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Pelvic Inflammatory Disease

• Pelvic inflammatory disease (PID) is an acute infection of the upper genital tracts in women, which may include the endometrium, fallopian tubes, ovaries, peritoneum and adjacent pelvic organs.
  • Often a sexually transmitted disease.
  • May occur post-operatively/ post instrumentation, e.g., IUCD insertion, termination or spontaneous abortion.
  • Causative organisms include N. gonorrhoeae, C. trachomatis, mycoplasmas, mixed anaerobes.
  • Risk factors include age <25 years, new or multiple sexual partners, previous sexually transmitted disease.
• Presenting symptoms include:
  • Up to 60% of cases are sub-clinical with minimal signs or symptoms.
  • Lower abdominal pain usually bilateral and of recent onset.
  • Deep dyspareunia.
  • Abnormal uterine bleeding (post-coital, intermenstrual).
  • Vaginal or cervical discharge.
• Clinical signs:
  • Uterine or adnexal tenderness.
  • Cervical motion tenderness.
  • Mucopurulent cervical discharge.
  • Fever.

Investigations

• All women with suspected PID should have a bimanual pelvic examination and speculum examination with endocervical swabs taken for PCR (N. gonorrhoeae and Chlamydia) and culture (N. gonorrhoeae) as well as high vaginal swab for culture.
• MSU, urine pregnancy test.
• CBC, CRP.
• Serology for syphilis, hepatitis B and HIV recommended.
• No single symptom, sign or investigation is diagnostic therefore a low threshold for treatment is recommended. The current syndromic criteria used to initiate antibiotics is a woman at risk for STIs with lower abdominal pain and one or more of:
  • Cervical motion tenderness or
  • Adnexal tenderness or
  • Uterine tenderness.

Management

• Consult with Sexual Health or Gynaecology.
• Patients who are pregnant or with severe PID or who have failed previous therapy should be referred to Gynaecology for management. Definition of treatment failure is based on 72 hour review.

See also: NZ Sexual Health Guideline http://www.nzshs.org/treatment_guidelines/Pelvic_Inflammatory_Disease_2009.pdf

Antibiotics

Mild to Moderate PID

• Ceftriaxone 500 mg IM single dose, plus
• Doxycycline 100 mg PO BD for 14 days, plus
• Metronidazole 400 mg PO BD for 14 days (may be discontinued if not tolerated).

In cases where compliance may be an issue, substitute azithromycin 1 g PO stat and on day 8 instead of doxycycline.

For patients with severe penicillin allergy, use gentamicin 5 mg/kg IV as a single dose (see below) instead of ceftriaxone.

Severe PID or failed therapy

• Ceftriaxone 1 g IV q24h, plus
• Metronidazole 500 mg IV q8h, plus
• Doxycycline 100 mg PO BD until afebrile for 24 hours, then
• Metronidazole 400 mg PO BD, plus
• Doxycycline 100 mg PO BD, to complete 14 days of therapy.

For patients with severe penicillin allergy replace ceftriaxone with gentamicin 5 mg/kg IV once daily. Adjust dose according to levels. See the gentamicin/tobramycin dosing guidelines in the Pink Book.

For patients with tubo-ovarian abscess or intolerance to metronidazole or doxycycline, clindamycin 450 mg PO QID may be used.

Notes:

• PID in pregnancy can be difficult to treat as some of the antibiotics used may cause nausea and vomiting. Seek advice.
• All patients should be given a PID information sheet, encouraged to notify sexual partners and to advise them to present for testing and treatment regardless of negative test results.
• Patients should be followed up to confirm resolution of symptoms and signs.

See also Pelvic Inflammatory Disease on HealthPathways.

Topic Code: 35921