Pelvic Inflammatory Disease (PID) - Michigan



PELVIC INFLAMMATORY DISEASE (PID)INTRODUCTIONPID comprises a spectrum of inflammatory disorders of the upper female genital tract, including any combination of endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis. Sexually transmitted organisms, especially N. gonorrhoea and C. trachomatis, are implicated in many cases; however, microorganisms that comprise the vaginal flora (e.g., anaerobes, G. vaginalis, Haemophilus influenzae, enteric Gram-negative rods, and Streptococcus agalactiae) also have been associated with PID. In addition, cytomegalovirus (CMV), M. hominis, U. urealyticum, and M. genitalium might be associated with some cases of PID. All women who have acute PID should be tested for N. gonorrhoe and C. trachomatis and should be offered testing for HIV infection and other STDs.SUBJECTIVE DATAHistory may include:Past STDsSexual activity (last exposure, exposure sites)Contraceptive method (condom/spermicide use, recent IUD insertion) New or multiple partners &/or partner has multiple partnersInfected PartnerSymptoms may include:Abnormal vaginal dischargeAbnormal vaginal bleedingDyspareuniaPelvic or lower abdominal painFeverOBJECTIVE DATAPhysical exam findings:Mucopurulent cervical dischargeAdnexal tendernessUterine tendernessCervical motion tendernessCervical friabilityASSESSMENTDiagnosis of PID can be made if one or more of the following minimum criteria is present on pelvic examination:Uterine tendernessAdnexal tendernessCervical motion tendernessOther assessment diagnostics may include:Presence of WBC’s on wet prep microscopyOral temperature >101 F (>38.3 C)Abnormal mucopurulent cervical dischargeCervical friabilityCervical infection with N. gonorrhea or C trachomatisPLANTest: N. Gonorrhea and C. trachomatisPregnancy test to rule ectopic pregnancy Encourage testing for HIVTreatment: Outpatient treatment for women with PID of mild or moderate severity includes: Recommended Regimes:Ceftriaxone 250 mg IM in a single dosePLUSDoxycycline 100 mg orally twice a day for 14 days* WITH or WITHOUT (see below)Metronidazole 500 mg orally twice a day for 14 daysORCefoxitin 2 g IM in a single dose and Probenecide 1 g orally administered concurrently in a single dosePLUSDoxycycline 100 mg orally twice a day for 14 daysWITH OR WITHOUTMetronidazole 500 mg orally twice a day for 14 daysOROther parenteral third-generation cephalosporin (e.g. ceftizoxime orCefotaxime)PLUSDoxcycline 100 mg orally twice a day for 14 daysWITH OR WITHOUTMetronidazole 500 mg orally twice a day for 14 days****Alternative Oral Regimen if Doxycycline Allergy:Ceftriaxone 250 mg IM in a single dosePLUSAzithromycin 1 gram orally once a week for 2 weeks*WITH or WITHOUTMetronidazole 500 mg orally twice a day for 14 days ****Noted in small studies* The recommended third-generation cephalsporins are limited in the coverage of anaerobes. Therefore, until it is known that extended anaerobic coverage is not important for treatment of acute PID, the addition of metronidazole to treatment regimens with third-generation cephalosporins should be considered (Source: Walker CK, WiesenfeldHC. Antibiotic therapy for acute pelvic inflammatory disease: the 2015 CDC Sexually Transmitted Diseases Treatment Guidelines. Clin Infect Dis 2007;28[Supp 1]:S29–36).Clients with severe PID (i.e., extreme cervical motion tenderness, tachycardic, septic, high temperature) must be referred for evaluation/management.SPECIAL CONSIDERATIONSPregnancy: Because of the high risk for maternal morbidity and preterm delivery, pregnant women who have suspected PID should be emergently referred to the client’s prenatal provider for potential hospitalization for intravenous antibiotic therapy.Intrauterine Contraceptive Devices: The risk for PID associated with IUD use is primarily confined to the first 3 weeks after insertion. If an IUD user receives a diagnosis of PID, the IUD does not need to be removed. However, the woman should receive treatment according to these recommendations and should have close clinical follow-up. If no clinical improvement occurs within 48–72 hours of initiating treatment, providers should consider removing the IUD. A systematic review of evidence found that treatment outcomes did not generally differ between women with PID who retained the IUD and those who had the IUD removed.CLIENT EDUCATION/COUNSELINGAll male sex partners of women with PID should be examined and treated if they had sexual contact with the client during the 60 days preceding the client’s onset of symptoms. Sex partners should be treated empirically with regimens effective against both GC and CT, regardless of the etiology of PID or pathogens isolated from the infected woman. Timely treatment of sex partners, as indicated, is to decrease the risk for re-infection. Clients should be instructed to abstain from sexual intercourse until they and their sex partners have completed treatment. Abstinence should be continued until therapy is completed, symptoms have resolved, and sex partners have been adequately treated.Provide Medication Information SheetProvide STD education and informationOffer other STD testingProvide current educational information on PIDProvide contraceptive information, if indicated Encourage consistent and correct condom use to prevent STDs Efforts to educate partners about symptoms and to encourage partners to seek clinical evaluationFOLLOW-UP Client should be re-evaluated in 72 hours after initiation of treatment for clinical improvement (e.g., reduction in direct or rebound abdominal tenderness; reduction in uterine, adnexal and cervical motion tenderness). All women who have received a diagnosis of chlamydial or gonococcal PID should be retested 3 months after treatment, regardless of whether their sex partners were treated. If retesting at 3 months is not possible, these women should be retested whenever they next present for medical care in the 12 months following treatment.REFERRALSevere Symptoms-nausea, vomiting, Oral temperature >101 F (>38.3 C)Pregnant ClientsIf worsening symptoms or no clinical improvement after 72 hours, client must be referred for further evaluation/management.REPORTING No mandated state reporting is required for PID. If identified, chlamydia and gonorrhea infections must be reported.REFERENCESCDC: Sexually Transmitted Disease Treatment Guidelines, 2015 Reportable Diseases in Michigan: A Guide for Physicians, Health Care Providers and Laboratories 2019Reviewed/Revised: 2020 ................
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