Pelvic inflammatory disease: Difference between revisions
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=== Outpatient Options ===
=== Outpatient Options ===
#[[Ceftriaxone]] 250mg IM x1 + [[doxycycline]] 100mg PO BID x14d +/- [[metronidazole]] 500mg PO BID x14d <ref>Ness RB et al. Effectiveness of inpatient and outpatient treatment strategies for women with pelvic inflammatory disease: results from the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) Randomized Trial. Am J Obstet Gynecol 2002;186:929–37</ref>
#[[Ceftriaxone]] 250mg IM x1 + [[doxycycline]] 100mg PO BID x14d +/- [[metronidazole]] 500mg PO BID x14d <ref>Ness RB et al. Effectiveness of inpatient and outpatient treatment strategies for women with pelvic inflammatory disease: results from the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) Randomized Trial. Am J Obstet Gynecol 2002;186:929–37</ref>
##[[Metronidazole]] based upon assessment of risk for [[anaerobes]]; consider in:
#*[[Metronidazole]] based upon assessment of risk for [[anaerobes]]; consider in:
###Pelvic abscess  
#**Pelvic abscess  
###Proven or suspected infection w/ [[Trichomonas]] or [[Bacterial Vaginosis]]
#**Proven or suspected infection w/ [[Trichomonas]] or [[Bacterial Vaginosis]]
###History of gynecological instrumentation in the preceding 2-3wks
#**History of gynecological instrumentation in the preceding 2-3wks
 
#OR, [[Cefoxitin]] 2 g IM in a single dose and Probenecid, 1 g PO administered concurrently in a single dose<ref>CDC PID Treatment http://www.cdc.gov/std/treatment/2010/pid.htm</ref> + [[Doxycycline]] 100 mg PO BID x 14 days +/- [[flagyl]] based on above criteria
#[[Cefoxitin]] 2 g IM in a single dose and Probenecid, 1 g PO administered concurrently in a single dose<ref>CDC PID Treatment http://www.cdc.gov/std/treatment/2010/pid.htm</ref> + [[Doxycycline]] 100 mg PO BID x 14 days +/- flagyl based on above criteria


===Alternative Outpatient Options===
===Alternative Outpatient Options===
#[[Ceftriaxone]] 250mg IM x1 + 1 g of [[Azithromycin]] per week, x 2 weeks<ref name="Savaris">Savaris RF. et al. Comparing ceftriaxone plus azithromycin or doxycycline for pelvic inflammatory disease: a randomized controlled trial. Obstet Gynecol. 2007 Jul;110(1):53-60</ref> +/- flagyl based on above criteria
#[[Ceftriaxone]] 250mg IM x1 + 1 g of [[azithromycin]] per week, x 2 weeks<ref name="Savaris">Savaris RF. et al. Comparing ceftriaxone plus azithromycin or doxycycline for pelvic inflammatory disease: a randomized controlled trial. Obstet Gynecol. 2007 Jul;110(1):53-60</ref> +/- flagyl based on above criteria
##Great cure rates in the Azithromycin group (98.2% vs 87.5%)<ref name="Savaris"></ref>
#*Great cure rates in the [[azithromycin]] group (98.2% vs 87.5%)<ref name="Savaris"></ref>


=== Inpatient ===
=== Inpatient ===
#[[Cefoxitin]] 2gm IV q6hr OR [[cefotetan]] 2gm IV q12hr) + [[doxycycline]] PO or IV 100 mg q12hr OR
#[[Cefoxitin]] 2gm IV q6hr OR [[cefotetan]] 2gm IV q12hr) + [[doxycycline]] PO or IV 100 mg q12hr OR
#[[Clindamycin]] 900mg IV q8h + [[gentamicin]] 2mg/kg QD OR
#[[Clindamycin]] 900mg IV q8h + [[gentamicin]] 2mg/kg QD OR
#Ampicillin/sulbactam 3gm IV q6hr + [[doxycycline]] 100mg IV/PO q12hr
#[[Ampicillin-sulbactam]] 3gm IV q6hr + [[doxycycline]] 100mg IV/PO q12hr


==Disposition==
==Disposition==

Revision as of 14:53, 22 February 2015

Background

  • Pelvic Inflammatory Disease (PID) comprises spectrum of infections of the upper reproductive tract:
    • Salpingitis, endometritis, myo/parametritis, oophoritis
      • Perihepatitis (Fitz-Hugh-Curtis) is caused by lymphatic spread
      • Tubo-ovarain abscess is caused by direct extension
  • Most common serious infection in women aged 16 to 25 years
    • Most common cause of death is rupture of a tubo-ovarian abscess
  • Begins as cervicitis w/ GC or chlamydia that may progress to polymicrobial infection
    • Initial lower tract infection may be asymptomatic

Diagnosis

History

  1. Pelvic Pain (90%)
  2. Vaginal discharge (75%)
  3. Vaginal and postcoital bleeding (>33%)
  4. Dysuria, fever, malaise, N/V

Physical Exam

  1. CMT
  2. Adnexal tenderness
    • Most sensitive finding (Sn ~95%)
  3. Mucopurulent cervicitis
    • Absence should raise consideration of another dx
  4. RUQ Pain
    • May indicate perihepatic inflammation (particularly w/ jaundice)

CDC Treatment Criteria

  1. Woman at risk for STIs
  2. Pelvic or lower abdominal pain
  3. No cause for the illness other than PID can be identified
  4. At least one of the following on pelvic exam:
    1. CMT
    2. Uterine tenderness
    3. Adnexal tenderness.
  5. Additional criteria that make the dx more likely:
    1. Oral temperature >101° F (>38.3° C)
    2. Abnormal cervical or vaginal mucopurulent discharge
    3. Pesence of abundant numbers of WBC on saline microscopy of vaginal fluid
    4. Elevated ESR
    5. Elevated CRP
    6. Laboratory documentation of cervical infection with GC or chlamydia

Work-Up

  1. Urine pregnancy
  2. Wet mount
  3. Endocervical swab (for GC, Chlamydia)
  4. CBC
  5. ESR/CRP
  6. Urine culture, analysis (to excl UTI)

Imaging

  1. Pelvic U/S
    1. Ultrasound sensitivity may be as low as 56% and specificity of 85% [1]
  2. CT

Differential Diagnosis

Acute Pelvic Pain

Differential diagnosis of acute pelvic pain

Gynecologic/Obstetric

Genitourinary

Gastrointestinal

Musculoskeletal

Vascular

Treatment

Tx all partners who had sex w/ pt during previous 60d prior to onset of sx

Outpatient Options

  1. Ceftriaxone 250mg IM x1 + doxycycline 100mg PO BID x14d +/- metronidazole 500mg PO BID x14d [3]
  2. OR, Cefoxitin 2 g IM in a single dose and Probenecid, 1 g PO administered concurrently in a single dose[4] + Doxycycline 100 mg PO BID x 14 days +/- flagyl based on above criteria

Alternative Outpatient Options

  1. Ceftriaxone 250mg IM x1 + 1 g of azithromycin per week, x 2 weeks[5] +/- flagyl based on above criteria

Inpatient

  1. Cefoxitin 2gm IV q6hr OR cefotetan 2gm IV q12hr) + doxycycline PO or IV 100 mg q12hr OR
  2. Clindamycin 900mg IV q8h + gentamicin 2mg/kg QD OR
  3. Ampicillin-sulbactam 3gm IV q6hr + doxycycline 100mg IV/PO q12hr

Disposition

Admit:

Discharge:

  • 72hr f/u
  • Instruct pt to abstain from sex or adhere strictly to condom use until sx have abated

Complications

  1. Tubo-Ovarian Abscess
  2. Fitz-Hugh-Curtis
    1. Perihepatic inflammation seen only on CT, not US; LFTs are normal
    2. Responds to standard abx regimen
  3. Infertility
  4. Ectopic Pregnancy
  5. Chronic pelvic pain

See Also

Source

  1. ↑ Lee DC, Swaminathan AK. Sensitivity of ultrasound for the diagnosis of tubo-ovarian abscess: a case report and literature review. J Emerg Med. 2011 Feb;40(2):170-5. doi: 10.1016 PMID 20466506
  2. ↑ Norris DL, Young JD. UTI. EM Clin N Am. 2008; 26:413-30.
  3. ↑ Ness RB et al. Effectiveness of inpatient and outpatient treatment strategies for women with pelvic inflammatory disease: results from the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) Randomized Trial. Am J Obstet Gynecol 2002;186:929–37
  4. ↑ CDC PID Treatment http://www.cdc.gov/std/treatment/2010/pid.htm
  5. ↑ 5.0 5.1 Savaris RF. et al. Comparing ceftriaxone plus azithromycin or doxycycline for pelvic inflammatory disease: a randomized controlled trial. Obstet Gynecol. 2007 Jul;110(1):53-60
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