PELVIC INFLAMMATORY DISEASE Flashcards
What is PID
A polymicrobial infection of the upper genital tract (cervix, uterus, fallopain tubes, ovaries, parametrium and pelvic peritoneum)
Inflammatory cascade in PID
Cervicitis
Endometritis
Parametritis
Salpingitis
Oophoritis
Pelvic peritonitis
Complications of PID
Tubo-ovarian abscess
Hydrosalpinx
Pelvic peritonitis
Perihepatitis or Fitz-Hugh Curtis syndrome
Chronic pelvic pain
Infertility
Ectopic pregnancy
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
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
Symptoms of PID
Abnormal bleeding
Lower abdominal pain
Dyspareunia
Dysuria
Offensive vaginal discharge
Right upper quadrant pain (perihepatitis)
Rectal pain (pelvic abscess)
Signs of PID
Fever >38
Cervical motion tenderness
Uterine tenderness
Adnexal tenderness
Adnexal mass
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
Differentials of PID
Appendicitis
Urinary Tract Infections
Ectopic pregnancy
Endometriosis
Complications of ovarian cyst
Irritable bowel syndrome
Functional pain
Purpose of endometrial biopsy in PID
To identify endometritis
Findings on speculum examination
Shows a mucopurulent vaginal discharge
Differentiate between PID and irritable bowel syndrome
IBS presents with disturbance in bowel habit
Differentiate between PID and endometriosis
Dyschezia is moslty present in endometriosis
Symptoms related to menstrual cycle in endometriosis
Differentiate between PID and UTI
More common dysuria, haematuria and urinary frequency in UTI
Differentiate between PID and appendicitis
Nausea and vomiting are more common in appendicitis
Cervical motion tenderness is less common in appendicitis
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
- 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 - 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
