Pelvic Inflammatory Disease CDC, 2010 European Guidelines, 2012

Pelvic

Inflammatory

Disease

CDC, 2010

European Guidelines, 2012

Prof. Aboubakr Elnashar Benha University Hosp. Egypt

ABOUBAKR ELNASHAR

Definition

Inflammatory disorders of the upper

FGT

Any combination of

endometritis,

salpingitis,

tubo-ovarian abscess&

pelvic peritonitis.

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Pathophysiology I. Ascending: common, from the LGT

1. Through sperm, TV, along surfaces

traveling from the cervix to the endometrium,

through the salpinx, and into the peritoneal

cavity

2. Through the lymphatic systems:

infection of the parametrium from IUCD

II. Lateral:

Rare, from infected appendix

III. Through hematogenous routes

Rare: tuberculosis

ABOUBAKR ELNASHAR

Factors associated with PID:

I. Factors related to sexual behaviour

•young age

•multiple partners

•recent new partner (within previous 3 months)

•past history of (STIs) in the patient or their partner

II. Instrumentation of the uterus / interruption of the

cervical barrier

• termination of pregnancy

• insertion of IUCD within the past 6 w

• HSG

• IVF

ABOUBAKR ELNASHAR

Types Primary

No precipitating

cause

STD

Secondary

Precipitating

cause

IUCD,

HSG,

abortion or

infection

elsewhere in the

body;

appendicitis ABOUBAKR ELNASHAR

Aetiology ST organisms:

N. Gonorrhoeae (NG), C. trachomatis (CT)

Vaginal flora:

Anaerobes, G. vaginalis,

H influenzae, enteric Gram- rods

Streptococcus agalactiae

Rare

M. hominis, U. urealyticum, M. genitalium.

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Diagnosis

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•Difficult:

1. No single historical, physical, or lab finding

is both sensitive & specific

Combinations of diagnostic findings to

improve sensitivity &specificity

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2. Clinical Diagnosis

PPV: 65%– 90% compared with laparoscopy. a. Wide variation in S & S. b. Sym:

± No ±Subtle, mild, non specific e.g. AUB Dyspareunia VD

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3. Laparoscopy:

accurate diagnosis of salpingitis

bacteriologic diagnosis.

not readily available

not easy to justify when sym are mild or vague.

not detect endometritis

might not detect subtle inflammation of FT.

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Grading (Soper,1991):

Mild: erythema, edema, exudates, tubes are patent & mobile,

Moderate: purulent discharge & fixed tubes

Severe: TO abscess, pyosalpinx ABOUBAKR ELNASHAR

bilateral pyosalpinx.

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Hager criteria (Hager et al,1983)

1. Abdominal pain & tenderness,

2. Cervical movement tenderness &

3. Adenxal tenderness + 1 or more of the following

1. T >38.3°C,

2. Discharge: mucopurulent

3. Saline microscopy: WBC 6-10/HPF

4. ESR: elevated (> 15 mm/h)

5. CRP: elevated

6. laboratory documentation of NG or CT. {Gram –ve

intracellular diplcocci, I.F. stain: CT} 7. Leucocytosis > 10000

8. U/S: adenxal mass

9. Culdocentesis: purulent discharge

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CDC (2010)

Minimum criteria: one is enough

1. Cervical motion tenderness

2. Uterine tenderness

3. Adnexal tenderness

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•One or more of the following minimum criteria must

be present on pelvic examination to diagnose PID:

•The requirement that all 3 minimum criteria be

present before the initiation of empiric tt: insufficient

sensitivity for the diagnosis of PID.

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Supportive criteria:

Improving the specificity of the minimum criteria

1. T >38.3°C,

2. Discharge: mucopurulent

3. Saline microscopy: WBC 6-10/HPF

4. ESR: elevated

5. CRP: elevated

6. laboratory documentation of NG or CT.

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Specific criteria:

1. TVS or MRI showing

thickened, fluid-filled tubes with or without free pelvic

fluid or tubo-ovarian complex, or

Doppler studies suggesting pelvic infection (e.g.,

tubal hyperemia)

2. Laparoscopic abnormalities consistent with PID 3. Endometrial biopsy with histopathologic evidence of endometritis

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Ovarian abscess

Pelvic abscess ABOUBAKR ELNASHAR

PID & tubo-ovarian complex

Tubo-ovarian abscess: an echo poor

septated process close to the uterus

(U).

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Complications • Tuboovarian abscesses and pelvic peritonitis:

Acute lower abdominal pain and fever are usually

present.

US: confirm a pelvic abscess

CT: rule out other peritonitis.

• The Fitz-Hugh-Curtis syndrome:

Rt upper quadrant pain associated with Perihepatitis

±dominant symptom.

treatment for PID

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• In pregnancy PID

Uncommon

: increase maternal and fetal morbidity

parenteral therapy effective against gonorrhoea,

chlamydia and anaerobic infections

(e.g. i.v. cefoxitin 2g three times daily plus i.v.

erythromycin 50mg/kg continuous infusion, with the

possible addition of i.v. metronidazole 500mg three

times daily)

(Evidence level III, B)

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Differential Diagnosis

lower abdominal pain in a young woman:

• ectopic pregnancy

• acute appendicitis

• endometriosis

• irritable bowel syndrome

• complications of an ovarian cyst i.e. rupture,

torsion

• functional pain (pain of unknown physical origin)

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Treatment

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Empiric treatment of PID

WHY? 1. Diagnosis is difficult

2. Delay in diagnosis & tt: inflam sequelae in upper

FGT.

3. Empiric antimicrobial tt of PID:

Not impair Diagnosis & management of other causes of

lower abd pain: ectopic pregnancy

ac appendicitis

functional pain

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Recommendation

{lack of definitive clinical diagnostic criteria}

a low threshold for empirical tt of PID is

recommended (RCOG, 2003, B)

Outpatient antibiotic tt should be commenced as

soon as the diagnosis is suspected. (RCOG, 2003, A)

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When? 1. Sexually active young women and other

women at risk for STDs

2. Pain: pelvic or lower abd

3. Other causes are excluded 4. Tenderness on pelvic examination (minimum criteria):

a) cervical motion OR

b) uterine OR

c) adnexal.

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Treatment should be initiated as soon

as the presumptive diagnosis has been

made {prevention of long-term

sequelae}

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Indication of hospitalization

1. Surgical emergencies (appendicitis) cannot

be excluded

2. Pregnant

3. No response to oral antimicrobial therapy

4. Unable to follow or tolerate an outpatient

oral regimen

5. Severe illness (N&V, or high fever)

6. Tubo-ovarian abscess.

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General measures include:

• Rest is advised for those with severe disease (Evidence level C)

• If there is a possibility that the patient could be

pregnant, a pregnancy test should be

performed (Evidence level C)

• Appropriate analgesia should be provided (Evidence level C)

• Intravenous therapy is recommended for patients

with more severe clinical disease (Evidence level IV, C)

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In inpatients the tt response can be monitored by changes in C

reactive protein and WBC .

In severe cases and cases with failure of the initial tt tuboovarian

abcess should be excluded by TVS, CT or MRI

All patients should be offered screening for STD (Evidence level IV, C) .

It is likely that delaying treatment increases the risk of long term

sequelae such as ectopic pregnancy, infertility and pelvic pain 15.

Because of this, and the lack of definitive diagnostic criteria, a low

threshold for empiric treatment of PID is recommended (Evidence

level IV, C).

In cases with suspected repeat PID, especially if it is of mild

severity, other causes should be sought and treated accordingly,

especially functional pain, pain originating in the ileopsoas

muscles, the pelvic floor and urinary tract (Evidence level IV, C).

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Choice of treatment regime should be influenced

by the following:

• Mild and moderate cases should be treated as

outpatients with oral therapy16 (Evidence

level Ib, A).

• Intravenous therapy, when given, should be

continued until 24 hours after clinical improvement

and then switched to oral (Evidence level IV, C).

• Dosage recommendations may need to be

adjusted slightly depending on local licensing

regulations and the availability of drug formulations.

• The optimal duration of treatment is not known but

most clinical trials report a response to 10-14 days

of therapy.

• No difference in efficacy has been demonstrated

between the recommended regimens ABOUBAKR ELNASHAR

Selection of antibiotics

1. Effective against N. G&C. T. {negative endocervical screening does not rule out PID}.

The need to eradicate anaerobes has not

been determined definitively. Regimens with anaerobic activity should be considered

{a. Anaerobic bacteria have been isolated b. BV is present in many women who have PID}

2. Consider

availability

cost

patient acceptance.

3. Parenteral & oral therapy have similar

efficacy in mild or moderate PID

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Recommended Parenteral Regimen A (RCOG, 2003, B)

I. Initial:

Cefotetan (Cefotan) 2 g IV/12 h

OR

Cefoxitin (Mefoxin) 2 g IV/ 6 h

PLUS Doxycycline 100 mg orally or IV*/12 h *Oral and IV administration of doxycycline provide similar bioavailability.

II. Continued

24 h after a patient improves clinically

doxycycline (100 mg twice a day) to complete 14

days ABOUBAKR ELNASHAR

Recommmended Parenteral Regimen B I. Initial

Clindamycin 900 mg IV/8 h

PLUS Gentamicin loading dose IV or IM (2 mg/kg),

followed by a maintenance dose (1.5 mg/kg)/8

h. Single daily dosing may be substituted. Although use of a single daily dose of

gentamicin has not been evaluated for the treatment of PID, it is efficacious in

analogous situations.

II. Continued:

24 h after a patient improves clinically

doxycycline 100 mg orally twice a day or

clindamycin 450 mg orally four times a day to complete a total

of 14 days of therapy.

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•Bevan CD, Ridgway GL, Rothermel CD. Efficacy and safety of azithromycin as monotherapy or combined with metronidazole compared with two standard multidrug regimens for the treatment of acute PID. (J Int Med Res 2003;31:45–54).

•Azithromycin (Zithromax)

500 mg/d IV for 1 day or 2 days followed by 250 mg/d orally for a total of 7 days, alone or with Metronidazole 400 mg tds or 500 mg IV then orally for a total of 14 days.

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•Rates of clinical success for Azithromycin alone: 97.1% with metronidazole: 98.1% Conclusion: Azithromycin, alone or with metronidazole, provides a shorter, simpler treatment option for the successful management of acute PID.

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Recommended Regimen A (RCOG, 2003, B) Levofloxacin (levaquin) 500 mg orally once

daily for 14 days*

OR

Ofloxacin (floxin) 400 mg orally once daily

for 14 days*

WITH OR WITHOUT

Metronidazole 500 mg orally twice a day

for 14 days

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Azithromycin: 250 mg daily for 7 days Plus Metronidazole: 500 mg tds for 14 d {effective against anaerobes and BV} (Bevan et al, 2003).

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Surgical treatment should be

considered in severe cases or where

there is clear evidence of a pelvic

abscess (RCOG, 2003,B)

1. Hospitalization: at least 24 h

2. Laparotomy/laparoscopy:

a. division of adhesions & drainage of pelvic

abscesses.

b. adhesiolysis in cases of perihepatitis

although there is no evidence as to whether

this is superior to antibiotic therapy alone.

3. US-guided aspiration:

less invasive and may be equally effective.

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Tubo-ovarian abscess:

I. Initial

II. Contiued:

Clindamycin or metronidazole with

doxycycline {more effective anaerobic

coverage}.

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Management of Sex Partners •Examined and treated if they had sexual contact

with the patient during the 60 days preceding the

patient’s onset of symptoms.

{ a. Risk for reinfection of the patient

b. strong likelihood of urethral gonococcal or

chlamydial infection in the sex partner}. •With regimens effective against both of these

infections Patients should be advised to avoid unprotected intercourse until they, and their partner(s), have completed treatment and follow-up (Evidence level IV, C)

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IUD •Risk of PID

confined to the first 3 w after insertion

uncommon thereafter. A Cochrane review:

Doxycycline or azithromycin (Zithromax) before

IUD insertion confers little benefit. •PID in IUD users: No evidence that IUDs should be removed

Close clinical follow-up is mandatory.

IUCD may be left in mild PID but should be

removed in severe cases (RCOG, 2003,B)

In women with an intrauterine contraceptive device (IUD) in situ, consider removing the IUD

since this may be associated with better short term improvement in symptoms and signs.

(Evidence level Ib, A)

ABOUBAKR ELNASHAR

Role of Prophylactic Antibiotics (2014)

Recommendation

Routine use of prophylactic antibiotics is not

recommended prior to IUD insertion, although it may

be used in certain high-risk situations. (I-C) Management of PID with IUD In Situ Recommendation In treating mild to moderate PID, it is not necessary to remove the IUD during treatment unless the patient requests removal or there is no clinical improvement after 72 hours of appropriate antibiotic treatment. In cases of severe PID, consideration can be given to removing the IUD after an appropriate antibiotic regimen has been started. (I-B)

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HSG:

{Postoperative PID is an uncommon but

potentially serious complication.

Patients with dilated fallopian tubes are at

greater risk}.

1. Dilated fallopian tubes: 100 mg of

doxycycline twice daily for 5 d.

2. History of pelvic infection: doxycycline

before the procedure & continued if dilated

fallopian tubes are found (ACOG, 2006).

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Surgical Abortion/D&C

{periabortal antibiotics had a 42% overall

decreased risk of infection}.

ACOG: antibiotic prophylaxis is effective,

regardless of risk.

Doxycycline: 100 mg orally 1 h before

procedure & 200 mg after procedure

Metronidazole: 500 mg orally twice daily

for 5 d

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COC and PID

BTB: screen for C. trachomatis (RCOG, 2003,

C)

COC has been regarded as protective

against symptomatic PID.

Increased risk of CT. may mask endometritis.

Effectiveness may be reduced when

taking antibiotic

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Recent data suggest that few antibiotics

(azithromycin and moxifloxacin, mainly) are

effective against Mycoplasma genitalium

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Syndromic Management of Pelvic Inflammatory Disease

(for use where initial investigations are not available)

lower abdominal pain +/- abnormal vaginal/cervical discharge

with adnexal tenderness or cervical motion tenderness on

bimanual examination

missed or overdue period

sudden onset severe pain

bowel symptoms or signs

intermittent cyclical abdominal pain

positive pregnancy test

screen for STD if possible

treat with recommended regimen (see below)

educate patient about PID

treat partner(s) with ceftriaxone 500mg i.m. single dose

plus azithromycin 1g single dose

(or an alternative regimen locally effective against N. gonorrhoeae and C. trachomatis) review after 3 days to ensure clinical improvement

Refer for

further

investigation

No

Yes

No

ABOUBAKR ELNASHAR

PID is a polymicrobial infection of the upper genital

tract. It primarily affects young, sexually active

women.

The diagnosis is made clinically; no single test or

study is sensitive or specific enough for a definitive

diagnosis.

PID should be suspected in at-risk patients who

present with pelvic or lower abdominal pain with no

identified etiology, and who have cervical motion,

uterine, or adnexal tenderness.

Chlamydia trachomatis and Neisseria gonorrhoeae

are the most commonly; however, other

microorganisms may be involved.

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The spectrum of disease ranges from

asymptomatic to life-threatening tubo-ovarian

abscess.

Patients should be treated empirically, even if they

present with few symptoms. Most women can be

treated successfully as outpatients with a single

dose of a parenteral cephalosporin plus oral

doxycycline, with or without oral metronidazole.

Delay in treatment may lead to major sequelae,

including chronic pelvic pain, ectopic pregnancy,

and infertility.

Hospitalization and parenteral treatment are

recommended if the patient is pregnant, has

human immunodeficiency virus infection, does not

respond to oral medication, or is severely ill. ABOUBAKR ELNASHAR

No single clinical finding or laboratory test is

sensitive or specific enough to definitively

diagnose PID.

Empiric antibiotic treatment should be initiated at

the time of presentation in patients with symptoms

suspicious for PID, even if the diagnosis has not

been confirmed. B

Women with mild to moderate PID may receive

outpatient oral medical treatment without

increased risk of long-term sequelae.

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