PELVIC INFLAMMATORY DISEASE Flashcards by Qúophy Calbert

What is PID

A polymicrobial infection of the upper genital tract (cervix, uterus, fallopain tubes, ovaries, parametrium and pelvic peritoneum)

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Inflammatory cascade in PID

Cervicitis
Endometritis
Parametritis
Salpingitis
Oophoritis
Pelvic peritonitis

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Complications of PID

Tubo-ovarian abscess
Hydrosalpinx
Pelvic peritonitis
Perihepatitis or Fitz-Hugh Curtis syndrome
Chronic pelvic pain
Infertility
Ectopic pregnancy

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Implicated organisms

Neisseria gonorrhae
Chlamydia trachomatis
Mycobacterium genitalium

Anaerobes: Prevotella spp and Leptotrichia and Atopobium
Organisms in bacterial vaginosis: G. vaginalis, M. hominis, U. urealyticum

Respiratory organisms: H. influenzae, Streptococcus, Staphylococcus

Enteric pathogens: E. coli, Bacteroides fragillis, Group B streptococcus

Viral: CMV

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Risk factors for PID

Age > 25 yeras
History of STI or PID
Multiple sexual partners
New sexual partner
History of
Assisted reproductive technologies
History of abortion
Early coitarche
Unprotected sex
History of IUD insertion within past 6 weeks
Hysterescopy
Saline infusion sonography

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Symptoms of PID

Abnormal bleeding
Lower abdominal pain
Dyspareunia
Dysuria
Offensive vaginal discharge
Right upper quadrant pain (perihepatitis)
Rectal pain (pelvic abscess)

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Signs of PID

Fever >38
Cervical motion tenderness
Uterine tenderness
Adnexal tenderness
Adnexal mass

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Investigations in PID

Elevated CRP
Elevated ESR
Elevated WBC on saline microscopy
NAAC for N. gonorrhae and C. trachomatis
Ultrasonography
MRI
CT scan
Dopple studies
Laparoscopy-gold standard
Pregnancy test
Pelvic examination
Speculum examination
Test for syphilis and HIV
Endometril biopsy

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Differentials of PID

Appendicitis
Urinary Tract Infections
Ectopic pregnancy
Endometriosis
Complications of ovarian cyst
Irritable bowel syndrome
Functional pain

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Purpose of endometrial biopsy in PID

To identify endometritis

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Findings on speculum examination

Shows a mucopurulent vaginal discharge

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Differentiate between PID and irritable bowel syndrome

IBS presents with disturbance in bowel habit

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Differentiate between PID and endometriosis

Dyschezia is moslty present in endometriosis
Symptoms related to menstrual cycle in endometriosis

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Differentiate between PID and UTI

More common dysuria, haematuria and urinary frequency in UTI

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Differentiate between PID and appendicitis

Nausea and vomiting are more common in appendicitis
Cervical motion tenderness is less common in appendicitis

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Differentiate between PID and complications of ovarian cysts

Sudden onset of symptoms and unilateral pain in omplications of ovarian cysts

STG management of mild PID

Ciprofloxacin 500mg BD for 3 days
Doxycycline 100mg bd for 14 days
Metronidazole 400mg bd for 14 days

STG management of severe PID

IM Ceftriaxone 250mg daily for 3 days
Doxycycline 100mg bd for 3 days
then
Doxycycline 100mg bd for 14 days
Metronidazole 400mg bd for 14days

Metronidazole in PID

Used for anaerobes
Not require when a second gen. cephalosporin is used
Can be removed from management of severe infections in hospitals by IV therapy with good outcome

Role of moxifloxacin in PID

Preferred when M. genitalium is implicated

European guidelines management for PID, 2017, outpatient

IM ceftriaxone 500mg single dose
Doxycycline 100mg bd for 14 days
Metronidazole 500mg bd for 14days
or
PO Ofloxacin 400mg bd for 14 days
Metronidazole 500mg bd for 14days
or
PO Levofloxacin 500mg daily for 14 days
Metronidazole 500mg bd for 14days
or
PO Moxifloxacin 400mg daily for 14 days

European guideline inpatient management for PID, 2017

IV/IM Ceftriaxone 1g daily
PO/IV Doxycycline 100mg bd
then
PO/IV Doxycycline 100mg bd for + PO Metronidazole 500mg bd to complete 14 days
or
IV Clindamycin 900mg tds
IV/IM Gentamicin 3-6mg/kg
then
Oral Clindamycin 450mg qid/ Oral Doxycycline 100mg bd + Oral Metronidazole 500mg bd to complete 14 days
or
IV Ofloxacin 400mg bd
IV Metronidazole 500mg bd for 14 days
or
IV Ceftriaxone 500mg single dose
PO Azithromycin 1g then PO Azithrmycin 1g a week later

Main CDC regimen for outpatient management for PID

IM Ceftriaxone 500mg single dose or
IM Cefoxitin 2g + Probenecid PO Ig as a single concurrent dose or
other parenteral cephalosporins (cefotaxime, ceftizoxime)
+ PO Doxycycline 100mg bd for 14 days
+/- PO Metronidazole 500mg bd for 14days

Main CDC regimen for inpatient management for PID

IM Cefotetan 2g 12 hrly or
IM Cefoxitin 2g 8hrly
+
PO/IV Doxycycline 100mg bd
then
PO Doxycycline and PO Metro for 14 days

Alternative CDC regimen for outpatient management for PID

PO Levofloxacin 500mg daily + PO Metronidazole 500mg bd for 14 days or IV Azithromycin 500mg daily for 1-2 doses then PO Azithromycin 250mg daily for total of 7 days or PO Azithromycin 250mg daily PO Metronidazole 500mg bd all for 12 -14 days or Moxifloxacin

Alternative CDC regimen for inpatient management of PID

1. IV Clindamycin 900mg tds+ IV/IM Gentamycin 2mg/kg loading dose, then 1.5mg/kg tds or single daily dose of 3-5mg/kg then PO Clind. and PO Metro or PO Doxy and PO Metro. or 2. Ampicillin/Sulbactam 3g IV every hours Doxycycline 100mg PO/IV bd

Criteria for parenteral or inpatient management in PID

Pregnancy Not able to tolertae oral regimen Problems with adherence Not able to return for follow-up Presence of tubo-ovarian abscess Surgical emergency cannot be excluded Severe signs and symptoms Clinical failure or oral therapy

Severe signs and symtptoms in PID

Nausea Vomiting High fever

Duration for parenteral therapy

For 24-72 hours or till 24 hours after clinical improvement

Should IUD be removed

Do not remove IUD if patient is improving within 24-72 hours Remove if patient doesn't improve witin 72 hours

Duration of treatment for PID

10 to 14 days

Prophylactic management for sexual partners of PID patients

Doxycycline 100mg bd for a week

Monitoring of inpatient therapy

C-reactive protein WBC count

Follow up for PID patients

Follow up after 48-72 hours of discharge and for outpatients to review effectiveness of therapy

Concerns about penicillin allergy in PID management

Crossreactivity is with first and second gen. cephalosporins, third gen. ceph. can be given Can also hospitalize and give IV clindamycin and Gentamycin

When is retesting done for patients diagnosed with chlamydial or gonococcal PID

after 3 months

Screening tests for PID

Annual screening for gonorrhea and chlamydia in women<25 yrs and women at high risk

Taking care of patners of PID patients

Screen partners for chlamydia and gonorrhea Advise partners to avoid unprotected sex till completion of treatment Trace all sexual partners encountered within 6 months prior to presentation if no sex within last six months, trace to last sexual partner

Management of PID in pregnancy

IV Cectriaxone 2g od and IV Erythromycin 50mg/kg od and Metronidazole 500mg bd