Management of Pelvic Inflammatory Disease (PID)

Lecture delivered at BOGSCON 41 (The Annual Conference of Bengal Obstetric and Gynaecological Society)

1. Management of PID Dr Sujoy Dasgupta MBBS (Gold Medalist, Hons ) MS (OBGY- Gold Medalist) DNB (OBGY)

2. Albert Ludwig Sigesmund Neisser

3. Pelvic Inflammatory Disease (PID) Acute/ Chronic inflammation of upper genital tract Endometrium → Endometritis Fallopian tubes → Salpingitis Ovaries → Oophoritis → TO abscess Adjoining structures → Parametritis → Pelvic peritonitis → Pelvic abscess

4. EPIDEMIOLOGY

5. DIAGNOSIS

6. Dilemma Vague signs/ symptoms Variety of s/s Often asymptomatic or mild No single finding is both sensitive and specific Higher PPV among the population at risk of STI

7. If delayed Chronic pelvic pain and ill health Infertility Adhesions Tubo -ovarian abscess Ectopic pregnancy

8. Clinical Diagnostic Criteria

9. Additional Criteria

10. Most Specific Criteria

11. Differential Diagnosis Appendicitis Disturbed ectopic pregnancy Twisted/ruptured ovarian cyst Endometriosis Diverticulitis Urinary tract infection Functional pain

12. Further Testing (CDC 2015, European Guideline 2012) Serology for HIV Testing for N. gonrrhoeae Testing for Chlamydia Testing for bacterial vaginosis (BV)- ? Urine pregnancy test

13. TREATMENT

14. Principles Prompt (as soon as presumptive diagnosis) Empiric broad spectrum- N.gonorrhoeae and C. trachomatis Re gimens with anti-anaerobic activity should be considered Therapeutic goal : Elimination of acute infection. Prevention of complications. (PEACH Study, 2002)

15. Which regime? Optimum treatment regime and duration- ? Oral or parenteral - OPD or In patient- Consider Cost Availability Local epidemiology Disease severity Patient acceptance

16. Recommended Treatment Regimens

17. Outpatient Therapy of Acute PID Regimen A: * Better coverage against N gonorrhoeae **500 mg (UK Guideline, 2011) Ceftriaxone * 250 mg** IM Single dose Plus Doxycycline 100 mg Orally BD 14 days With/ without Metronidazole 500 mg Orally BD 14 days

18. REGIMEN B: * Better anaerobic coverage Cefoxitin * 2 g IM Single dose } Concurrently Probenacid 1 g Oral Single dose Plus Doxycycline 100 mg Oral BD 14 days With/ Without Metronidazole 500 mg Oral BD 14 days Outpatient Therapy of Acute PID (Contd..)

19. Outpatient Therapy of Acute PID (Contd...) Other Cephalosporins Ceftizoxime / Cefotaxime Single dose Plus Doxycycline 100 mg BD x 14 days With/ without Metronidazole 500 mg BD x 14 days 2. Macrolide Azithromycin 1g orally once a week x 2 weeks Plus Ceftriaxone 250 mg IM single dose Specially active against N gonorrhoeae 3. Amoxiclav Plus D oxycycline More GI side effects 4. Quinolones Emergence of quinolone -resistant N gonorrhoeae (QRNG) Used only if cephalosporin not available/ allergic to it a nd prevalence and risk of gonrrhoea is low Diag test for N gonorrhoeae must be performed Levofloxacin 500 mg OD x 14 days Or Ofloxacin 400 mg BD x 14 days Or Moxifloxacin 400 mg OD x 14 days Plus Metronodazole 500 mg BD x 14 days Alternative Regimes:

20. Review After 72 hours Clinical improvement is evident by Defervescence Reduction in: Direct and rebound abdominal tenderness Uterine, adnexal and cervical motion tenderness.

21. Consider: Subsequent hospitalisation (for out patient therapy) Antimicrobial sensitivity assessment Review diagnosis Diag Lap Surgical modalities If no improvement in 72 hours

22. Indications for Admission Surgical emergency cannot be excluded Clinically severe disease (severe illness, peritonitis, nausea and vomiting, or high fever) Tubo -ovarian abscess ( at least 24 hr observation) PID in pregnancy Lack of response to oral therapy (within 72 hr) Intolerance to oral therapy

23. Parenteral Regimen A: * Oral is preferred for same bioavailability Inpatient Therapy of Acute PID Cefotetan 2 g IV q 12 hrly Or Cefoxitin 2 g IV q 6 hrly Plus Doxycycline 100 mg IV/ Oral* q 12 hrly Followed by (at least 24 hr after clinical improvement) Doxycycline 100 mg Oral BD 14 days

24. Parenteral Regimen B: * a single daily dose of 3-5 mg/kg may be substituted Inpatient Therapy of Acute PID (Contd..) Clindamycin 900 mg IV q 8 hrly Plus Gentamicin * Loading 2 mg/kg f/b 1.5 mg/kg IV IV q 6 hrly Followed by either (at least 24 hr after clinical improvement) 1. Clindamycin 450 mg Oral QDS 14 days Or (especially in case of TO abscess) 2. Doxycycline 100 mg Oral BD 14 days Plus Metronidazole 400 mg Oral BD 14 days

25. Inpatient Therapy of Acute PID (Contd..) Quinolones Levofloxacin 500 mg IV OD Ofloxacin 400 mg IV q 12 hrly With/ Without Metronidazole 500 mg IV q 8 hrly Penicillin Ampicillin / Sulbactam 3 g IV q 6 hrly Plus Doxycycline 100 mg IV/ Oral q 12 hrly Covers  C. trachomatis ,  N. gonorrhoeae and anaerobes in TO abscess 3 rd Generation Cephalosporins Ceftizoxime , Cefotaxime , Ceftriaxone Limited data No anaerobic coverage Macrolide Azithromycin 500 mg IV/d 1-2 days f/b 250 mg/d Oral x 5-6 days With/ Without 12 days course of Metronidazole Alternative Parenteral Regimens:

26. Surgical Management Indications: Uncertain diagnosis Failed medical management. Severe diseases TO Abscess, Pelvic Abscess

27. Laparoscopy Confirm diagnosis Prognosis predicted Management can be planned Explore all the organs Aspiration Drainage of abscess Peritoneal fluid send for culture and sensitivity Adhesiolysis - pelvic and perihepatic adhesions Irrigation

28. Pelvic abscess Resuscitation Management of septic shock Drainage Percutaneous guided USG guided- Less invasive If fails→ CT guided Drain may is placed Laparoscopy Colpotomy Laparotomy Peritoneal wash Vault left open for drainage Penrose drain is kept Consider abdominal suction drains

29. Other Advices Avoidance of unprotected intercourse until declared cured Review at 4 weeks If documented chlamydial or gonococcal PID → retest 3 months after treatment (or at least once before next 12 months)

30. Chronic PID Surgical decision depends on Age Parity Symptoms Pelvic pathology Laparopscopic adhesiolysis adnexectomy salpingectomy tuboplasty salpingoscopy hysterectomy Hysteroscopic falloposcopy balloonplasty

31. Management of sexual partners Contact and offer health services Screening for gonorrhoea and chlamydia (especially those who contacted the woman within 60 days of onset of PID symptoms) Empirical therapy for both gonorrhoea and chlamydia Abstinence until both have completed the treatment course.

32. Management of sexual partners (Contd..) Test for HIV Condom promotion Expedited Partner Therapy (EPT) or Patient-Delivered Partner Therapy (PDPT)

33. SPECIAL CASES

34. Adolescents No difference between OPD and in patient management Ofloxacin should be avoided in young women Doxycycline can be safely used >12 years

35. HIV/ AIDS Same antibiotic regimens as women HIV negative Increased incidence of Mycoplasma hominis and Streptococcus More incidence of TO abscess

36. Pregnancy High risk for maternal morbidity and preterm delivery Hospitalized and treated with IV antibiotics. Avoid teratogens - e.g., tetracycline group Chlamydia - can affect neonate If infected with C trachomatis , → Confirm cure by lab test after 3-4 weeks, after 3 months, 3 rd trimester (for high risk group)

37. IUCD Mild disease- left in situ If no improvement after 72 hours of antibiotic- Remove Severe disease- Remove after the antibiotic attains therapeutic plasma concentration

38. SYNDROMIC MANAGEMENT

39. Client-oriented treatment approach for low resource settings History Clinical exam Lab exam- wherever feasible Treatment with drugs Follow up Partner management

40. Syndromic Management for PID C/O lower abdominal pain ± Vaginal discharge Elicit H/O P/A, P/V and P/S examination- Adnexal / Uterine/ Cx motion tenderness Urine Pregnancy Test Missed/ overdue period Vaginal bleeding Recent delivery/ abortion Rebound tenderness, guarding Pelvic mass Bowel sign/ symptoms Sudden severe pain Dyspareunia + ve UPT Y es Refer to higher level urgently Set up UV access Resuscitation N o Start Treatment

41. Treat For PID ( Kit-6- Yellow Colour ) Cefixime 400mg Oral Stat Metronidazole 400mg BD Oral For 14 Days Doxycycline 100mg BD For 14 Days Educate, Counsel Provide Condom & Promote Use Treat Partner Refer To ICTC Review After 3 Days Follow Up After 7, 14 Day Symptoms persist No Y es Cured Educate, Counsel Provide Condom & Promote Use Refer to higher level Treatment Steps Syndromic Management for PID (Contd..)

42. Conclusion Overdiagnosis of PID is better than inviting complications Broad spectrum antibiotics Surgery when indicated Partner treatment Prevention- education and counseling