pelvic inflammatory disease: case presentation & disease overview

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 I nflammatory Disease C ase Presentation & Disease O verview Farah al S ouheil , P harmD , RPh Lebanese International University

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

3. Patient presentation 3

4. History taking 4

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

6. ROS 6

7. Differentials 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 10

11. Microbiologic Testing & Antibacterial S ensitivity Tests 11

12. Assessment 12

13. Medication Route Dose Frequency 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 R epeat 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. 19

20. PID 20

21. Differentiating s/ sx 21

22. Etiology 22

23. Stages 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 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. 28

29. Non-pharmacologic 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. Outpatient treatment options Choice of 3 rd 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 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 34

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