Diagnosis

• Acute PID
  • Laparoscopy can be used to obtain a more accurate diagnosis of salpingitis and a more complete bacteriologic diagnosis. However, this diagnostic tool often is not readily available, and its use is not easy to justify when symptoms are mild or vague. Moreover, laparoscopy will not detect endometritis and may not detect subtle inflammation of the fallopian tubes. Consequently, a diagnosis of PID usually is based on clinical findings
  • The clinical diagnosis of acute PID is imprecise
  • Combinations of diagnostic findings that improve either sensitivity (i.e., detect more women who have PID) or specificity (i.e., exclude more women who do not have PID) do so only at the expense of the other. For example, requiring two or more findings excludes more women who do not have PID but also reduces the number of women with PID who are identified.
• Most women with PID have either mucopurulent cervical discharge or evidence of WBCs on a microscopic evaluation of a saline preparation of vaginal fluid
• More elaborate diagnostic evaluation often is needed, because incorrect diagnosis and management might cause unnecessary morbidity. These additional criteria may be used to enhance the specificity of the minimum criteria. Additional criteria that support a diagnosis of PID include the following:
  • Oral temperature >101 F (>38.3 C);
  • Abnormal cervical or vaginal mucopurulent discharge;
  • Presence of white blood cells (WBCs) on saline microscopy of vaginal secretions;
  • Elevated erythrocyte sedimentation rate;
  • Elevated C-reactive protein; and
  • Laboratory documentation of cervical infection with N. gonorrhoeae or C. trachomatis.
• The most specific criteria for diagnosing PID include the following:
  • Endometrial biopsy with histopathologic evidence of endometritis;
  • Transvaginal sonography or magnetic resonance imaging techniques showing thickened, fluid-filled tubes with or without free pelvic fluid or tubo-ovarian complex; and
  • Laparoscopic abnormalities consistent with PID

Treatment

• PID treatment regimens must provide empiric, broad-spectrum coverage of likely pathogens
• Antimicrobial coverage should include N. gonorrhoeae, C. trachomatis, anaerobes, Gram-negative facultative bacteria, and streptococci
• Several antimicrobial regimens have been effective in achieving clinical and microbiologic cure in randomized clinical trials with short-term follow- up. However, few investigations have assessed and compared these regimens with regard to elimination of infection in the endometrium and fallopian tubes or determined the incidence of long-term complications of antimicrobial regimens.
• All regimens should be effective against N. gonorrhoeae and C. trachomatis, because negative endocervical screening does not preclude upper reproductive tract infection
• Until treatment regimens that do not adequately cover these microbes have been demonstrated to prevent sequelae as successfully as the regimens that are effective against these microbes, the recommended regimens should provide anaerobic coverage
• Treatment should be initiated as soon as the presumptive diagnosis has been made, because prevention of long-term sequelae has been linked directly with immediate administration of appropriate antibiotics
• The following criteria for hospitalization are based on observational data and theoretical concerns:
  • Surgical emergencies (e.g., appendicitis) cannot be excluded;
  • The patient is pregnant;
  • The patient does not respond clinically to oral antimicrobial therapy;
  • The patient is unable to follow or tolerate an outpatient oral regimen;
  • The patient has severe illness, nausea and vomiting, or high fever; and
  • The patient has a tubo-ovarian abscess.
• Parenteral Treatment
  • No efficacy data compare parenteral with oral regimens
  • Clinical experience should guide decisions regarding transition to oral therapy, which usually can be initiated within 24 hours of clinical improvement
  • Most clinicians recommend at least 24 hours of direct inpatient observation for patients who have tubo-ovarian abscesses, after which time home antimicrobial therapy is adequate

  Parenteral Regimen A
  Cefotetan 2 g IV every 12 hours
  OR
  Cefoxitin 2 g IV every 6 hours
  PLUS
  Doxycycline 100 mg orally or IV every 12 hours.

  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. Single daily dosing may be substituted.

  Alternative Parenteral Regimens

  • Limited data support the use of other parenteral regimens, but the following three regimens have been investigated in at least one clinical trial, and they have broad spectrum coverage

  Ofloxacin 400 mg IV every 12 hours
  OR
  Levofloxacin 500 mg IV once daily
  WITH or WITHOUT
  Metronidazole 500 mg IV every 8 hours
  OR
  Ampicillin/Sulbactam 3 g IV every 6 hours
  PLUS
  Doxycycline 100 mg orally or IV every 12 hours.

  Oral Treatment

  • As with parenteral regimens, clinical trials of outpatient regimens have provided minimal information regarding intermediate and long-term outcomes
  • The following regimens provide coverage against the frequent etiologic agents of PID, but evidence from clinical trials supporting their use is limited
  • Patients who do not respond to oral therapy within 72 hours should be reevaluated to confirm the diagnosis and should be administered parenteral therapy on either an outpatient or inpatient basis.

  Regimen A
  Ofloxacin 400 mg orally twice a day for 14 days
  OR
  Levofloxacin 500 mg orally once daily for 14 days
  WITH or WITHOUT
  Metronidazole 500 mg orally twice a day for 14 days.

  Regimen B
  Ceftriaxone 250 mg IM in a single dose
  OR
  Cefoxitin 2 g IM in a single dose and Probenecid, 1 g orally administered concurrently in a single dose
  OR
  Other parenteral third-generation cephalosporin (e.g., ceftizoxime or cefotaxime)
  PLUS
  Doxycycline 100 mg orally twice a day for 14 days
  WITH or WITHOUT
  Metronidazole 500 mg orally twice a day for 14 days.

Follow-Up

• Patients should demonstrate substantial clinical improvement (e.g., defervescence; reduction in direct or rebound abdominal tenderness; and reduction in uterine, adnexal, and cervical motion tenderness) within 3 days after initiation of therapy
• Patients who do not improve within this period usually require hospitalization, additional diagnostic tests, and surgical intervention

Pregnancy

• Because of the high risk for maternal morbidity, fetal wastage, and preterm delivery, pregnant women who have suspected PID should be hospitalized and treated with parenteral antibiotics

Reference

Please log-in or register in order to submit comments.

Powered by AkoComment!