pelvic inflammatory disease is a very common type of Sexually transmitted disease among young sexually active females. in this presentation we discuss a case suffering from PID and then we evaluate the plan of discharge based on disease and treatment overview

1. Pelvic Inflammatory Disease
Case Presentation & Disease Overview
Farah al Souheil, PharmD, RPh
Lebanese International University

2. Outline
• Case presentation
• Plan and interventions
• Disease overview
• Treatment overview
• References
2

3. Patient presentation
21 year old single female
CC: Severe abdominal pain
HPI:
• 1 week prior to admission
• Fever (relieved by APAP)
• Epigastric pain, non-radiating, temporarily relieved by ranitidine
• 2 days prior to admission
• Persistence of epigastric pain more on left upper quadrant (hepatitis?)
• Outpatient data:
• wbc: 21.54 (!)
• Lymphocytes 3 (!)
• Hgb 8 (!)
• Hct 26.3 (!)
• On day of admission:
• Right lower quadrant pain + hypogastric pain
• PS: bilateral lower abdomen pain is indicative of PID
3

4. History taking
PMH: no
other
complaints
(no hx of
vaginal
discharge)
No past
surgeries
(except for
abortion)
Social hx:
smoker (6
pack year),
alcohol
drinker(
3x/week)
NKDA
Family hx:
DM and
breast cancer
Gynecologic
hx:
• Menarche at 12
yo
• Not on
contraceptives
• Sexually active
• Period length:
3-5 days
4

5. Vitals
• BP: 90/60 HR:88 RR:20 temp:37.2
• Weight: 45 kg
5

6. ROS
Skin: no pallor, warm ( decreases the odds of ectopic pregnancy or hepatitis)
HEENT: normal
Lungs: clear breath sounds and lung mvt
CVS: normal rate and rhythm
Abd: normoactive bowel sounds, tender at left upper and right lower quadrants, no
hepatosplenomegaly
Ext: strong pulses
GUT: wart like lesions on vaginal wall, bloody vaginal discharge
• Note: purulent or foul smelling is indicative of PID
Uterus: small, no cervical motion tenderness ( chandelier sign), +ve for adnexal tenderness on deep
palpation
6

7. Differentials
IBS IBD
Pyelonephritis
(UTI)
Endometrosis PID Appendicitis
7

8. Labs
2 days prior to
admission
Day 1 Day 2 Day 3
WBC 21.54* 12.98* 9.99 9.44
N 85* 74 69 70
L 3* 16* 18 18
Hgb 8* 7.4* 9.7 10.9
HCT 26.3* 24.6* 31.4 36.3
Scr 0.87 0.9
PLT 581* 763* 624 833
Missed: ESR,
B-HCG , LFTs,
electrolytes (if
vomitting)
8

9. Transvaginal ultrasound
• Normal sized uterus( R/O uterine fibroid)
• Cystic structure within the RO (corpus luteum or
endrometrial cyst)
• Bilateral adnexal tubulo-cystic structures
9

10. Peripheral blood smear
Microcytic
hyprochromic RBC
( anemia of chronic
disease or iron
deficiency anmeia)
Leycocytosis with
neutrophillic
predominance
Thrombocytosis
• High platelet counts can
occur due to:
• Primary bone marrow
disorder (for example,
essential
thrombocytosis)
• Chronic inflammation
in the body
• Infection
• Iron deficiency anemia
• Removal of a person's
spleen
10

11. Microbiologic Testing & Antibacterial Sensitivity Tests
NOT DONE
Determines the causative organism
& guides definitive treatment
N gonorrhea has a high probability
of resistance to fluoroquinolones
11

12. Assessment
Microcytic anemia on
top of pelvic
inflammatory disease
12

13. Medication Route Dose Frequenc
y
Indication
Ranitidine (No longer
available: NMDA impurities )
IV 50mg TID Epigastric pain
Clindamycin IVD 900mg TID PID( switch to PO after
clinically improving)
Gentamycin IV 60mg TID PID ( stop when
clinically improving)
Ferrous sulfate (substitute by
fe gluconate if not tolerated)
PO 300mg
(65mg
elemental
iron)
QD Anemia (continue for 3
months)
Paracetamol PO 1g TID Pain
Naproxen PO 250mg TID/QID Pain
pRBC IV 2 packs Over 1-2
hrs
Anemia
13
Meds Chart

14. pRBC
• 1 unit pRBC increase hgb by 1
• Massive or rapid transfusion may lead to
▫ Arrhythmias
▫ Body temperature below 95 F (hypothermia)
▫ Hyperkalemia
▫ Hypocalcemia
▫ Dyspnea
▫ Heart failure
14

15. Follow up
• Day 1:
• S: afebrile but RLQ pain (4/10) with vaginal spotting
• O: BP:110/70 HR:80 RR:20 T 36.8
• A: stable
• P:
▫ Monitor for persistence of abdominal pain
▫ Repeat cbc after the 2 pRBC
▫ Continue meds
15

16. Follow-up
• Day 2:
• S: afebrile, RLQ pain (2/10), no more vaginal
spotting
• O: BP:110/80 HR:68 RR:20 T 36.7
• A: stable
• P:
▫ Continue meds
16

17. Follow-up
• Day 3,4:
• S: afebrile, mild hypogastric tenderness, on& off epigastric
pain associated with nausea
• O: BP:120/80 HR:76 RR:20 T 36.4
• A: stable
• P:
▫ Clindamycin 300mg TID for 14 days
 Right dose 450mg QID alone
▫ Ofloxacin 400mg BID for 14 days
 Microbiologic sensitivity test not done! Check for N gonorrhea
 clindamycin monotherapy is enough after clinical improvement
▫ Pantoprazole 40 mg qAM for 8-16 weeks
▫ Follow-up after 14 days
17

18. Followup
• 14 days after discharge
▫ Relief of epigastric pain
▫ Completed 14 days of antibiotics
18

19. Discussion
19

20. PID
Endometritis
(mostly)
Salpingitis
(mostly)
Oophoritis
(rare)
Myometritis
(rare)
Peritonitis
(rare)
20

21. Differentiating s/sx
21

22. Etiology
Ascending
infection from
vagina and
cervix
In girls 16-25
yo female
Causes:
Transperitoneal
spread of
infection from
Perforated
appendix or
intra-abdominal
abscess
Hematogeneous Lymphatics
IUD insertion
•6x increased risk
•within the first 3
weeks of insertion
Causative
agents:
N gonorrhea
(more rapid and
acute onset of
pain: 3 days)
Chlamydia (5-7
days): More foul
smelling discharge
Mycoplasma
Other: strep,
Ecoli, anaerobes
22

23. Stages
1
•Major criteria + >1 minor criteria
2
•Peritonitis
3
•Tubo-ovarian abscess
4
•Ruptured tubo-ovarian abscess
Violin string adhesions in pelvis &
around the liver (chlamydial infection)
23

24. s/sx
• Asymptomatic
• Lower abd pain
• RUQ pain (rare): concomitant peri-hepatitis with
salpingitis
▫ Trans-peritoneal or vascular dissemination of gonococcal or
chlamydial infection
• Fever
• Vaginal discharge ( maybe yellow greenish and foul
smelling if caused by gonorrhea)
• Dyspareunia
• Dysuria
• Irregular bleeding (endometritis)
Appear immediately after
menstruation
24

25. Work- up
• Most specific
▫ Endometrial biopsy (histopathologic evidence of endometritis)
▫ MRI or sonography (tubuovarian abscess)
▫ Laparoscopy
 Direct visualization of internal organs
 Done after 48 hr if no response or unclear diagnosis
• Ultrasound:
▫ Pelvic area
▫ Check for enlarged fallopian tube or abscess or peritoneal fluid ( non specific finding)
• Leykocytosis
▫ Doesn’t relate to the need for hospitalization
• ESR
• B-HCG : R/O ectopic pregnancy
• Gram stain: endo-cervical mucus examination for chlamydia/ gonorrhea
• Pelvic mass on examination: consider ocarian cyst, ovarian torsion, uterine fibroid,
endometrosis
• Urinalysis to R/O UTI
25

26. Diagnosis
• CERVICAL MOTION tenderness (chandelier sign)
• Uterine tenderness
• Adnexal tenderness
Should have
at least one of
the following:
• Oral temp>38.3
• Vaginal/ cervical discharge
• Increased number of WBC in vaginal secretions
• Increased ESR
• Increased CRP
• Lab results: Cervical infection with N.gonorrhea/ chlamydia
For a better
specificity in
diagnosis:
26

27. When to Hospitalize?
• Pregnancy
• Not responding to PO antibiotics (72 hours)
• Unable to tolerate PO drugs (N/V)
• Severe illness (HGF)
• Tubo-ovarian abscess
• Sepsis
• peritonitis
27

28. Treatment
28

29. Non-pharmacologic
Abstinence from sexual
intercourse until the
completion of the treatment
(14 days)
Use of physical barriers (latex
condom)
Limit number of sexual
partners (chlamydia)
Anti-inflammatory agents
COC:
•Protection of ovaries against
inflammation
•Cervical mucus prevents re-infection
•Decreased period length -> short
interval of bacterial colonization of
upper tract
Manage partner if had sex in
60days prior to sx
•Males are asymptomatic
Remove IUD if no
improvement in 72 hrs post
anntimicrobials initiation
29

30. Causative agent targeted treatment
Organism
N gonorrhea Cephalosporin, FQ
Chlamydia Doxycyline, FQ
Anaerobes Metronidazole, clindamycin, doxycycline
Strep & EColi Penicillin, tetracycline, cephalo,
gentamycin
30

31. Regimen
A
Levofloxacin
500mg/ ofloxacin
400mg PO QD
+/- metronidazole
500mg PO BID
Regimen
B
Ceftriaxone 250mg
IM once/ cefoxitin
2g IM once+ PO
probenecid 1g once
Doxycycline 100
mg PO BID
+/- metronidazole
500mg PO BID
Regimen c
Ceftriaxone 250mg
IV once
Azithromycin 1g
qw for 2 weeks
Outpatient treatment options
Choice of 3rd generation cephalosporin: Cefixime is not recommended/ Cefoxitin: better anaerobe
coverage/ ceftriaxone: better activity on N gonorrhea
Metronidazole: anaerobes and bacterial vaginosis that accompany PID
If cephalosporin is not feasible : FQ+/- metro OR FQ + azithromycin 2g PO(once)
31

32. In-patient treatment options
Regimen
A
IV Cefotetan 2g BID or
IV cefoxitin QID
D/c 24 hr after clinical
improvement
Doxycycline 100mg
PO/IV BID
Add metro/clinda in case
of tubo ovarian anscess
Regimen
B
Clindamycin 900mg IV
TID swtiched to 450mg
QID or doxycycline
100mg BID PO (except
if tubulo ovarian
abscess)
Gentamycin
• LD 2mg/kg
• MD: 1.5 mg/kg TID
Regimen c
Ofloxacin 400mg BID/
levofloaxcin 500mg
+/- metronidazole 500mg
IV TID
Regimen
D
Ampicillin sulbactam 3g
IV QID
Doxycycline 100mg BID
IV doxy is painful
& PO has F=1
Preferred if pelvic
abscess
32

33. Complications
• Dyspareunia
• Infertility
• Ectopic pregnancy
• Abscess
• Chronic pelvic pain
33

34. Plan
Repeat cultures and
smears 7 days after
regimen completion
Repeat tests after each
menstrual cycle until
negative for 3
consecutive tests
34

35. References
• Medscape
• Up-to-date
• US pharmacist
35