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blood cells.
Gram staining
- First: obtain edocervical mucus for inflammatory cells and perform NAAT for b
oth N. gonorrhoeae and C. trachomatis
- C. trachomatis has surpassed N. gonorrhea as the most prevalent sexually tran
smitted bacteria-producing upper tract infection in the developed world
Endometrial biopsy
- for evidence of endometritis
- primarily used to help confirm a clinical suspicion
Ultrasonography
- of limited value for patients with mild or moderate PID due to its low sensiti
vity
- helpful in documentaing an adnexal mass and differentiating between a tuboovar
ian abscess and tuboovarian complex
- also a noninvasive diagnostic aid for patients who are so tender during pelvic
examination that the pysician cannot determine the presence or absence of a pel
vic mass
Magnetic Resonance Imaging
- is sensitive but its expense and limited acute availability in some locations
have restrected its role in PID diagnosis.
MANAGEMENT
Two ost important goals of the medical therapy of acute PID:
1. resolution of symptoms
2. preservation of tubal function
Indications for Hospitalizing Patients with Acute Pelvic Inflammatory Disease
1.
2.
3.
4.
5.
6.
Advantage
* excellent for community- acquired infection because it treats bith gonorrhea
and chlamydial infection
* doxycycline and cefoxitin provide excellent coverage for N. gonorrhoeae, C, t
rachomatis, and also penicillinase-producing N. gonorrhoeae
* cefoxitin is an excellent antibiotic against Peptococcus, Peptostreptococcus,
and E. colli
Disadvantage
* combination is that the two drugs are less than ideal for a pelvic abscess or
for anaerobic infections
Parenteral Regimen B
Clindamycin 900 mg IV every 8 hours
PLUS
Gentamicin loading dose IV or IM (2 mg/kg of body weight) followed by a maintena
nce dose (1.5 mg/kd) every 8 hours.
Singe daily dosing may be substituted.
Advanatage
* provides excellent coverage for anaerobic infections and facultative gram-neg
ative rods -> preferred for patients with
- an abscess
- IUD- related infections
- pelvic infections after a diagnostic or operative procedure
Alternative Parenteral Regimens
Levofloxacin 500 mg IV once daily
or
Ofloxacin 400 mg IV every 12 hours
WITH OR WITHOUT
Metronidazole 500 mg IV every 8 hours
OR
Ampicillin/Sulbactam 3 g IV every 6 hours
PLUS
Doxycycline 100 mg PO or IV every 12 hours
IV ofloxacin has veen investigated as a single agent; however, because of concer
ns regarding its spectrum, metronidazole may be included in the regimen. Prelimi
nary data suggest that levoflaxicn is as effective as ofloxacin and may be submi
tted; its single daily dosing makes it advantageous.
OPERATIVE TREATMENT
- life-threatening infections
- ruptured tuboovarian abscesses
- laparoscopic drainange of a pelvic abscess
- persistent masses in some older women for whom future childbearing is not a co
nsideration
- removal of a persistent symptomatic mass
Abscess
- is a collection of pus within a newly created space
Tuboovarian complex
- a collection of pus within an anatomic space created by adherence of adjacent
organs
- mixture of anaerobes and facultative or aerobic organisms
- environment of an abscess cavity results in a low level of oxygen tenstion ->
anaerobic organisms predominate
Treatment
- combinatio of clindamycin and an aminoglycoside (combination does not treat th
e enterococcus, and ampicillin should be added if there is suspicion that this o
rganism is involved)
- metronidazole alone is an effective alternative to clindamycin for anaerobic i
nfections but does not provide gram-negative coverage
- if abscesses do not respond to parenteral broad-spectrum antibiotics, drainage
is imperative
Sequelae
-
ACTINOMYCES INFECTION
- a rare cause of upper genital tract infection
- caused by Actinomyces israelii
- gram positive anaerobic bacterium that is difficult to culture
- to sucessfully culture this organism, an anaerobic enviroment must be
maintained for 2 to 3 weeks
- discovered either by histologic examination or culture from women with
tuboovarian abscesses
- may produce a chronic endometritis with an associated foul-smelling discharge
- Manisfestations:
- widespread adhesions
- induration
- fibrosis
- Diagnosis of Actinomyces infection
- classic "sulfur granules" are observed histologically along with grampositive filaments.
- Treatment
* oral penicillin
* doxycycline
* fluoroquinolones
TUBERCULOSIS
- may be produced by either Mycobacterium tuberculosis or M. bovis
- primary site of infection for tuberculosis: lungs
- early in the course of pulmonary infection the bacteria spread hematogenously
-> infection becomes located in the oviduct -> bacilli usually spread to the en
dometrium and less commonly to the ovaries
- primary and predominant site of pelvic tuberculosis: oviducts
- clinical symptoms and signs of pelvic tuberculosis are similar to the chronic
sequelae of nontuberculous acute PID
- predominant presentations of this chronic infection:
- infertility
- abnormal uterine bleeding
- mild to moderate chronic abdominal and pelvic pain occur in 35% of women with
disease
- advanced cases are often accompanied by ascites
- some women may be asymptomatic
- finding at pelvic examination are normal in approximately 50% of cases (remain
ing patients have mild adnexal tenderness and bilateral adnexal masses, with an
inability to manipulate the adnexa because of scarring and fixation.
TUBERCULOSIS SALPINGITIS
- may be suspected when a patient is not responding to conventional antibiotic t
herapy for acute bacterial PID
- results of a tuberculin skin test will be positive
- Diagnosis: performing an endometrial biopsy late in the secretory phase of the
cycle
* findings of classic giant cells, granulomas, and caseous necrosis conf
irm the diagnosis
- laparotomy or celiotomy
- distal ends of the oviduct remain everted, producing a "tobacco pouch" appeara
nce
- chest radiographic examination
- IV pyelogram
- serial gastric washings
- urine cultures for tuberculosis
- Treatment:
- Medical: initial therapy in a patient with newly diagnosed tuberculos
is usually will include five drugs because of the emergence of multidrug-resista
nt organisms
-Operative (reserved for):