An Update on Pelvic Inflammatory Disease
/We last covered PID and TOA on the podcast in February 2019 — and since then, as with our gonorrhea and chlamydia update, have some new updates to reflect the 2021 CDC Treatment Guidelines.
What is PID/TOA?
PID: pelvic inflammatory disease
This is a wide variety of inflammatory disorders of the upper female genital tract, including:
Endometritis
Salpingitis
TOA: tubo-ovarian abscess
Pelvic peritonitis
Caused by many infectious diseases.
Most common: N. gonorrhoeae and C. trachomatis (gonorrhea and chlamydia)
50% of PID diagnoses test positive for GC/CT, though this proportion is decreasing.
Other organisms that can be implicated:
Anaerobes,
G. vaginalis
H. influenzae
Enteric GNRs
Strep agalactiae
Cytomegalovirus
Trichomonas (Trichomonas vaginalis)
Mycoplasima hominis and M. genitalium
Ureaplasma urealyticum
Diagnosis of PID
Can be difficult because of many vague symptoms, and some are asymptomatic
Differential diagnosis is broad for abdominopelvic pain:
Appendicitis
Ectopic pregnancy
Ovarian torsion or ovarian cysts
Diverticulitis
Functional GI pain, IBS, IBD
Etc. etc. etc.
A presumptive dx should be made, and treatment started,
In sexually active women and those at risk for STIs experiencing pelvic/lower abdominal pain, if no other cause for illness can be identified,
and if they have 1 or more of these minimum clinical criteria:
Cervical motion tenderness
Uterine tenderness
Adnexal tenderness
One or more of the following can be used to enhance specificity of the minimal clinical criteria:
Oral temp > 101 F (38.3)
Abnormal cervical mucopurulent discharge or friability
Presence of abundant WBC on saline microscopy of vaginal fluid
Elevated erythrocyte sedimentation rate
Elevated C-reactive protein
Laboratory documentation of cervical infection with N. gonorrhoeae or C. trachomatis
Even more specific criteria can include:
Endometrial biopsy with histopathologic evidence of endometritis
TVUS or MRI showing thickened, fluid-filled tubes with or without free fluid or tubo-ovarian complex
Laparoscopic findings of PID (Fitz-Hugh-Curtis syndrome)
What should I do if I think someone has PID?
Testing:
HIV
Testing recommended by CDC “in all persons seeking STI testing who do not have a known diagnosis of HIV.”
GC/CT
50% will test positive, so they are high yield for PID testing.
NAAT testing is preferred method.
Patient self-collected swabs are just as accurate as clinician-collected.
First void urine is most sensitive; decreases with later voids during the day.
Urine testing may miss over 400k infections per year in USA - vaginal swab testing should be offered first, and patient-collected may help improve acceptability.
Imaging
Not recommended outright by CDC in PID evaluation.
Will frequently be part of your evaluation in a differential diagnosis
TVUS - may continue to have cervical motion tenderness, can demonstrate TOA. Can also demonstrate other GYN pathologies.
CT/MRI - unlikely to demonstrate specific findings for PID outside of large TOAs.
Treatment:
Primary Considerations:
Choice of medication:
Treatment is empiric, requiring broad spectrum coverage of likely pathogens
All treatment types should be effective against gonorrhea and chlamydia
Need for hospitalization:
Recommended if:
A surgical emergency (ie. appendicitis) cannot be excluded
Presence of tubo-ovarian abscess
Pregnancy
Severe illness including nausea, vomiting, or high fever,
Inability to tolerate or follow outpatient regimen
Failed outpatient therapy based on follow up
Parenteral treatments
Ceftriaxone (1g IV q24 hrs) + doxycycline (100 mg oral or IV q12hrs) + metronidazole (500mg oral or IV q12h).
Cefoxitin (2g IV q6hrs) + doxycycline (100mg oral or IV q12hrs)
Cefotetan (2g IV q12h) + doxycycline (100mg oral or IV q12hrs)
Because of pain associated with IV infusion, doxycycline should be given orally whenever possible.
Oral and IV doxycycline and metronidazole have similar bioavailability
Alternative regimens pending allergies and antibiotic availability:
Clindamycin (900 mg IV q8hrs) + gentamicin (2mg/kg loading dose IV or IM, then maintenance of 1.5mg/kg every 8 hrs, or single daily dosing of 3-5mg/kg)
Ampicillin-sulbactam (Unasyn) 3g IV q6hrs + doxycycline 100mg q12hrs
Goal of parenteral therapy will be to transition to oral antibiotics within 24-48 hours if clinical improvement.
Those with TOA should have at least 24 hours of inpatient observation
IM/Oral treatment - For continuation of inpatient treatment, or start here in those with mild-to-moderate symptoms of acute PID.
Clinical outcomes are similar to those treated with IV therapy, but if women don’t respond in 72 hours, should be re-evaluated and treated with IV
Ceftriaxone 500mg IM x1 + doxycycline 100mg BID x14 days + metronidazole 500 mg BID x14 days
Cefoxitin 2g IM + Probenecid 1g orally + doxycyline 100mg BID x14 days + metronidazole 500mg BID x14 days
Some other 3rd generation cephalosporin + doxy + metronidazole
If starting with outpatient treatment, improvement should be documented by follow up within 72 hours.
If no improvement has occurred, then hospitalization, assessment of the antimicrobial regimen, and considering potential additional diagnostics (imaging, laparoscopy) are indicated.
Retesting should occur at 3 months after treatment, regardless of treatment of sex partners, to assess for reinfection.
Patients should refrain from sex until treatment is completed, symptoms resolved, and sex partners have been treated.
Sex partners within previous 60 days of patients with PID should also be treated presumptively for gonorrhea and chlamydia
This is regardless of PID etiology or pathogens isolated
Consider expedited partner therapy (EPT).
Managing TOAs
Surgical drainage indicated if:
Failure to respond to treatment within 48-72 hours
Clinical decline (ie. becoming septic)
Likelihood of need for surgical intervention is related to the size of TOA:
60% of those with abscess >10cm
30% in 7-9cm
15% in those of 4-6 cm
Special considerations for treatment in certain populations:
Pregnancy
Pregnant patients with PID are at high risk of morbidity, pregnancy loss, preterm delivery.
Hospitalization and consultation with ID are recommended.
Persons with HIV
Patients with HIV may be more likely to have TOA, though symptoms are similar overall to those without HIV.
No data currently to suggest more aggressive therapy is needed in patients with HIV.
If patient has an IUD:
IUD is not required to be removed with a diagnosis of PID.
However, if there is no clinical improvement in 48-72 hours, then should consider removing the IUD.
