOUCHING
AA Race
Early Age Sex / Multiple Sex Partners
WSW
Intrapartum IAIS
Intra-Amniotic Infectious Syndrome
AKA: Chorioamnionitis
TREATMENT
SOURCE CONTROL:
is DELIVERY
Start Intrapartum ABx (during) to prevent systemic infections
Target B-Strep + E. Coli:
AMPICILLIN** + **GENTAMICIN
If C-Section:
- *Add ANAEROBIC COVERAGE**
- *Clindamycin / Flagyl** or B-Lactam ONLY (covers all 3)
TREATMENT
Surgical Site Infection:
Pelvic ABSCESS
- *PELVIC ABSCESS**
- *Same as Cellulitis but…**
- *DRAIN MASS if**:
- *>8 cm** OR <8 cm & not improving on therapy
Hospitilization + IV TREATMENT until patient FEBRILE (24-48hrs)
complete regimen OUTPATIENT
14 DAY TREATMENT
Augmentin 875 BID
- PCN ALLERGY:*
- *CIPRO 500mg BID_ + _FLAGYL 500mg BID**
Endomyometritis
Postpartum infxn of the uterus
TREATMENT
Endomyoetritis
Treatment is similar to IAIS w/ EMPHASIS on ANAEROBES
GENTAMICIN** + **CLINDAMYCIN
Drug of choice
Alternates:
Amp/Sulb - Pip/Tazo - Cefoxitin - Carbapenems
Need to cover:
Penicillin Resistant Prevotella
TREATMENT
Surgical Site Infection:
Vaginal Cuff Cellulitis
Infxn @ surgical margins / Discharge+lower abdominal Pain
Vaginal Cuff Cellulitis
ORAL ABx
AUGMENTIN 875mg BID
Gynecological / Fetal Friendly Antibiotics
What does this ABx Cover?
- *B-Lactams**
- *Cefoxitin** / Cefotetan
- *B- Lactams**
- *Cefoxitn / Cefotetan**
-GRAM NEG-
E. Coli
+Gram POS+
Streptococcus
ANAEROBES
Peptostreptococcus / Prevotella / Bacteroides / Mycoplasma
+ G. Vaginalis
Bacteria found in:
Surgical Site Infections
Cuff / Pelvic Cellulitis + Pelvic Abscess
Surgical Site Infections
Cuff / Pelvic Cellulitis + Pelvic Abscess
Normal Vaginal Flora:
B - Strep** + **E. Coli** + **Anaerobes (PPMP)
PLUS
GARDNERELLA VAGINALIS
Bacterial Vaginosis
TREATMENT
Goal is to ↓Anaerobes Present,
since its an alteration of normal flora
Empiric treatment:
Metronidazole 500mg BID x 7 days
or
Metronidazole 0.75% gel QD x 5 days
or
Clindamycin 300mg BID x7 days
not routinely recommended to treat partner
