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 16:29, 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