Pelvic inflammatory disease
From IDWiki
- Upper genital tract infection in women that involves a 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
- About 10-15% of women have at least one episode
Clinical Presentation
- Pelvic or abdominal pain is the main complaint
- May be febrile and have adnexal, uterine, or cervical motion tenderness
- Must rule out an ectopic pregnany
- May present with tuboovarian abscess
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
Management
- There are many possible 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
- 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
- Ceftriaxone 250 mg IM once plus docycycline 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
- Often recommended to add 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
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.