Transcript PID

Katie DePlatchett, M.D.
AM Report
January 4th, 2010
Pelvic Inflammatory Disease
 An infection in the upper genital tract not
associated with pregnancy or intraperitoneal
pelvic operations
Anatomy 101
Epidemiology
 Annual incidence: 300,000 cases
 ~20% of 1.5 million cases of GC/Chlamydia
 85% of infections are spontaneous in sexually
active females.
 15% of infections develop following procedures
that break the cervical mucus barrier
Risk Factors
 age at first voluntary intercourse less than 18
 nonuse of barrier contraception
 less than 12 years of education
 more than one male sexual partner in the
previous 30 days
 prior gonorrhea infection
 intercourse during menses
Pathogenesis
Ascending infection
- Along mucosa
- Bacterial colonization
fallopian tubes &
endometrium
- Chlamydia trachomatis
- Neisseria gonorrhoeae
Complications
 Tuboovarian abscesses
 Perihepatitis, also known as Fitz-Hugh–Curtis
syndrome
 tubal factor infertility
 ectopic pregnancy
 chronic pelvic pain
Symptoms according to ACOG
 Abnormal vaginal discharge
 Pain in the lower abdomen (often of a mild, aching
nature)
 Fever and chills
 Dysuria
 Nausea and vomiting
 Dysparunea
Diagnosis, per CDC Guidelines
Minimum Criteria:
Sexually active
 Lower abdominal tenderness or Adnexal tenderness or Cervical
motion tenderness
 No other plausible causes

Routine Criteria:
Oral temperature >38° C
 Abnormal cervical or vaginal discharge (mucopurulent)
 Presence of abundant WBCs on microscopy of vaginal secretions
 Elevated erythrocyte sedimentation rate
 Elevated C-reactive protein
 Laboratory documentation of cervical infection with N.
gonorrhoeae or C. trachomatis

Diagnosis, per CDC Guidelines
Definitive Criteria for Diagnosing PID
 Histopathologic evidence of endometritis on
endometrial biopsy
 Transvaginal sonography or MRI showing thickened
fluid-filled tubes with or without free pelvic or
tuboovarian complex
 Laparoscopic abnormalities consistent with PID
Diagnosis
 Gold Standard = Direct visualization via the
laparoscope
 However… operative laparoscopy during acute
infection has not been proven to reduce the
prevalence of long-term sequelae.
 Hence, the diagnosis of the majority of episodes
of acute PID is made on the basis of clinical
history and physical examination.
Imaging
 Ultrasonography
 sensitivity 75%–82%
 helpful in documenting an adnexal mass, especially
during difficult pelvic examination (tenderness or
BMI)
 CT
 sensitivity 90%–100%
CDC Ambulatory Management of
Acute PID
 Levofloxacin 500 mg PO once daily for 14 days
PLUS
 Metronidazole 500 mg PO bid for 14 days
OR
 Ceftriaxone 250 mg IM in a single dose OR other
parenteral third-generation cephalosporin
PLUS
 Doxycycline 100 mg PO bid for 14 days
 Metronidazole 500 mg PO bid for 14 days
Admission Worthy
• Surgical emergencies (eg, appendicitis) cannot be
excluded
• Pregnancy
• The patient does not respond clinically to oral
antimicrobial therapy
• The patient is unable to follow or tolerate an
outpatient oral regimen
• Severe illness, nausea and vomiting, or high fever
• The patient has a TOA (tuboovarian abscess)
Inpatient Treatment
 Cefotetan 2 g intravenously (IV) every 12 hours
OR
Cefoxitin 2 g IV every 6 hours
PLUS
Doxycycline 100 mg orally or IV every 12 hours
 “carefully monitored for an adequate response to
antibiotics and any signs of rupture of the TOA
and discharged after sufficient response to
parenteral antibiotics is demonstrated “
Surgical Management
 life-threatening infections
 ruptured tuboovarian abscesses
 laparoscopic drainage of a pelvic abscess
 persistent masses in older women for whom
future childbearing is not a consideration
 removal of a persistent symptomatic mass.
Back to our patient…
 Studies have demonstrated an overall 70% success
rate with conservative medical management of
TOAs
 Success of medical management has been
demonstrated to be inversely proportional to the
size of the TOA.
 Reed and colleagues evaluated 119 women with
TOAs
 >10 cm 60% required surgery
 4 to 6 cm 20% required surgery
What about IUDs??
 Increase risk in developing PID in the first month after
insertion
 The PID risk in IUD users is modified by:
 the number of sexual partners of the IUD user and that
of her partner(s)
 community prevalence of STDs
 age of the IUD user
 Case reports of pelvic/abdominal actinomyces
abscesses in IUD users , mostly out of Europe
Why Should You Care?
Chronic Pain
-- pelvic pain
--dyspareunia
-- abdominal pain
Why should you care?
 Lifetime cost of $1060 to $3180 per case.
 During 2008:
 $15.9 billion annually spent on tx of STDs
 $166 million was spent on treatment of chronic
pelvic pain
 $295 million was spent on treatment of ectopic
pregnancies
 $360 million was spent on infertility treatments as a
direct result of previous PID infection.
What Can You Do?
 CDC recommends :
yearly chlamydia testing of all sexually active women
age 25 or younger.
2. Older women with risk factors for chlamydial
infections (those who have a new sex partner or
multiple sex partners),
1.
References
 Katz. Comprehensive Gyn, 5th Ed. 2006.
 Pelvic Inflammatory Disease and Tubo-ovarian Abscess.
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Infectious Disease Clinics of North America - Volume 22, Issue 4
(December 2008).
Centers for Disease Control and Prevention: 2006 Guidelines for
treatment of sexually transmitted disease. MMWR 55:11, 2006
Intrauterine devices - upper and lower genital tract infections.
Contraception. 2007 Jun;75(6 Suppl):S41-7.
Yeh J., Hook , III , IIIE., Goldie S.: A refined estimate of the
average lifetime cost of pelvic inflammatory disease. Sex Transm
Dis 30. 369-378.2003
Rein D.B., Kassler W.J., Irwin K.L., et al: Direct medical cost of
pelvic inflammatory disease and its sequelae: decreasing, but
still substantial. Obstet Gynecol 95. 397-402.2008.