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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 and cervical motion tenderness on exam with tests positive for gonorrhea
    2. A 32 year old homeless woman who does not have stable shelter or transportation who presented to the emergency room with 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 clinical symptoms of pelvic inflammatory disease
    5. An 18 year old sexually active woman who was treated with emperical antibiotics for pelvic inflammatory disease in the outpatient setting 3 days ago without clinical improvement on re-evaluation.
    1. Single dose of ceftriaxone 250mg intramuscularly PLUS doxycycline 100mg twice a day orally PLUS metronidazole 500mg orally for 14 days
    2. Single dose of ceftriaxone 250mg imtramuscularly PLUS single dose of azithromycin 1 g orally
    3. Clindamycin 900mg orally three times a day PLUS metronidazole 500mg orally twice a day for 7 days
    4. Single dose of ceftriaxone 250mg imtramuscularly PLUS a single dose of metronidazole 1g orally
    5. Clindamycin 900mg IV every 8 hours PLUS gentamycin 650mg IV every 8 hours
    1. Hospitalization, abscess drainage plus antibiotic treatment
    2. Hospitalization, antibiotic treatment with daily ultrasound monitoring for abscess resolution
    3. Outpatient antibiotic treatment with scheduled 3 day follow up
    4. Outpatient antibiotic treatment with next day follow up and repeat imaging
    5. Hospitalization for intravenous antibiotic therapy only

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

     John Fisher, MD

    John Fisher, MD


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