1. Morning Report
January 31, 2011

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

3. 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

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

8. 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.

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
Cefotaxime IM or ceftixozime PLUS doxycycline x 14d

12. 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

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 Counseling Clinical improvement Adherence
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