RISK FACTORS: Sexually active, reproductive age, Most common in adolescents, Multiple sexual partners, Use of an IUD, greatest risk in first few months after insertion, Previous history of PID; 20-25% will have a recurrence, Chlamydial
RISK FACTORS
β’ Sexually active, reproductive age
β’ Most common in adolescents
β’ Multiple sexual partners
β’ Use of an IUD, greatest risk in fi rst few months after insertion
β’ Previous history of PID; 20-25% will have a recurrence
β’ Chlamydial or gonococcal cervicitis; 8-10% will develop PID
β’ Gonococcal salpingitis occurs commonly within 7 days of onset of menses
β’ Condoms and vaginal spermicides lessen the risks of PID
β’ Oral contraceptives may reduce the risk of PID
Most patients are now managed as outpatients, but physicians should consider hospitalization for patients with the following conditions, although no clear data suggest that these patients benefit from hospitalization:
Uncertain diagnosis
Pelvic abscess on ultrasound
Pregnancy
Failure to respond to outpatient management
Inability to tolerate outpatient PO regimen
Severe illness or nausea and vomiting precluding outpatient treatment
Immunodeficiency (eg, HIV with low CD4 count, using immunosuppressive medications)
Failure to improve clinically after 72 hours with outpatient therapy
Inpatient treatment includes the following:
Regimen A: Administer cefoxitin 2 g IV or cefotetan 2 g IV plus doxycycline 100 mg PO/IV q12h. Continue this regimen for 48 hours after the patient remains clinically improved, and then start doxycycline 100 mg PO bid for a total of 14 days. Administer doxycycline PO when possible because of pain associated with infusion. Bioavailability is similar with PO and IV administrations. IV antibiotics may be discontinued 24 hours after the patient improves clinically, and PO therapy with doxycycline is continued for a total of 14 days. If tubo-ovarian abscess is present, use clindamycin or metronidazole with doxycycline for more effective anaerobic coverage.
Regimen B: Administer clindamycin 900 mg IV q8h plus a 2 mg/kg loading dose of gentamicin IV or IM followed by a maintenance dose of 1.5 mg/kg q8h. IV therapy may be discontinued 24 hours after the patient improves clinically, and PO therapy of 100 mg bid of doxycycline should be continued for a total of 14 days of therapy.
Outpatient treatment
Regimen A: Administer ofloxacin 400 mg PO bid for 14 days or levofloxacin 500 mg PO qd for 14 days with or without metronidazole 500 mg PO bid for 14 days.
Regimen B: Administer ceftriaxone 250 mg IM in a single dose or cefoxitin 2 g IM in a single dose and probenecid 1 g PO concurrently in a single dose or other parenteral third-generation cephalosporin plus doxycycline 100 mg PO bid for 14 days with or without metronidazole 500 mg PO bid for 14 days.
Surgical Care: The advantage of laparoscopy is that it allows direct visualization of the pelvis and provides a more accurate and bacteriologic diagnosis if cultures are obtained. However, laparoscopy is not always available in acute PID. In addition, this procedure is costly and requires general anesthesia. It should be used if the diagnosis is in doubt. However, if operative laparoscopy is used early in the course of the disease, copious irrigation and separation of thin adhesions by blunt dissection may prevent later sequelae.
DRUG TREATMENT :
1. ANTIBIOTICS :
- CEFOXITIN
- CEFOTETAN
- DOXYCYCLINE
- CLINDAMYCIN
- METRONIDAZOLE
- MEROPENEM
- CEFTRIAXONE
- OFLOXACIN
- GENTAMICIN
2. URICOSURIC AGENTS
- PROBENECID
DRUG(S) OF CHOICE
Several antibiotic regimens are highly effective with no single regimen of choice, but coverage should include
chlamydia, gonorrhea, anaerobes, gram-negative rods, and streptococci. The CDC regimens that follow are
recommendations and the specific antibiotics named are examples.
. Parenteral; regimen A
. Cefoxitin 2 g IV every 6 hours or cefotetan IV 2 g every 12 hours (or other cephalosporins such as ceftizoxime, cefotaxime, and ceftriaxone) plus doxycycline 100 mg orally or IV every 12 hours
. Therapy for 24 hours after clinical improvement and doxycycline continued after discharge for a total of
10-14 days
. Parenteral; regimen B
. Clindamycin 900 mg IV every 8 hours plus gentamicin loading dose IV or IM (2 mg/kg of body weight) followed by a maintenance dose (1.5 mg/kg) every 8 hours
. Therapy for 24 hours after clinical improvement with doxycycline after discharge as above, or clindamycin
450 mg orally qid for a total of 14 days
. Outpatient treatment; regimen A
. Ofloxacin 400 mg orally bid for 14 days or levofloxacin 500 mg orally once daily for 14 days with or without metronidazole 500 mg orally bid for 14 days
. Outpatient treatment; regimen B
. Cefoxitin 2 g IM plus probenecid, 1 g orally, concurrently or ceftriaxone 250 mg IM or equivalent cephalosporin plus doxycycline 100 mg orally bid for 10-14 days with or without metronidazole 500 mg orally bid for 14 days
ALTERNATIVE DRUGS
Many other antibiotic regimens have been proposed and used with success. For example, tobramycin in place of gentamicin, tetracycline in place of doxycycline.
PATIENT MONITORING
β’ Close observation of clinical status, in particular for fever, symptoms, level of peritonitis, white cell count
β’ Follow adnexal abscess size and position with ultrasonography
PREVENTION/AVOIDANCE
β’ Educational programs about safe sex practices
β’ Education, particularly for those who have had an episode of PID
β’ IUD contraindicated in women with history of PID or lifestyle associated with STD
β’ Oral contraceptive appears to decrease risk of PID in cases with cervicitis and the PID cases which do occur are generally less severe
β’ Barrier contraceptives, especially condoms, and spermicidal creams or sponges provide protection, the extent of which is not well documented
β’ Insure evaluation and treatment of sex partners β’ Comply with management instructions
β’ Seek medical care early when genital lesions or discharge appear
β’ Seek routine check-ups for STD if in non-mutually monogamous relationship(s)
POSSIBLE COMPLICATIONS
β’ A tubo-ovarian abscess will develop in approximately 7-16% of patients
β’ Recurrent infection occurs in 20-25% of patients
β’ Risk of ectopic pregnancy increased by 7-10-fold to about 8% of women who have had PID
β’ Tubal infertility in 15, 35, and 55% of women after one, two, and three episodes of PID, respectively
β’ Chronic pelvic pain in 20% related to adhesion formation, chronic salpingitis, or recurrent infections
EXPECTED COURSE/PROGNOSIS
β’ Wide variation with good prognosis if early, effective therapy instituted and further infection avoided
β’ Poor prognosis related to late therapy and continued unsafe lifestyle