Pelvic Inflammatory Disease (PID): Management and Etiology

by John Fisher, MD

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    00:01 So then, how do we treat PID? Well, fortunately we have regimens to treat most patients as an outpatient.

    00:12 We would hospitalize patients only for clinically severe disease (high fever, nausea, vomiting) or patients unable to tolerate or follow an outpatient oral regimen.

    00:26 That includes a sizeable minority of individuals.

    00:30 We would certainly, for the safety of mother and baby, hospitalize all pregnant women with PID.

    00:39 One of the major concerns is, "Is there pus that needs to be drained -- a tubo-ovarian abscess?" So they would need to be admitted because antibiotics will fail to resolve a big abscess.

    00:57 The antibiotics don't penetrate well, and the abscess needs, as we say in medicine, fresh air and sunshine -- it needs drainage.

    01:07 And then sometimes acute appendicitis is in the differential diagnosis.

    01:12 And when a physician can't exclude appendicitis, it would be prudent to admit the patient.

    01:19 Pelvic rest is another form of therapy.

    01:24 It's very, very important to resolve this process and so in terms of treating patients with antibiotics, for outpatients, we use a combination of intramuscular and oral regimens.

    01:37 And the classic regimen is that of ceftriaxone 250 milligrams in a single dose and as you remember, this is a treatment for gonorrhea.

    01:48 We also add doxycyline, twice a day for 14 days and this will cover our chlamydia and mycoplasma organisms, if they're present.

    02:00 We also add metronidazole.

    02:02 Metronidazole is a wonderful agent to treat anaerobic organisms, which may be involved in this infection, as I mentioned.

    02:12 And also it is a treatment for bacterial vaginosis that might be present.

    02:19 Another regimen that's commonly used would be that of cefoxitin plus probenecid, to keep the levels of cefoxitin high, plus doxycycline, plus metronidazole.

    02:36 Now for inpatients, we're going to be using essentially IV cefoxitin every 12 hours or every 6 hours plus doxycycline every 12 hours or clindamycin plus gentamicin which will cover the aerobic Gram-negative rods and the anaerobes, and some alternative parenteral regimen.

    03:07 One choice, for example, would be ampicillin/sulbactam, which is a beta-lactamase inhibitor which covers anaerobes very, very well.

    03:18 and then the doxycycline.

    03:21 So we would expect patients to improve within 3 days.

    03:28 If there's no improvement after our outpatient intramuscular or oral therapy, we would then hospitalize and re-assess our antibiotic regimen, and consider diagnostic laparoscopy.

    03:43 We would also repeat the tests for Neisseria gonorrhoeae and Chlamydia trichomatis, and then 3 months after treatment, we would retest again.

    03:55 So we would expect, clinical improvement within 3 days another important thing would be to counsel our patients about the problems and complications of pelvic inflammatory disease.

    04:12 And we would have to honestly tell the patients there is an increase incidence of ectopic pregnancy because of the scarring of the fallopian tubes and the adhesions that develop as part of this process.

    04:27 So in terms of preventing further episodes of PID, we'd recommend that a person who's been exposed to a woman with PID during 60 days before the onset of symptoms, should be tested for gonorrhea and chlamydia.

    04:45 Now, for a woman whose last sexual intercourse is more than 60 days, we would recommend that we treat the most recent sex partner for both gonorrhea and chlamydia empirically.

    04:59 We would also recommend abstinence from sex until a therapy has been completed, and the symptoms have resolved completely for both woman and for her partner.

    05:12 And this bring us to our conclusion of the discussion of pelvic inflammatory disease.

    About the Lecture

    The lecture Pelvic Inflammatory Disease (PID): Management and Etiology by John Fisher, MD is from the course Genital and Sexually Transmitted Infections. It contains the following chapters:

    • Pelvic Inflammatory Disease – Management
    • Pelvic Inflammatory Disease – Etiology

    Included Quiz Questions

    1. A 25-year-old college student with abdominal pain, cervical motion tenderness, and a positive smear for gonorrhea
    2. A 32-year-old homeless woman with abdominal pain, fever, cervical motion tenderness, and mucopurulent cervicitis
    3. A 21-year-old sexually active woman with right lower abdominal pain, nausea, vomiting, and mild cervical motion tenderness
    4. A 27-year-old pregnant woman with lower abdominal pain
    5. An 18-year-old woman who has not improved after 72 hours of oral therapy
    1. A single intramuscular dose of ceftriaxone (250mg) AND oral doxycycline (100mg) twice a day for 14 days
    2. A single dose of intramuscular ceftriaxone (250mg) AND single oral dose of azithromycin (1 g)
    3. Oral clindamycin (900mg) thrice a day AND oral metronidazole 500mg orally twice a day for 7 days
    4. A single dose of intramuscular ceftriaxone (250mg) AND oral metronidazole (250mg) thrice a day for 7 days
    5. Oral clindamycin (900mg) thrice a day AND a single oral dose of azithromycin (1 g)
    1. Hospitalization, intravenous antibiotic therapy, and surgical drainage
    2. Hospitalization and intravenous antibiotic therapy
    3. Outpatient treatment with oral antibiotics and follow-up within 3 days
    4. Outpatient treatment with oral antibiotics and follow-up the next day
    5. Hospitalization and surgical drainage

    Author of lecture Pelvic Inflammatory Disease (PID): Management and Etiology

     John Fisher, MD

    John Fisher, MD

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