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PID: A NEGLECTED ISSUE• Low disease awareness• Sub-optimal management• 50% named correct antibiotic regimen• < 25% examined the sexual partners
OBJECTIVES• What is Pelvic Inflammatory Disease?• Why is it important to treat timely?• Causative factors and transmission?• How does the patient present?• Treatment Plan?- Drug therapies- Surgical procedures- Follow up
PELVIC INFLAMMATORY DISEASE• Clinical syndrome associated with ascending spread of microorganisms from the vagina or cervix to the endometrium, fallopian tubes, ovaries, and contiguous structures.• Comprises a spectrum of inflammatory disorders including any combination of endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis.
NORMAL CERVIX WITH ECTOPY
INCIDENCE• The exact prevalence is hard to ascertain as many cases may go undetected, but is thought to be in the region of 1-3% of sexually active young women.
Transmission• • Sexual transmission via the vagina & cervix • Gynecological surgical procedures • Child birth/ Abortion • A foreign body inside uterus (IUCD)
Transmission• • Contamination from other inflamed structures in abdominal cavity (appendix, gallbladder) • Blood-borne transmission (pelvic TB)
PREDISPOSING FACTORS• • Frequent sexual encounters, many partners • Young age, early age at first intercourse • Exposure immediately prior to menstruation. • Relative ill-health & poor nutritional status. • Previously infected tissues (STD/ PID) • Frequent vaginal douching
Pyosalpinx (tubular structure with debris in adnexa
Tuboovarian abscess resulting from tuberculosis
Right hydrosalpinx with an occluded left fallopian tube
SYNDROMIC DIAGNOSIS OF PIDMINIMUM CRITERIA FOR DIAGNOSIS (CDC 2002)• Lower abdominal tenderness on palpation• Bilateral adnexal tenderness• Cervical motion tenderness No other established cause Negative pregnancy test
ADDITIONAL CRITERIA (CDC 2002)• Oral temperature > 38.3°C (101°F)• Abnormal cervical / vaginal discharge• Elevated ESR• Elevated C-reactive protein• WBCs on saline micro. of vaginal sec.• Lab. documentation of cervical infection with N. gonorrhea/ C. trachomatis
Definitive Criteria (CDC 2002)• Endometrial biopsy with histopathology evidence of endometritis• TVS/ MRI: Thickened fluid filled tubes/ free pelvic fluid / tubo-ovarian complex• Laparoscopic abnormalities consistent with PID
MANAGEMENT ISSUES• • Inpatient vs. outpatient management ? • Broad-spectrum antibiotic therapy without microbiological findings vs. Antibiotic treatment adapted to the microbiological agent identified ? • Oral vs. Parenteral therapy? • Duration of the treatment ? • Associated treatment ? • Prevention of re-infection ?
GENERAL PID CONSIDERATIONSRegimens must provide coverage of N. gonorrhea, C.trachomatis, anaerobes, Gram-negative bacteria, andstreptococciTreatment should be instituted as early as possible toprevent long term squeal
CRITERIA FOR HOSPITALIZATION• Inability to exclude surgical emergencies• Pregnancy• Non-response to oral therapy• Inability to tolerate an outpatient oral regimen• Severe illness, nausea and vomiting, high fever or tubo-ovarian abscess• HIV infection with low CD4 count
ANTIBIOTIC THERAPY Gonorrhea : Cephalosporins, Quinolones Chlamydia: Doxycycline, Erythromycin &Quinolones (Not to cephalosporins) Anaerobic organisms: Flagyl, Clindamycin and in some cases to Doxycycline. Beta hemolytic streptococcus and E. ColiPenicillin derivatives, Tetracyclines, andCephalosporins., E. Coli is most often treatedwith the penicillins or gentamicin.
ORAL REGIMENS• CDC-recommended oral regimen A • Ceftriaxone 250 mg IM in a single dose, PLUS • Doxycycline 100 mg orally 2 times a day for 14 days With or Without • Metronidazole 500 mg orally 2 times a day for 14 days• CDC-recommended oral regimen B • Cefoxitin 2 g IM in a single dose and Probenecid 1 g orally in a single dose, PLUS • Doxycycline 100 mg orally 2 times a day for 14 days With or Without • Metronidazole 500 mg orally 2 times a day for 14 days• CDC-recommended oral regimen C • Other parenteral third-generation cephalosporin (e.g., Ceftizoxime, Cefotaxime), PLUS • Doxycycline 100 mg orally 2 times a day for 14 days With or Without • Metronidazole 500 mg orally 2 times a day for 14 days
FOLLOW-UP• Patients should demonstrate substantial improvement within 72 hours.• Patients who do not improve usually require hospitalization, additional diagnostic tests, and surgical intervention.• Some experts recommend re-screening for C. trachomatis and N. gonorrhea 4-6 weeks after completion of therapy in women with documented infection due to these pathogens.• All women diagnosed clinical acute PID should be offered HIV testing.
PARENTERAL REGIMENS• CDC-recommended 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• CDC-recommended parenteral regimen B • Clindamycin 900 mg IV every 8 hours, PLUS • Gentamicin loading dose IV or IM (2 mg/kg), followed by maintenance dose (1.5 mg/kg) every 8 hours. Single daily gentamicin dosing may be substituted.
ALTERNATIVE PARENTERAL REGIMEN • Ampicillin/Sulbactam 3 g IV every 6 hours, PLUS • Doxycycline 100 mg orally or IV every 12 hours. • It is important to continue either regimen A or B • or alternative regimens for at least 24 hours after substantial clinical improvement occurs and also to complete a total of 14 days therapy with: • Doxycycline 100mg orally twice a day OR • Clindamycin 450mg orally four times a day.
CDC RECOMMENDATIONS• No efficacy data compare parenteral with oral regimens• Clinical experience should guide decisions reg. transition to oral therapy• Until regimens that do not adequately cover anaerobes have been demonstrated to prevent squeal as successfully as regimens active against these microbes, anaerobic coverage should be provided
When should treatment be stopped ? • Parenteral changed to oral therapy after 72 hrs., if substantial clinical improvement • Continue Oral therapy until clinical &biological signs (leukocytosis, ESR, CRP)disappear or for at least 14 days • If no improvement, additional diagnostic tests/ surgical intervention for pelvic mass/ abscess rupture
Associated treatment Rest at the hospital or at home Sexual abstinence until cure is achieved Anti-inflammatory treatment Dexamethasone 3 tablets of 0.5 mg a day or Non steroidal anti-inflammatory drugs Oestro-progestatives: contraceptive effect + protection of the ovaries against aperitoneal inflammatory reaction + cervical mucus induced by OP haspreventive effect against re-infection.
Special SituationsPregnancy - Augmentin or Erythromycin - HospitalizationConcomitant HIV infection - Hospitalization and i.v. antimicrobials - More likely to have pelvic abscesses - Respond more slowly to antimicrobials - Require changes of antibiotics more often - Concomitant Candida and HPV infections
Surgery in PIDIndicationsAcute PID- Ruptured abscess- Failed response to medical treatment- Uncertain diagnosisChronic PID- Severe, progressive pelvic pain- Repeated exacerbations of PID- Bilateral abscesses / > 8 cm. diameter- Bilateral ureteral obstruction
SURGERY IN PID• Timing of Surgery - No improvement within 24-72 hours - Quiescent (2-3 months after acute stage)• Type of Surgery - Colpotomy - Percutaneous drainage/ aspiration - Exploratory Laparotomy• Extent of Surgery - Conservation if fertility desired - U/L or B/L S.Ophrectomy ē/ š subtotal/ TAH - Drainage of abscess at laparotomy - Identification of ureters
FOLLOW UP● Re-screening for Chlamydia & Gonorrhea● Patient counseling: - Risk of re- infection and sequel. - Sexual counseling - Avoid douching
Management of sex partners• Examination and treatment if they had sexual contact with patients during the 60 days preceding the onset of symptoms in the patients.• Empirical treatment with regimens effective against C. trachomatis and N. gonorrhea
OPPORTUNITIES FOR CONTROL STD PID Infertility STD Influenced by Interaction of following Environments Genital Microbial Environment Individual Behavioral Environment Socio-geographic Environment
PREVENTION• PRIMARY PRVENTION• To reduce the incidence of PID, screen and treat for chlamydia.• Annual chlamydia screening is recommended for: • Sexually active women 25 and under • Sexually active women >25 at high risk• Screen pregnant women in the 1st trimester.
PARTNER MANAGEMENT• Male sex partners of women with PID should be examined and treated if they had sexual contact with the patient during the 60 days preceding the patient’s onset of symptoms.
PARTNER MANAGEMENT (CONTINUED)• Male partners of women who have PID caused by C. trachomatis or N. gonorrhea are often asymptomatic.• Sex partners should be treated empirically with regimens effective against both C. trachomatis and N. gonorrhea, regardless of the apparent etiology of PID or pathogens isolated from the infected woman.
REPORTING• Report cases of PID to the local STD program in states where reporting is mandated.• Gonorrhea and chlamydia are reportable in all states.
PATIENT COUNSELING AND EDUCATION • Nature of the infection • Transmission • Risk reduction • Assess patients behavior-change potential • Discuss prevention strategies • Develop individualized risk-reduction plans
. Secondary Prevention:• - Screening for infections in high- risk. - Rapid diagnosis and effective treatment of STD and lower urinary tract infections. Tertiary Prevention: - Early intervention & complete treatment.
CONCLUSION● PID in women - “Silent epidemic”● Can have serious consequences.● Be aware of limitations of clinical diagnosis.● Adequate analgesia and antibiotics.● Proper follow up is essential.● Treatment of male partner● Educational campaigns for young women and health professionals.● Prevention by appropriate screening for STD and promotion of condom usage.
SUMMARY● PID in women - “Silent epidemic”● Can have serious consequences.● Be aware of limitations of clinical diagnosis.● Adequate analgesia and antibiotics.● Proper follow up is essential.● Treatment of male partner● Educational campaigns for young women and health professionals.● Prevention by appropriate screening for STD and promotion of condom usage.