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Morning Report

Morning Report. January 31, 2011. PID. Acute infection of upper genital tract Uterus Oviducts Ovaries Community-acquired STD Gonorrhea and/or chlamydia Anaerobes and enteric GNR. PID. Risk Factors Age <25y Young age at first sex Nonbarrier contraception

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Morning Report

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  1. Morning Report January 31, 2011

  2. PID • Acute infection of upper genital tract • Uterus • Oviducts • Ovaries • Community-acquired STD • Gonorrhea and/or chlamydia • Anaerobes and enteric GNR

  3. PID • Risk Factors • Age <25y • Young age at first sex • Nonbarrier contraception • New, multiple or symptomatic sexual partners • Oral contraception • Cervical ectopy • Facilitating factors for PID • Previous episode of PID • Sex during menses • Vaginal douching • Bacterial vaginosis

  4. Diagnostic Criteria • Minimal Criteria for empirical treatment • Lower abdominal pain PLUS • Cervical motion tenderness OR • Adenexal tenderness • Supportive Criteria • Oral temperature >101 • Abnormal cervical or vaginal mucopurulent discharge • Abundant numbers of WBCs in vaginal secretions • Elevated ESR • Elevated CRP

  5. Diagnostic Criteria • Confirmation criteria • Acute or chronic endometritis or acute salpingitis on histologic evaluation of biopsy • Demonstration of N.gonorrhoeae or C.trachomatis in the genital tract • Gross salpingitis at laparoscopy or laparotomy • Isolation of pathogenic bacteria from upper genital tract • Inflammatory/purulent pelvic peritoneal fluid without another source

  6. Other Symptoms • Pain • Worse with coitus or jarring movement • Abnormal uterine bleeding • RUQ pain • Perihepatitis

  7. Diagnostic Testing • UPT • UA • Fecal occult blood • CBC • Microscopic exam of vaginal discharge • Nucleic acid amplification tests for chlamydia and gonorrhea • CRP • Test for other STDs!!

  8. Imaging • Ultrasound • Transvaginal • Absence of findings does not diminish the probability of PID

  9. Hospitalization • Pregnancy • Lack of response or tolerance to oral medications • Nonadherence to therapy • Inability to take oral medications due to nausea and vomiting • Severe clinical illness • High fever • Nausea/Vomiting • Severe abdominal pain • Pelvic abscess • Need for surgical intervention

  10. Treatment • Inpatient • Cefoxitin or cefotetan PLUS doxycycline • Clindamycin PLUS gent • Ampicillin-sulbactam PLUS doxycycline • *Administer doxy orally

  11. Treatment • Outpatient • Ceftriaxone IM x1 PLUS doxycycline x 14d • +/- Flagyl x 14d • Cefoxitin IM x 1 with probenicid PLUS doxycycline x 14d • +/- Flagyl x 14d • Cefotaxime IM or ceftixozime PLUS doxycycline x 14d • +/- Flagyl x 14d

  12. Treatment • +/- Flagyl x 14d • Risk for anaerobes • Pelvic abscess • Proven or suspected infection with Trichomonas or BV • History of gynecological instrumentation in the preceding 2-3 weeks • Azithromycin instead of doxy • 1g PO/week x 2 weeks

  13. Treatment • PCN Allergy • Hospitalize • Clinda + gent • Followed by Clinda or gent + flagyl • Attempt cephalosporine if non-IgE-mediated allergy

  14. Follow-up • 48-72h • Clinical improvement • Adherence • Counseling • Partner treatment • 60 days • Safe sex practices • Other STD testing

  15. Complications • Secondary to scarring and adhesion • Chronic pelvic pain • Infertility • Ectopic pregnancy • TOA • Hydrosalpinx

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