pelvic%20inflammatory%20disease
PELVIC INFLAMMATORY DISEASE
Pelvic inflammatory disease (PID) is the ascent of bacteria from the vagina or cervix resulting in infection of the reproductive organs eg uterus, fallopian tubes, ovaries. It may also be a complication of sexually transmitted infections.
The most common symptoms of PID are lower abdominal pain (crampy or dull) that usually starts a few days after the onset of the last menstrual period, dyspareunia, abnormal vaginal or cervical discharge, postcoital or irregular vaginal bleeding, dysuria, fever, nausea and vomiting, although some have minimal symptoms or silent pelvic inflammatory disease.

Principles of Therapy

Antibiotic Therapy

General Principles

  • Goals of therapy are to control the acute infection & to prevent long-term sequelae
  • Initiate antibiotic therapy as soon as presumptive diagnosis has been made because prevention of long-term adverse effect depends on immediate administration of proper antibiotic
    • The risk of tubal infertility or ectopic pregnancy may increase by 3x in female treated >72 hr after symptom onset
    • Treatment w/ antibiotics does not reverse any damage already incurred by the reproductive organs
  • All antibiotic regimens must provide adequate coverage for the following possible etiologic organisms for PID:
    • N gonorrhoeae, C trachomatis, anaerobes (Bacteroides, Gram-positive cocci), Mycoplasma hominis, facultative Gram-negative rods & Gram-positive aerobes
      • Rates of gonorrheal resistance are increasing for quinolones
  • The need to eliminate anaerobes in patients w/ PID has not been definitively determined
    • In vitro studies show that some anaerobes can cause tubal & epithelial destruction & many women w/ PID also have bacterial vaginitis; recommended regimens should therefore include anaerobic coverage
  • Oral vs parenteral therapy
    • Oral & parenteral therapy appear to be similarly effective in patients w/ mild-moderate PID
    • Most trials used parenteral therapy for 48 hr but this time-frame is arbitrary
      • Direct inpatient observation is recommended for at least 24 hr in those who have tubo-ovarian abscesses
    • Time to switch from parenteral to oral therapy should be guided by clinical experience
      • Shift to oral therapy can be started w/in 24 hr of clinical improvement (ie defervescence, decreased abdominal tenderness, & decreased uterine, adnexal, or cervical cervical motion tenderness)
  • Consider drug availability, cost & patient acceptance, together w/ local antimicrobial susceptibility & epidemiology patterns when choosing an antibiotic regimen

Pharmacotherapy

Symptomatic Therapy

  • May give analgesics (eg Paracetamol) for pain

Empiric Antibiotic Therapy

Aminopenicillin/Beta-lactamase Inhibitor

  • Effective for patients w/ tubo-ovarian abscess when given w/ Doxycycline

Azithromycin

  • Data regarding use as monotherapy for PID is limited & should not be used w/o Ceftriaxone

Cephalosporins

  • Recommended agents: Cefotetan, Cefoxitin, Ceftizoxime, Cefotaxime, Ceftriaxone
    • Effective against N gonorrhoeae, enteric Gram-negative rods, Streptococci
  • Ceftriaxone is less effective than Cefoxitin or Cefotetan against anaerobic bacteria but Ceftriaxone has better coverage for N gonorrhoeae
  • Limited data on other cephalosporins

Clindamycin

  • Good anaerobic coverage
  • Usually given when there is associated tubo-ovarian abscess

Doxycycline

  • Effective against C trachomatis
  • Contraindicated in pregnancy
  • Should be administered orally when possible due to infusion-associated pain

Gentamicin

  • Effective against enteric Gram-negative rods
  • Single daily dosing may be used

Metronidazole

  • Good anaerobic coverage
  • Effective against organisms causing bacterial vaginosis which is often present in PID patients
  • Usually given when there is associated tubo-ovarian abscess

Non-Pharmacological Therapy

Intrauterine Device (IUD) Removal
  • No evidence that removal of the IUD provides any additional benefit
    • Effect of continued use of IUD on treatment failure & recurrence of PID is unknown
  • May remove if the patient does not want to keep the IUD or if symptoms have not resolved w/in 72 hr after start of treatment
    • Caution & close clinical follow-up are needed if IUD will not be removed
    • If IUD will be removed, should wait until after therapy has been initiated & at least 2 doses of antibiotics have been given
  • Provide contraceptive counseling if IUD is removed
  • If patient still requests for an IUD as a contraceptive but is likely to be at risk of future PID, Levonorgestrel-intrauterine system (LNG-IUS) should be recommended

Evaluation & Treatment of Sex Partners

  • Even if asymptomatic, sexual partners of STI patients are likely to be infected & should be offered treatment to prevent further STI transmission & reinfection
  • Examine & treat all partners who had sexual contact w/ the patient during the 60 days preceding the onset of the patient’s symptoms
  • Treat empirically w/ regimens effective against both C trachomatis & N gonorrhoeae
    •  See Gonorrhea- & Chlamydia-Uncomplicated Anogenital Infection management chart for details
Digital Edition
Asia's trusted medical magazine for healthcare professionals. Get your MIMS JPOG - Malaysia digital copy today!
DOWNLOAD
Editor's Recommendations
Most Read Articles
27 Nov 2017
Transdermal oestradiol added to progesterone reduces menopause-related depression, researchers reported at the annual meeting of The North American Menopause Society in Philadelphia, US.
5 days ago
Intravenous (IV) iron is less toxic and more effective compared to oral iron, making it a potential frontline therapy for neonatal iron deficiency anaemia, suggests a recent study.
Tracy TC Kwan, BSc (Nursing), MPH; Hextan YS Ngan, MBBS, FHKAM (O&G), MD (HK), FRCOG, 01 Aug 2013

Human papillomavirus (HPV) infection is a prevalent disease worldwide. Consequences of HPV infection vary, depending on the infected individuals and the HPV genotype involved. Life-threatening consequences are not uncommon, and cervical cancer is a clear demonstration of the virus’s potency. While the incidence of cervical cancer is heavily concentrated on developing countries,1 the impact of HPV-related diseases on developed countries has not ceased. In the United States alone, HPV infections are the most common sexually transmitted disease with an estimated 5 million new cases being diagnosed in 2000 among young adults, incurring nearly US$3 billion in terms of direct medical costs.2 A multinational study involving 18,498 women showed that cervical HPV prevalence varied greatly geographically, ranging from the low of 1.6% in North Vietnam to the high of 27% in Nigeria. In general, HPV prevalence peaked among young, sexually active women and declined with age. In selected countries, however, a second peak was noted in women older than 55 years.3 The high prevalence of HPV-related diseases incurs a heavy burden on the healthcare systems of developed and developing countries alike, which renders HPV research and prevention a global public health imperative. On an individual level, the afflictions caused by HPV-related diseases go beyond that of physical suffering to affecting the psychological well-being of the infected. This is the focus of our paper.

27 Nov 2017
Chronic hepatitis B virus (HBV) infection is a global problem. Chronic HBV infection is probably the most common maternal infection encountered in Hong Kong, China, and Southeast Asia. In Hong Kong, which is one of the endemic areas, immunisation against HBV was first provided in 1983 to infants born to mothers who were screened positive for hepatitis B surface antigen (HBsAg). Immunisation became widespread since November 1988, but HBsAg-positive mothers are still encountered frequently.1