Morning Report January 31, 2011

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

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

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

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

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

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!! UPT – r/o ectopic and intrauterine UA – UTI OB – other causes CBC – leukocytosis in <50%

Imaging Ultrasound Transvaginal Absence of findings does not diminish the probability of PID Endovaginal ultrasound scan. Endometritis with air in the endometrial cavity and bilateral tubo-ovarian abscesses are shown.

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

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

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

Treatment +/- Flagyl x 14d Azithromycin instead of doxy 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

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

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

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