Pelvic inflammatory disease: Difference between revisions
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==Background== |
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* Upper genital tract infection in women that involves a combination of endometrium, fallopian tubes, and peritoneum |
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*Upper genital tract infection in women that involves infection of any combination of endometrium, fallopian tubes, and peritoneum |
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== Background == |
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=== Microbiology === |
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* Often polymicrobial |
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* Most commonly associated with [[Chlamydia trachomatis]] or [[Neisseria gonorrhoeae]] |
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* May also involve [[Mycoplasma hominis]], [[Mycoplasma genitalium]], [[Ureaplasma urealyticum]], [[Escherichia coli]], [[Gardnerella vaginalis]], [[Streptococcus species]], [[Haemophilus influenzae]], [[Bacteroides species]], [[Prevotella species]], [[Trichomonas vaginalis]], and [[Herpes simplex virus]] |
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=== |
===Microbiology=== |
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* About 10-15% of women have at least one episode |
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*Often polymicrobial |
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== Clinical Presentation == |
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*Most commonly associated with [[Chlamydia trachomatis]] or [[Neisseria gonorrhoeae]] |
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* Pelvic or abdominal pain is the main complaint |
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*Other contributory microbes include: |
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* May be febrile and have adnexal, uterine, or cervical motion tenderness |
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**Other sexually-transmitted organisms |
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* Must rule out an ectopic pregnany |
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***[[Herpes simplex virus]] |
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* May present with tuboovarian abscess |
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***[[Trichomonas vaginalis]] |
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**Genitourinary microbiota |
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***[[Mycoplasma genitalium]] |
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***[[Mycoplasma hominis]] |
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***[[Ureaplasma urealyticum]] |
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**Anaerobes |
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***[[Bacteroides]] |
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***[[Peptostreptococcus]] |
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***[[Prevotella]] |
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**Aerobes |
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***[[Escherichia coli]] |
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***[[Gardnerella vaginalis]] |
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***[[Haemophilus influenzae]] |
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***[[Streptococcus]] |
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===Epidemiology=== |
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== Investigations == |
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* β-hCG to rule out ectopic pregnancy |
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* Endocarvical swabs for gonorrhea and chlamydia, and possibly HSV |
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* Vaginal swabs for culture, pH, whiff testing, wet preps, and Gram stain |
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* Ultrasound can be helpful, especially for tuboovarian abscess |
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*About 10-15% of women have at least one episode |
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== Management == |
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* There are many possible regimens |
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** [[Is treated by::Cefoxitin]] 2 g IV q6h plus [[Is treated by::doxycycline]] 100 mg IV/PO q12h, stepped down to oral [[doxycycline]] once clinical improvement to complete 14 days |
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** [[Is treated by::Clindamycin]] 900 mg IV q8h plus [[Is treated by::gentamicin]] 2mg/kg loading dose then 1.5 mg/kg q8h maintenance dose (or 5 mg/kg q24h dosing), steped down to [[Is treated by::doxycycline]] or [[Is treated by::clindamycin]] 450 mg PO qid to complete 14 days |
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** [[Is treated by::Ofloxacin]] 400 mg IV q12h or [[Is treated by::levofloxacin]] 500 mg IV daily, ± [[Is treated by::metronidazole]] 500 mg IV q8h |
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** [[Is treated by::Ampicillin-sulbactam]] 3 g IV q6h plus [[Is treated by::doxycycline]] 100 mg IV/PO q12h |
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** [[Is treated by::Ciprofloxacin]] 200 mg IV q12h plus [[Is treated by::doxycycline]] 100 mg IV/PO q12h ± [[Is treated by::metronidazole]] 500 mg IV q8h |
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** [[Is treated by::Ceftriaxone]] 250 mg IM once plus [[Is treated by::docycycline]] 100 mg PO bid for 14 days, ± [[Is treated by::metronidazole]] 500 mg IV q8h |
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** [[Is treated by::Cefoxitin]] 2 g IM once plus [[Is treated by::probenecid]] 1 g po once plus [[Is treated by::doxycycline]] 100 mg PO bid for 14 days, ± [[metronidazole]] 500 mg IV q8h |
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** Another third-generation cephalosporin plus [[Is treated by::doxycycline]] 100 mg PO bid for 14 days, ± [[metronidazole]] 500 mg IV q8h |
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** [[Is treated by::Ofloxacin]] 400 mg PO bid for 14 days, ± [[Is treated by::metronidazole]] 500 mg IV q8h |
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** [[Is treated by::Levofloxacin]] 500 mg PO daily, ± [[Is treated by::metronidazole]] 500 mg IV q8h |
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* Often recommended to add [[Is treated by::metronidazole]] to any of the above regimens that do not have |
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* Only consider fluoroquinolones if there is susceptibility testing done or a test of cure is possible |
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* If an intrauterine device is in situ, remove it only after at least 2 doses of antibiotics have been given |
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==Clinical Manifestations== |
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== Further Reading == |
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* [https://www.canada.ca/en/public-health/services/infectious-diseases/sexual-health-sexually-transmitted-infections/canadian-guidelines/sexually-transmitted-infections/canadian-guidelines-sexually-transmitted-infections-22.html Management and treatment of specific syndromes – Pelvic Inflammatory Disease (PID)]. Canadian Guidelines on Sexually Transmitted Infections. |
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*Pelvic or abdominal pain is the main complaint |
|||
*May be febrile and have adnexal, uterine, or cervical motion tenderness |
|||
*May present with tubo-ovarian abscess |
|||
*Minimum diagnostic criteria for treatment include lower abdominal pain, adnexal tenderness, and cervical motion tenderness |
|||
*Additional supportive criteria include |
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**Fever >38.3ºC |
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**Presence of leukocytes on saline microscopy of vaginal secretions |
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**Elevated ESR or [[CRP]] |
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**Diagnosed [[gonorrhea]] or [[chlamydia]] |
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===Complications=== |
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*Short-term: |
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**[[Fitz-Hugh-Curtis syndrome]] |
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**[[Tubo-ovarian abscess]] |
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*Long-term: |
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**[[Ectopic pregnancy]] |
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**[[Infertility]] |
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**[[Chronic pelvic pain]] |
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==Differential Diagnosis== |
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*Gynecologic/obstetrical |
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**Complications of pregnancy |
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***Ectopic pregnancy |
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**Endometriosis |
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**Endometritis |
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**Adnexal disorders |
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**Mentrual disorders |
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*Gastrointestinal |
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**[[Appendicitis]] |
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**[[Gastroenteritis]] |
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**[[Inflammatory bowel disease]] |
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*Genitourinary |
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**[[Cystitis]] |
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**[[Pyelonephritis]] |
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**[[Nephrolithiasis]] |
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*Musculoskeletal causes |
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*Neurologic causes |
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==Investigations== |
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*No combination of routine investigations (including swabs and ultrasound) can be used to completely rule out PID |
|||
*Laboratory investigations |
|||
**β-hCG to rule out ectopic pregnancy |
|||
**Endocarvical swabs for [[gonorrhea]] and [[chlamydia]], and possibly HSV |
|||
**Vaginal swabs for culture, pH, whiff testing, wet preps, and Gram stain |
|||
*Radiography |
|||
**Ultrasound can be helpful, especially for tuboovarian abscess |
|||
**Ideally done as transvaginal ultrasound |
|||
==Diagnosis== |
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*Definitive diagnosis is rarely obtained; more commonly, the disease is treated based on clinical findings |
|||
*Definitive diagnostic criteria include: |
|||
**Endometrial biopsy with evidence of endometritis |
|||
**Transvaginal ultrasound showing thickened fluid-filled tubes, with or without free pelvic fluid or tubo-ovarian complex |
|||
**Laparoscopy showing findings of PID, including fallopian tube erythema or mucopurulent exudates |
|||
==Management== |
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*All patients must have a β-hCG to rule out pregnancy |
|||
*Criteria for hospitalization include: |
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**Possible surgical emergency |
|||
**Pregnancy |
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**No response to oral antibiotics |
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**Unable to tolerate oral antibiotics |
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**Severe illness, nausea and vomiting, or high fever |
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**Presence of tubo-ovarian abscess |
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**Pediatric patients |
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*There are many possible regimens |
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**[[Fluoroquinolones]] and [[doxycycline]] are contraindicated in pregnancy and breastfeeding |
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**Often recommended to add [[Is treated by::metronidazole]] to any regimen that does not have adequate anaerobic coverage, which likely improves outcomes[[CiteRef::wiesenfeld2020a]] |
|||
**Only consider [[fluoroquinolones]] if there is susceptibility testing done or a test of cure is possible |
|||
**First-line regimens |
|||
***[[Is treated by::Cefoxitin]] 2 g IV q6h plus [[Is treated by::doxycycline]] 100 mg IV/PO q12h, stepped down to oral [[doxycycline]] once clinical improvement to complete 14 days |
|||
***[[Is treated by::Clindamycin]] 900 mg IV q8h plus [[Is treated by::gentamicin]] 2mg/kg loading dose then 1.5 mg/kg q8h maintenance dose (or 5 mg/kg q24h dosing), steped down to [[Is treated by::doxycycline]] or [[Is treated by::clindamycin]] 450 mg PO qid to complete 14 days |
|||
**Alternative regimens |
|||
***[[Is treated by::Ofloxacin]] 400 mg IV q12h or [[Is treated by::levofloxacin]] 500 mg IV daily, ± [[Is treated by::metronidazole]] 500 mg IV q8h |
|||
***[[Is treated by::Ampicillin-sulbactam]] 3 g IV q6h plus [[Is treated by::doxycycline]] 100 mg IV/PO q12h |
|||
***[[Is treated by::Ciprofloxacin]] 200 mg IV q12h plus [[Is treated by::doxycycline]] 100 mg IV/PO q12h ± [[Is treated by::metronidazole]] 500 mg IV q8h |
|||
**Outpatient regimens |
|||
***[[Is treated by::Ceftriaxone]] 250 mg IM once plus [[Is treated by::doxycycline]] 100 mg PO bid for 14 days, ± [[Is treated by::metronidazole]] 500 mg IV q8h |
|||
***[[Is treated by::Cefoxitin]] 2 g IM once plus [[Is treated by::probenecid]] 1 g po once plus [[Is treated by::doxycycline]] 100 mg PO bid for 14 days, ± [[metronidazole]] 500 mg IV q8h |
|||
***Another third-generation cephalosporin plus [[Is treated by::doxycycline]] 100 mg PO bid for 14 days, ± [[metronidazole]] 500 mg IV q8h |
|||
***[[Is treated by::Ofloxacin]] 400 mg PO bid for 14 days, ± [[Is treated by::metronidazole]] 500 mg IV q8h |
|||
***[[Is treated by::Levofloxacin]] 500 mg PO daily, ± [[Is treated by::metronidazole]] 500 mg IV q8h |
|||
*If an intrauterine device is in situ, remove it only after at least 2 doses of antibiotics have been given |
|||
*Pain should start to improve within 48 to 72 hours of antibiotics; if it does not, then consider further investigations |
|||
*Rule out other [[Sexually-transmitted infection|sexually-transmitted infections]], including [[HIV]] and [[syphilis]] |
|||
*Immunize against [[hepatitis B]] and [[HPV]] if indicated |
|||
*Partners should be screened and treated |
|||
==Further Reading== |
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*[https://www.canada.ca/en/public-health/services/infectious-diseases/sexual-health-sexually-transmitted-infections/canadian-guidelines/sexually-transmitted-infections/canadian-guidelines-sexually-transmitted-infections-22.html Management and treatment of specific syndromes – Pelvic Inflammatory Disease (PID)]. Canadian Guidelines on Sexually Transmitted Infections. |
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[[Category:Genitourinary infections]] |
[[Category:Genitourinary infections]] |
Latest revision as of 17:02, 25 January 2022
Background
- Upper genital tract infection in women that involves infection of any combination of endometrium, fallopian tubes, and peritoneum
Microbiology
- Often polymicrobial
- Most commonly associated with Chlamydia trachomatis or Neisseria gonorrhoeae
- Other contributory microbes include:
- Other sexually-transmitted organisms
- Genitourinary microbiota
- Anaerobes
- Aerobes
Epidemiology
- About 10-15% of women have at least one episode
Clinical Manifestations
- Pelvic or abdominal pain is the main complaint
- May be febrile and have adnexal, uterine, or cervical motion tenderness
- May present with tubo-ovarian abscess
- Minimum diagnostic criteria for treatment include lower abdominal pain, adnexal tenderness, and cervical motion tenderness
- Additional supportive criteria include
Complications
- Short-term:
- Long-term:
Differential Diagnosis
- Gynecologic/obstetrical
- Complications of pregnancy
- Ectopic pregnancy
- Endometriosis
- Endometritis
- Adnexal disorders
- Mentrual disorders
- Complications of pregnancy
- Gastrointestinal
- Genitourinary
- Musculoskeletal causes
- Neurologic causes
Investigations
- No combination of routine investigations (including swabs and ultrasound) can be used to completely rule out PID
- Laboratory investigations
- Radiography
- Ultrasound can be helpful, especially for tuboovarian abscess
- Ideally done as transvaginal ultrasound
Diagnosis
- Definitive diagnosis is rarely obtained; more commonly, the disease is treated based on clinical findings
- Definitive diagnostic criteria include:
- Endometrial biopsy with evidence of endometritis
- Transvaginal ultrasound showing thickened fluid-filled tubes, with or without free pelvic fluid or tubo-ovarian complex
- Laparoscopy showing findings of PID, including fallopian tube erythema or mucopurulent exudates
Management
- All patients must have a β-hCG to rule out pregnancy
- Criteria for hospitalization include:
- Possible surgical emergency
- Pregnancy
- No response to oral antibiotics
- Unable to tolerate oral antibiotics
- Severe illness, nausea and vomiting, or high fever
- Presence of tubo-ovarian abscess
- Pediatric patients
- There are many possible regimens
- Fluoroquinolones and doxycycline are contraindicated in pregnancy and breastfeeding
- Often recommended to add metronidazole to any regimen that does not have adequate anaerobic coverage, which likely improves outcomes1
- Only consider fluoroquinolones if there is susceptibility testing done or a test of cure is possible
- First-line regimens
- Cefoxitin 2 g IV q6h plus doxycycline 100 mg IV/PO q12h, stepped down to oral doxycycline once clinical improvement to complete 14 days
- Clindamycin 900 mg IV q8h plus gentamicin 2mg/kg loading dose then 1.5 mg/kg q8h maintenance dose (or 5 mg/kg q24h dosing), steped down to doxycycline or clindamycin 450 mg PO qid to complete 14 days
- Alternative regimens
- Ofloxacin 400 mg IV q12h or levofloxacin 500 mg IV daily, ± metronidazole 500 mg IV q8h
- Ampicillin-sulbactam 3 g IV q6h plus doxycycline 100 mg IV/PO q12h
- Ciprofloxacin 200 mg IV q12h plus doxycycline 100 mg IV/PO q12h ± metronidazole 500 mg IV q8h
- Outpatient regimens
- Ceftriaxone 250 mg IM once plus doxycycline 100 mg PO bid for 14 days, ± metronidazole 500 mg IV q8h
- Cefoxitin 2 g IM once plus probenecid 1 g po once plus doxycycline 100 mg PO bid for 14 days, ± metronidazole 500 mg IV q8h
- Another third-generation cephalosporin plus doxycycline 100 mg PO bid for 14 days, ± metronidazole 500 mg IV q8h
- Ofloxacin 400 mg PO bid for 14 days, ± metronidazole 500 mg IV q8h
- Levofloxacin 500 mg PO daily, ± metronidazole 500 mg IV q8h
- If an intrauterine device is in situ, remove it only after at least 2 doses of antibiotics have been given
- Pain should start to improve within 48 to 72 hours of antibiotics; if it does not, then consider further investigations
- Rule out other sexually-transmitted infections, including HIV and syphilis
- Immunize against hepatitis B and HPV if indicated
- Partners should be screened and treated
Further Reading
- Management and treatment of specific syndromes – Pelvic Inflammatory Disease (PID). Canadian Guidelines on Sexually Transmitted Infections.
References
- ^ Harold C Wiesenfeld, Leslie A Meyn, Toni Darville, Ingrid S Macio, Sharon L Hillier. A Randomized Controlled Trial of Ceftriaxone and Doxycycline, With or Without Metronidazole, for the Treatment of Acute Pelvic Inflammatory Disease. Clinical Infectious Diseases. 2020;72(7):1181-1189. doi:10.1093/cid/ciaa101.