Pelvic inflammatory disease: Difference between revisions

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==Background==
* 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
== Background ==
=== Microbiology ===
* Often polymicrobial
* Most commonly associated with [[Chlamydia trachomatis]] or [[Neisseria gonorrhoeae]]
* 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]]


=== Epidemiology ===
===Microbiology===
* About 10-15% of women have at least one episode


*Often polymicrobial
== Clinical Manifestations ==
*Most commonly associated with [[Chlamydia trachomatis]] or [[Neisseria gonorrhoeae]]
* Pelvic or abdominal pain is the main complaint
*Other contributory microbes include:
* May be febrile and have adnexal, uterine, or cervical motion tenderness
**Other sexually-transmitted organisms
* Must rule out an ectopic pregnany
***[[Herpes simplex virus]]
* May present with tuboovarian abscess
***[[Trichomonas vaginalis]]
**Genitourinary microbiota
***[[Mycoplasma genitalium]]
***[[Mycoplasma hominis]]
***[[Ureaplasma urealyticum]]
**Anaerobes
***[[Bacteroides species]]
***[[Peptostreptococcus species]]
***[[Prevotella species]]
**Aerobes
***[[Escherichia coli]]
***[[Gardnerella vaginalis]]
***[[Haemophilus influenzae]]
***[[Streptococcus species]]


===Epidemiology===
== 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
* Ultrasound can be helpful, especially for tuboovarian abscess


*About 10-15% of women have at least one episode
== Management ==
* There are many possible 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
** [[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
** [[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
** [[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
* 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
* Only consider fluoroquinolones if there is susceptibility testing done or a test of cure is possible
* If an intrauterine device is in situ, remove it only after at least 2 doses of antibiotics have been given


==Clinical Manifestations==
== 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.
*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 >38.3ºC
**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
**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 ==

* 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 [[Is treated by::metronidazole]] to any regimen that does not have adequate anaerobic coverage, though it is unclear whether this makes any difference
**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::docycycline]] 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==

*[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]]

Revision as of 20:29, 18 September 2020

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 >38.3ºC
    • 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
    • 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

  • 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
  • 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