Management of acute pid

pelvic inflammatory disease

1. PRESENTED BY- Dr Pratyush Kumar GUIDED BY- Dr Satyabhama Marandi Management of acute PID : Recent Guidelines

2. CONTENTS Definition Risk factors Transmission Pathogenesis Clinical features Management : Clinical diagnostic criteria and staging Investigations Treatment Follow-up Complications Preventive measures

3. Definition Spectrum of infection and inflammation of the upper genital tract organs typically involving the uterus (endometrium), fallopian tubes , ovaries , pelvic peritoneum and surrounding structures.

4. Risk factors Menstruating teenagers Multiple sexual partners Absence of contraceptive pills Previous history of acute PID IUD users Area with high prevalence of STDs

5. Transmission Usually a polymicrobial infection caused by organisms ascending upstairs from downstairs. Primary organisms : N. gonorrhoeae 30% Chlamydia trachomatis 30% Mycoplama hominis 10% Secondary organisms: Aerobic : Non hemolytic streptococcus Anaerobic : Bacteroids Peptostreptococcus

6. Route : Through mucosal continuity and contiguity Reflux of menstrual blood into fallopian tubes Spread across parametrium e.g. Mycoplas ma hominis Lymphatics From gut(rarely)

7. Pathogenesis STD Agents Cervicitis Endometritis Endogenous ( polymicrobial ) flora Bacterial vaginosis Initiation of tubal damage Compromised host resistance Abortions, D&C, IUD insertion, other gyaenecologic procedures S alpingitis Restoration of normal anatomy Tubal deciliation Tubal occlusion Pelvic adhesion Pelvic abscess

8. Clinical Features Fever > 38⁰C B/L lower abdominal tenderness with radiation to the legs Abnormal vaginal discharge Deep dyspareunia On bimanual examination: Cervical motion tenderness Adnexal tenderness

9. Clinical Diagnostic Criteria(FOGSI-ICOG) Minimum criteria: Lower abdominal tenderness Adnexal tenderness Cervical motion tenderness Additional criteria: Oral temperature > 38.3⁰C Mucopurulent cervical or vaginal discharge Raised C- reactive protein &/or ESR Laboratory documentation of positive cervical infection with Gonorrhoea or C. trachomatis

10. Definitive criteria: Histopathologic evidence of endometritis on biopsy Imaging study (TVS / MRI) evidence of thickened fluid filled tubes ± tubo -ovarian complex Laparoscopic evidence of PID

11. CINICAL STAGES OF ACUTE PID Stage I : Acute salpingitis w/o peritonitis Stage II : Acute salpingitis with peritonitis Stage III : Acute s alpingitis with superimposed tubal occlusion or tubo -ovarian complex Stage IV : Ruptured tubo -ovarian abscess Stage V : Tubercular s alpingitis

12. Investigations Identification of organisms: Discharge from urethra or Bartholin’s gland Cervical canal Collected pus from fallopian tubes during laparotomy or laparoscopy Blood: Leucocytosis and an elevated ESR value > 15mm/ hr Sonography : Dilated and fluid filled tubes Fluid in Pouch of Douglas Adnexal masses

13. Laparoscopy: Gold standard Reserved only in those cases in which differential diagnosis includes salpingitis , appendicitis or ectopic pregnancy Mild: Tubes – Edema , Erythema, No purulent exudates and mobile Moderate: Purulent exudates from the fimbrial ends, Tubes not freely mobile Severe: Pyosalpinx , Inflammatory complex, Abscess Violin string like adhesions in the pelvis and around the liver suggests chlamydial infection (Fitz- Hugh- Curtis Syndrome) Culdocentesis : Aspiration of peritoneal fluid and its white cell count, if exceeds 30,000/ml is significant in acute PID.

14. Symptoms & Signs Acute Salpingitis Acute Appendicitis Disturbed Ectopic Pain Acute lower abdominal on both the sides Starts near umbilicus but settles to right iliac fossa Acute lower abdominal on one side Amenorrhea & bleeding PV Unrelated Unrelated Usually present Nausea & vomiting Inconsistently present Usual Absent General look Face- flushed Toxic Pale Tongue No significant change Furred Pale Temperature More raised Slightly raised Not raised Tenderness Lower abdomen on both sides On Mc Burney’s point Lower abdomen more on one side Pulse Rapid but proportionate with temperature Rapid, out of proportion to temperature Persistent rise even with normal temperature Per vaginum Tenderness on both fornices . A mass may be felt Tenderness on right fornix and high up Mass may be felt through one fornix extending up to pouch of Douglas

15. ICOG Guidelines for Outpatient therapy Regimen A: Oral Ofloxacin 400mg BD PLUS oral Metronidazole 400mg BD for 14 days Oral Levofloxacin 500mg OD PLUS oral Metronidazole 400mg BD for 14 days Regimen B: IM Ceftriaxone 250mg single dose or IM Cefoxitin 2gm single dose with oral Probenecid 1gm followed by oral Doxycycline 100mg BD PLUS oral Metronidazole 400mg BD for 14 days The patient should be re-evaluated after 48hrs and if no response, are to be hospitalised.

16. Criteria for hospitalization Inability to exclude surgical emergency (e.g. appendicitis) Presence of tubo -ovarian abscess PID in pregnancy Clinically severe disease Failure to respond to outpatient oral therapy Intolerance to oral therapy (e.g. severe nausea / vomiting)

17. Inpatient therapy Regimen A: Cefoxitin 2gm IV 6hrly or Ceftriaxone 2gm IV infusion daily + Doxycycline 100mg oral / IV every 12 hrly for 48 hrs followed by oral Doxycycline 100mg BD PLUS oral Metronidazole 400mg BD for 14 days Regimen B: Clindamycin 900mg IV 8 hrly + Gentamicin IV/IM (2mg/kg load, then 1.5mg/kg 8hrly) for 48hrs followed by oral Doxycycline 100mg BD PLUS oral Metronidazole 400mg BD for 14 days or oral Clindamycin 450mg 4 times daily for 14 days Alternative regimen: IV Ofloxacin 400mg BD PLUS IV Metronidazole 500mg 8 hrly for 14 days IV Ciprofloxacin 200mg BD PLUS IV/ oral Doxycycline 100mg BD PLUS IV Metronidazole 500mg TID for 14 days

18. Treatment in pregnancy In an ongoing intrauterine pregnancy, PID is extremely rare , except in the case of septic abortion. Cervicitis may occur and is associated with increased maternal and fetal morbidity including pre-term delivery. Treatment regimens will dependent on organisms isolated. A combination of Cefotaxime , Azithromycin and Metronidazole for 14 days may be used.

19. Treatment in children: Acute PID is rarely seen in very young girls. In girls over 12 yrs , Doxycycline can be safely used. Treatment in a woman with an IUCD: An IUCD may be left in-situ in women with clinically mild PID but should be removed in cases of severe disease and, especially, if symptoms have not resolved within 72 hrs. Treatment in a woman with HIV: Women with PID who are also infected with HIV should be treated with the same antibiotic regimens as women who are HIV negative. Low CD4 count is an indication for hospitalization.

20. Surgical treatment Indication: Generalised peritonitis Pelvic abscess Tubo -ovarian abscess Laparotomy/ laparoscopy may help early resolution of the disease by division of adhesions and drainage of pelvic abscesses. Ultrasound-guided aspiration of pelvic fluid collections is less invasive and may be equally effective. It is also possible to perform adhesiolysis in cases of peri -hepatitis due to Chlamydia.

21. Follow-up In the outpatient setting, review at 72hrs is recommended particularly for those with a moderate or severe clinical presentation. Failure to improve suggests the need for further investigations, parenteral therapy and/or surgical intervention. A full screen for all STDs including Hepatitis B and HIV should be offered for persistent infections.

22. RCOG guidelines Outpatient therapy: IM Ceftriaxone 500mg single dose followed by oral Doxycycline 100mg BD PLUS oral Metronidazole 400mg BD for 14 days Alternative regimen for outpatient therapy: IM Ceftriaxone 500mg immediately, followed by Azithromycin 1gm/week for 2 weeks.

23. COMPLICATIONS IMMEDIATE: Pelvic peritonitis or even generalised peritonotis Septicemia LATE: Dyspareunia Infertility either due to cornual block or damage to the wall of the tube. Risk increased with severity and no of episodes. Chronic PID Formation of adhesions or Hydrosalpinx or Pyosalpinx Tubo -ovarian abscess Increased risk of ectopic pregnancy (6-10 folds)

24. PREVENTIVE MEASURES Reproductive Health Education to be given to young girls. Importance of menstrual hygiene to be reinforced. Safe sexual practices to be advocated. Pamphlets/ Brochures regarding PID. Awareness program through mass media. Screening for infections in high risk group Rapid diagnosis and effective treatment of STDs & UTI

25. TAKE HOME MESSAGE Fallopian tubes ultimately bears the brunt of acute infection. It is a major problem to the reproductive health of young women. It may be asymptomatic or subclinical. Patient usually presents with chronic symptoms. The primary organisms of PID are predominantly sexually transmitted. Acute PID is polymicrobial in nature. As the symptoms are non specific, over treatment is preferred to missed diagnosis .