Pelvic inflammatory disease: Difference between revisions

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==Background==
βˆ’
* Upper genital tract infection in women that involves a combination of endometrium, fallopian tubes, and peritoneum
  
   
  +
*Upper genital tract infection in women that involves infection of any combination of endometrium, fallopian tubes, and peritoneum
βˆ’
== Background ==
  
βˆ’
=== Microbiology ===
  
βˆ’
* Often polymicrobial
  
βˆ’
* Most commonly associated with [[Chlamydia trachomatis]] or [[Neisseria gonorrhoeae]]
  
βˆ’
* 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]]
  
   
βˆ’
=== Epidemiology ===
 +
===Microbiology===
βˆ’
* About 10-15% of women have at least one episode
  
   
  +
*Often polymicrobial
βˆ’
== Clinical Presentation ==
  
  +
*Most commonly associated with [[Chlamydia trachomatis]] or [[Neisseria gonorrhoeae]]
βˆ’
* Pelvic or abdominal pain is the main complaint
  
  +
*Other contributory microbes include:
βˆ’
* May be febrile and have adnexal, uterine, or cervical motion tenderness
  
  +
**Other sexually-transmitted organisms
βˆ’
* Must rule out an ectopic pregnany
  
  +
***[[Herpes simplex virus]]
βˆ’
* May present with tuboovarian abscess
  
  +
***[[Trichomonas vaginalis]]
  +
**Genitourinary microbiota
  +
***[[Mycoplasma genitalium]]
  +
***[[Mycoplasma hominis]]
  +
***[[Ureaplasma urealyticum]]
  +
**Anaerobes
  +
***[[Bacteroides]]
  +
***[[Peptostreptococcus]]
  +
***[[Prevotella]]
  +
**Aerobes
  +
***[[Escherichia coli]]
  +
***[[Gardnerella vaginalis]]
  +
***[[Haemophilus influenzae]]
  +
***[[Streptococcus]]
   
  +
===Epidemiology===
βˆ’
== Investigations ==
  
βˆ’
* Ξ²-hCG to rule out ectopic pregnancy
  
βˆ’
* Endocarvical swabs for [[gonorrhea]] and [[chlamydia]], and possibly HSV
  
βˆ’
* Vaginal swabs for culture, pH, whiff testing, wet preps, and Gram stain
  
βˆ’
* Ultrasound can be helpful, especially for tuboovarian abscess
  
   
  +
*About 10-15% of women have at least one episode
βˆ’
== Management ==
  
βˆ’
* There are many possible regimens
  
βˆ’
** [[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
  
βˆ’
** [[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
  
βˆ’
** [[Is treated by::Ofloxacin]] 400 mg IV q12h or [[Is treated by::levofloxacin]] 500 mg IV daily, Β± [[Is treated by::metronidazole]] 500 mg IV q8h
  
βˆ’
** [[Is treated by::Ampicillin-sulbactam]] 3 g IV q6h plus [[Is treated by::doxycycline]] 100 mg IV/PO q12h
  
βˆ’
** [[Is treated by::Ciprofloxacin]] 200 mg IV q12h plus [[Is treated by::doxycycline]] 100 mg IV/PO q12h Β± [[Is treated by::metronidazole]] 500 mg IV q8h
  
βˆ’
** [[Is treated by::Ceftriaxone]] 250 mg IM once plus [[Is treated by::docycycline]] 100 mg PO bid for 14 days, Β± [[Is treated by::metronidazole]] 500 mg IV q8h
  
βˆ’
** [[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, Β± [[metronidazole]] 500 mg IV q8h
  
βˆ’
** Another third-generation cephalosporin plus [[Is treated by::doxycycline]] 100 mg PO bid for 14 days, Β± [[metronidazole]] 500 mg IV q8h
  
βˆ’
** [[Is treated by::Ofloxacin]] 400 mg PO bid for 14 days, Β± [[Is treated by::metronidazole]] 500 mg IV q8h
  
βˆ’
** [[Is treated by::Levofloxacin]] 500 mg PO daily, Β± [[Is treated by::metronidazole]] 500 mg IV q8h
  
βˆ’
* Often recommended to add [[Is treated by::metronidazole]] to any of the above regimens that do not have adequate anaerobic coverage, though it is unclear whether this makes any difference
  
βˆ’
* Only consider fluoroquinolones if there is susceptibility testing done or a test of cure is possible
  
βˆ’
* If an intrauterine device is in situ, remove it only after at least 2 doses of antibiotics have been given
  
   
  +
==Clinical Manifestations==
βˆ’
== Further Reading ==
  
  +
βˆ’
* [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.
  
  +
*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
  +
**Fever >38.3ΒΊC
  +
**Presence of leukocytes on saline microscopy of vaginal secretions
  +
**Elevated ESR or [[CRP]]
  +
**Diagnosed [[gonorrhea]] or [[chlamydia]]
  +
  +
===Complications===
  +
  +
*Short-term:
  +
**[[Fitz-Hugh-Curtis syndrome]]
  +
**[[Tubo-ovarian abscess]]
  +
*Long-term:
  +
**[[Ectopic pregnancy]]
  +
**[[Infertility]]
  +
**[[Chronic pelvic pain]]
  +
  +
==Differential Diagnosis==
  +
  +
*Gynecologic/obstetrical
  +
**Complications of pregnancy
  +
***Ectopic pregnancy
  +
**Endometriosis
  +
**Endometritis
  +
**Adnexal disorders
  +
**Mentrual disorders
  +
*Gastrointestinal
  +
**[[Appendicitis]]
  +
**[[Gastroenteritis]]
  +
**[[Inflammatory bowel disease]]
  +
*Genitourinary
  +
**[[Cystitis]]
  +
**[[Pyelonephritis]]
  +
**[[Nephrolithiasis]]
  +
*Musculoskeletal causes
  +
*Neurologic causes
  +
  +
==Investigations==
  +
  +
*No combination of routine investigations (including swabs and ultrasound) can be used to completely rule out PID
  +
*Laboratory investigations
  +
**Ξ²-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==
  +
  +
*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 Ξ²-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 [[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, Β± [[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 Β± [[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, Β± [[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, Β± [[metronidazole]] 500 mg IV q8h
  +
***Another third-generation cephalosporin plus [[Is treated by::doxycycline]] 100 mg PO bid for 14 days, Β± [[metronidazole]] 500 mg IV q8h
  +
***[[Is treated by::Ofloxacin]] 400 mg PO bid for 14 days, Β± [[Is treated by::metronidazole]] 500 mg IV q8h
  +
***[[Is treated by::Levofloxacin]] 500 mg PO daily, Β± [[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==
  +
  +
*[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.
   
 
[[Category:Genitourinary infections]]
  
[[Category:Genitourinary infections]]

Latest revision as of 13:02, 25 January 2022

Background

  • Upper genital tract infection in women that involves infection of any combination of endometrium, fallopian tubes, and peritoneum

Microbiology

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
    • Fever >38.3ΒΊC
    • Presence of leukocytes on saline microscopy of vaginal secretions
    • Elevated ESR or CRP
    • Diagnosed gonorrhea or chlamydia

Complications

Differential Diagnosis

Investigations

  • No combination of routine investigations (including swabs and ultrasound) can be used to completely rule out PID
  • Laboratory investigations
    • Ξ²-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

  • 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

Further Reading

References

  1. ^  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.

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