Antibiotic treatment should be started early on the grounds of clinical diagnosis, as delay could leads to long term complications. In-patient care is indicated in severe pelvic inflammatory disease or systemic effects; when parenteral treatment is deemed necessary. When the patient presents with acute abdomen, there is a case for further investigations, to exclude other gynaecological or surgical emergencies (e.g., appendicitis, ectopic pregnancy, pelvic or tubo-ovarian abscess). Awating the result should not delay the start of antibiotics, which could be reviewed at a later stage.

The patient’s general condition dictates the need for bed rest, which include abstinence from sexual intercourse. The sex partner should be adviced on investigations to exclude STIs. There is a case for offering him epidemiological treatment; as some of organisms are not routinely investigated (e.g., Mycoplasma hominis and genitalium). The patient requires two weeks of continuous antibiotic therapy. In severe PID, parenteral treatment should be started first. The regimen should include anti-microbial against C Trachomatis, N Gonorrhoeae and Anaerobes.

The initial parenteral regimens may be a choice of Ceftriaxone (250 mg, stat, IM) or Cefoxitin (2 g, stat, IM) plus Probenecid (1 g oral) or Cefoxitin (2 g, TID, IV) plus Doxycycline (100 mg, BD, IV) or Clindamycin (900 mg, TID, IV) plus Gentamicin (2 mg/kg of body weight loading dose, IV or IM; followed by 1.5 mg/kg TID).

The parenteral therapy should be continued for 24 hours after clinical improvement. Oral therapy should target a spectrum for Gram-negative facultative bacteria and Streptococci (e.g., Doxycycline, 100 mg, BD, orally and Metronidazole 400mg, BD, orally), to complete two weeks of treatment.

In mild/ moderate PID, the out-patient treatment should follow similar principles of compination therapy for a period of two weeks. Ofloxacin (400 mg, orally, BD) and Metronidazole (400 mg, orally, BD) provide alternative to Doxycycline/Metronidazole.

PID: Special Situations

  1. When Tubo-ovarian abscess is diagnosed, Clindamycin (450 mg orally 4 times a day) or Metronidazole (400 mg orally 4 times a day) is indicated, to extend the spectrum of treatment to Anaerobic infections.
  2. Ofloxacin was considered in combination therapy, but the lack of coverage for Anaerobic infections raises concern.
  3. Amoxycillin/Clavulanic Acid plus Doxycycline are notorious of gastrointestinal symptoms and can leads to patient compliance problems.
  4. Pelvic inflammatory disease with pregnancy is a high-risk situation which is associated with maternal and foetal morbidity, foetal demise or preterm delivery. Hospitalisation and parenteral antibiotics should be commenced as soon as possible.
  5. Doxycycline is contra-indicated during pregnancy and should be replaced with Erythromycin (50 mg/kg, IV,daily).
  6. HIV patient developing pelvic inflammatory disease carries an increased risk; which is higher at the later stage of immuno-compromise. The patient is more likely to have tubo-ovarian abscesses, higher rate of concomitant infections with M.hominis, Candida and Streptococcal infections.
  7. Pelvic inflammatory disease in immuno-deficient HIV patients requires hospitalisation and parenteral treatment but the response is good to standard antibiotics.

Prevention of PID

Sexual health education is viewed as a positive step towards prevention of sexually transmitted infections and their complications. Supportive evidence is drawn from comparative analysis of rates of conditions in countries/states that apply education with those who do not. Theoretically, the use of barrier contraception should give some protection from sexually transmitted infections and their complications. Contact tracing aim to identify patients and partners, who are at risk of complications and/or act as reservoirs for infections.

The National Chlamydia Screening programs are hypothesised to reduce the incidence of PID. Patient awareness of sexually transmitted infections consequences and early attendance to seek medical advice reflects on early diagnosis and treatment, which circumvent sexually transmitted infections and their complications, including PID. The association between BV and pelvic inflammatory disease is interesting but whether the increasing awareness and management of BV may reflect on the overall incidence of pelvic inflammatory disease is yet to be determined.

 

Selections from the book: “Sexually Transmitted Diseases”, Edited by A. R. Markos, 2009. Series “Disorders of the Lower Genito Urinary Tract”.

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