Pelvic inflammatory disease

• 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 Manifestations

• 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.