Pelvic inflammatory disease medical therapy: Difference between revisions

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{{Pelvic inflammatory disease}}
{{Pelvic inflammatory disease}}
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{{CMG}}; {{AE}} {{MehdiP}}
 
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==Overview==
==Overview==
Treatment depends on the cause and generally involves use of [[antibiotic]] therapy.  If the patient has not improved within two to three days after beginning treatment with the antibiotics, they should return to the hospital for further treatment.  Drugs should also be given orally and/or intravaneously to the patient while in the hospital to begin treatment immediately to increase the effectiveness of antibiotic treatment.   Hospitalization may be necessary if Tubo-ovarian abscess, very ill, immunodeficient, pregnancy, incompetence, or because this or something else life threatening can not be ruled out.  Treating partners for STD's is a very important part of treatment and prevention. Anyone with PID and partners of patients with PID since six months prior to diagnosis should be treated to prevent reinfection. Psychotherapy is highly recommended to women diagnosed with PID as the fear of redeveloping the disease after being cured may exist. It is important for a patient to communicate any issues and/or uncertainties they may have to a doctor, especially a specialist such as a gynecologist, and in doing so, to seek follow-up care.
In order to decrease the risk of complications, treatment should be initiated as soon as the presumptive diagnosis has been made. Hospitalization may be necessary for patients who are [[pregnant]], [[Immunodeficiency|immunodeficient]], and those with severe disease. Combination therapy is recommended to increase anti microbial coverage. Follow up is necessary in all treated patients and partner screening is recommended.


==Medical Therapy==
==Medical Therapy==
PID can be cured with several types of antibiotics. A health care provider will determine and prescribe the best therapy. However, antibiotic treatment does not reverse any damage that has already occurred to the reproductive organs. If a woman has pelvic pain and other symptoms of PID, it is critical that she seek care immediately. Prompt antibiotic treatment can prevent severe damage to reproductive organs. The longer a woman delays treatment for PID, the more likely she is to become infertile or to have a future ectopic pregnancy because of damage to the [[fallopian tube]]s.
*Treatment should be initiated as soon as the presumptive diagnosis has been made to decrease the risk of complications.<ref name="pmid12015517">{{cite journal |vauthors=Ness RB, Soper DE, Holley RL, Peipert J, Randall H, Sweet RL, Sondheimer SJ, Hendrix SL, Amortegui A, Trucco G, Songer T, Lave JR, Hillier SL, Bass DC, Kelsey SF |title=Effectiveness of inpatient and outpatient treatment strategies for women with pelvic inflammatory disease: results from the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) Randomized Trial |journal=Am. J. Obstet. Gynecol. |volume=186 |issue=5 |pages=929–37 |year=2002 |pmid=12015517 |doi= |url=}}</ref>
*The long term prognosis is highly dependent on immediate appropriate [[antibiotic therapy]].
*Combination therapy is recommended to increase antibacterial coverage.
*Patients are usually treated as [[outpatients]].  
Indications for hospital admission include:<ref name="pmid26042815">{{cite journal |vauthors=Workowski KA, Bolan GA |title=Sexually transmitted diseases treatment guidelines, 2015 |journal=MMWR Recomm Rep |volume=64 |issue=RR-03 |pages=1–137 |year=2015 |pmid=26042815 |doi= |url=}}</ref><ref name="pmid25992748">{{cite journal |vauthors=Brunham RC, Gottlieb SL, Paavonen J |title=Pelvic inflammatory disease |journal=N. Engl. J. Med. |volume=372 |issue=21 |pages=2039–48 |year=2015 |pmid=25992748 |doi=10.1056/NEJMra1411426 |url=}}</ref>


Because of the difficulty in identifying organisms infecting the internal reproductive organs and because more than one organism may be responsible              for an episode of PID, PID is usually treated with at least two antibiotics that are effective against a wide range of infectious agents. These antibiotics can be given by mouth or by injection. The symptoms may go away before the infection is cured. Even if symptoms go away, the woman should finish taking all of the prescribed medicine. This will help prevent the infection from returning. Women being treated for PID should be re-evaluated by their health care provider three days after starting treatment to be sure the [[antibiotics]] are working to cure the infection. In addition, a woman’s sex partner(s) should be treated to decrease the risk of re-infection, even if the partner(s) has no symptoms. Although sex partners may have no symptoms, they may still be infected with the organisms that can cause PID.
*[[Surgical emergency|Surgical emergencies]] (e.g., [[appendicitis]]) cannot be excluded
*[[Tubo-ovarian abscess]]
*[[Pregnancy]]
*Severe illness, [[nausea]] and [[vomiting]], or [[high fever]]
*Unable to follow or tolerate an outpatient oral regimen
*No clinical response to [[Antimicrobial agent|oral antimicrobial therapy]].


[[Hospitalization]] to treat PID may be recommended if the woman


(1) Is severely ill (e.g., [[nausea]], [[vomiting]], and high [[fever]])
===Antibiotic therapy===
====Parenteral treatment====
*[[Parenteral|Parenteral therapy]] has more benefits than oral/[[intramuscular]] therapy.<ref name="pmid26042815">{{cite journal |vauthors=Workowski KA, Bolan GA |title=Sexually transmitted diseases treatment guidelines, 2015 |journal=MMWR Recomm Rep |volume=64 |issue=RR-03 |pages=1–137 |year=2015 |pmid=26042815 |doi= |url=}}</ref><ref name="pmid27107781">{{cite journal |vauthors=Ford GW, Decker CF |title=Pelvic inflammatory disease |journal=Dis Mon |volume=62 |issue=8 |pages=301–5 |year=2016 |pmid=27107781 |doi=10.1016/j.disamonth.2016.03.015 |url=}}</ref><ref name="pmid25992748">{{cite journal |vauthors=Brunham RC, Gottlieb SL, Paavonen J |title=Pelvic inflammatory disease |journal=N. Engl. J. Med. |volume=372 |issue=21 |pages=2039–48 |year=2015 |pmid=25992748 |doi=10.1056/NEJMra1411426 |url=}}</ref>
*Clinical experience should guide decisions regarding the transition to oral therapy, which can usually be initiated within 24–48 hours of clinical improvement.


(2) Is pregnant


(3) Does not respond to or cannot take oral medication and needs intravenous antibiotics


(4) Has an abscess in the [[fallopian tube]] or [[ovary]] (tubo-ovarian abscess) or
{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
|+
! style="background: #4479BA; width: 180px;" | {{fontcolor|#FFFFFF|Rout of administration}}
! style="background: #4479BA; width: 500px;" | {{fontcolor|#FFFFFF|Regimen}}
|-
| style="padding: 7px 7px; background: #DCDCDC;" |'''Parenteral'''
| style="padding: 7px 7px; background: #F5F5F5;" |
Preferred:
:::::[[Cefotetan]] 2 g IV every 12 hours         
:::::::::'''PLUS'''
:::::[[Doxycycline]] 100 mg orally or IV every 12 hours
----
:::::[[Cefoxitin]] 2 g IV every 6 hours
:::::::::'''PLUS'''
:::::[[Doxycycline]] 100 mg orally or IV every 12 hours
----
:::::[[Clindamycin]] 900 mg IV every 8 hours
:::::::::'''PLUS'''
:::::[[Gentamicin]] [[loading dose]] IV or IM (2 mg/kg),
:::::followed by a [[maintenance dose]] (1.5 mg/kg) every 8 hours.
:::::Single daily dosing (3–5 mg/kg) can be substituted
----


(5) Needs to be monitored to be sure that her symptoms are not due to another condition that would require emergency surgery (e.g., [[appendicitis]]).
Alternative:
:::::[[Ampicillin/Sulbactam]] 3 g IV every 6 hours
:::::::::'''PLUS'''
:::::[[Doxycycline]] 100 mg orally or IV every 12 hours
|-
|}


If symptoms continue or if an abscess does not go away, surgery may be needed.
====Intramuscular/Oral Treatment====
 
*[[Intramuscular]]/oral therapy can be considered for women with mild-to-moderately severe acute PID, because the clinical outcomes among women treated with these regimens are similar to those treated with [[intravenous therapy]].<ref name="pmid26042815">{{cite journal |vauthors=Workowski KA, Bolan GA |title=Sexually transmitted diseases treatment guidelines, 2015 |journal=MMWR Recomm Rep |volume=64 |issue=RR-03 |pages=1–137 |year=2015 |pmid=26042815 |doi= |url=}}</ref>
;Shown below is a table summarizing the preferred and alternative empiric treatment for Pelvic inflammatory disease (includes [[salpingitis]], tubo-ovarian abscess and [[pelvic peritonitis]].
*Women who do not respond to IM/oral therapy within 72 hours should be reevaluated to confirm the diagnosis and should be administered intravenous therapy.<ref name="pmid12015517">{{cite journal |vauthors=Ness RB, Soper DE, Holley RL, Peipert J, Randall H, Sweet RL, Sondheimer SJ, Hendrix SL, Amortegui A, Trucco G, Songer T, Lave JR, Hillier SL, Bass DC, Kelsey SF |title=Effectiveness of inpatient and outpatient treatment strategies for women with pelvic inflammatory disease: results from the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) Randomized Trial |journal=Am. J. Obstet. Gynecol. |volume=186 |issue=5 |pages=929–37 |year=2002 |pmid=12015517 |doi= |url=}}</ref>
 
{| class="wikitable" border="1" style="background:FloralWhite"
|- align="center"
|'''Characteristics of the Patient'''
|'''Possible Pathogens'''
|'''Preferred Treatment'''
|'''Duration of Treatment'''
|- align="center"
|'''All women with Pelvic inflammatory disease'''
|N. gonorrhoeae
 
C. trachomatis
 
Gardnerella spp.
 
Ureaplasma urealyticum
 
Anaerobes (Prevotella spp., B. fragilis)
 
Gram negative rods
 
Streptococci
|'''Cefotetan'''
 
2g IV Q12H
 
'''+'''
 
'''Doxycycline'''
 
100mg PO BID
 
 
 
'''OR'''
 
 
 
'''Ertapenem'''
 
1g IV Q24H
 
'''+'''
 
'''Doxycycline'''
 
100mg PO BID
|14 days




{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
|+
! style="background: #4479BA; width: 180px;" | {{fontcolor|#FFFFFF|Rout of administration}}
! style="background: #4479BA; width: 500px;" | {{fontcolor|#FFFFFF|Regimen}}
|-
| style="padding: 7px 7px; background: #DCDCDC;" |'''Intramuscular/Oral'''
| style="padding: 7px 7px; background: #F5F5F5;" |
Preferred:


:::::[[Ceftriaxone]] 250 mg IM in a single dose     
:::::::::'''PLUS'''
:::::[[Doxycycline]] 100 mg orally twice a day for 14 days
:::::::::'''with/without'''
:::::[[Metronidazole]] 500 mg orally twice a day for 14 days
----
:::::[[Cefoxitin]] 2 g IM in a single dose and [[Probenecid]] 1 g orally administered concurrently in a single dose
:::::::::'''PLUS'''
:::::[[Doxycycline]] 100 mg orally twice a day for 14 days
:::::::::'''with/without'''
:::::[[Metronidazole]] 500 mg orally twice a day for 14 days
----
:::::[[Clindamycin]] 900 mg IV every 8 hours
:::::::::'''PLUS'''
:::::[[Gentamicin]] [[loading dose]] IV or IM (2 mg/kg),
:::::followed by a [[maintenance dose]] (1.5 mg/kg) every 8 hours.
:::::Single daily dosing (3–5 mg/kg) can be substituted
----
----
Alternative:
:::::[[Azithromycin]] 1 g orally once a week for 2 weeks
:::::::::'''PLUS'''
:::::[[ceftriaxone]] 250 mg IM single dose
:::::::::'''with'''
:::::[[Metronidazole]] 500 mg orally twice a day for 14 days
|-
|}


==Follow-up==
*Patients should return for re-evaluation on the third day of [[Antimicrobials|antimicrobial therapy]] to evaluate the success of therapy.
*Patients who do not improve within 3 days of therapy may require hospitalization, additional diagnostic tests, and/or surgical intervention.
*Women with documented [[chlamydial]] or [[Gonorrhea|gonococcal]] infections have a high rate of reinfection within 6 months of treatment.
*Repeat testing of all women who have been diagnosed with [[chlamydia]] or [[gonorrhea]] is recommended between 3 and 6 months after treatment, regardless of whether their sexual partners were treated.


 
==Treatment of Sexual Partners==
 
*Male partners of women who have PID are often asymptomatic.
 
*Both symptomatic and asymptomatic sexual partners of patients with pelvic inflammatory disease should be also be evaluated and, if necessary, treated.
 
 
 
14 days
|}


==References==
==References==
{{reflist|2}}
{{reflist|2}}
{{WH}}
{{WS}}


[[Category:Needs content]]
[[Category:Disease]]
[[Category:Disease]]
[[Category:Gynecology]]
[[Category:Abdominal pain]]
[[Category:Sexually transmitted diseases]]
[[Category:Infectious Disease Project]]
[[Category:Emergency mdicine]]
[[Category:Up-To-Date]]
[[Category:Infectious disease]]
[[Category:Infectious disease]]
[[Category:Gynecology]]
[[Category:Abdominal pain]][[Category:Sexually transmitted diseases]]
{{WH}}
{{WS}}

Latest revision as of 23:37, 29 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Seyedmahdi Pahlavani, M.D. [2]

Overview

In order to decrease the risk of complications, treatment should be initiated as soon as the presumptive diagnosis has been made. Hospitalization may be necessary for patients who are pregnant, immunodeficient, and those with severe disease. Combination therapy is recommended to increase anti microbial coverage. Follow up is necessary in all treated patients and partner screening is recommended.

Medical Therapy

  • Treatment should be initiated as soon as the presumptive diagnosis has been made to decrease the risk of complications.[1]
  • The long term prognosis is highly dependent on immediate appropriate antibiotic therapy.
  • Combination therapy is recommended to increase antibacterial coverage.
  • Patients are usually treated as outpatients.

Indications for hospital admission include:[2][3]


Antibiotic therapy

Parenteral treatment

  • Parenteral therapy has more benefits than oral/intramuscular therapy.[2][4][3]
  • Clinical experience should guide decisions regarding the transition to oral therapy, which can usually be initiated within 24–48 hours of clinical improvement.


Rout of administration Regimen
Parenteral

Preferred:

Cefotetan 2 g IV every 12 hours
PLUS
Doxycycline 100 mg orally or IV every 12 hours
Cefoxitin 2 g IV every 6 hours
PLUS
Doxycycline 100 mg orally or IV every 12 hours
Clindamycin 900 mg IV every 8 hours
PLUS
Gentamicin loading dose IV or IM (2 mg/kg),
followed by a maintenance dose (1.5 mg/kg) every 8 hours.
Single daily dosing (3–5 mg/kg) can be substituted

Alternative:

Ampicillin/Sulbactam 3 g IV every 6 hours
PLUS
Doxycycline 100 mg orally or IV every 12 hours

Intramuscular/Oral Treatment

  • Intramuscular/oral therapy can be considered for women with mild-to-moderately severe acute PID, because the clinical outcomes among women treated with these regimens are similar to those treated with intravenous therapy.[2]
  • Women who do not respond to IM/oral therapy within 72 hours should be reevaluated to confirm the diagnosis and should be administered intravenous therapy.[1]


Rout of administration Regimen
Intramuscular/Oral

Preferred:

Ceftriaxone 250 mg IM in a single dose
PLUS
Doxycycline 100 mg orally twice a day for 14 days
with/without
Metronidazole 500 mg orally twice a day for 14 days
Cefoxitin 2 g IM in a single dose and Probenecid 1 g orally administered concurrently in a single dose
PLUS
Doxycycline 100 mg orally twice a day for 14 days
with/without
Metronidazole 500 mg orally twice a day for 14 days
Clindamycin 900 mg IV every 8 hours
PLUS
Gentamicin loading dose IV or IM (2 mg/kg),
followed by a maintenance dose (1.5 mg/kg) every 8 hours.
Single daily dosing (3–5 mg/kg) can be substituted

Alternative:

Azithromycin 1 g orally once a week for 2 weeks
PLUS
ceftriaxone 250 mg IM single dose
with
Metronidazole 500 mg orally twice a day for 14 days

Follow-up

  • Patients should return for re-evaluation on the third day of antimicrobial therapy to evaluate the success of therapy.
  • Patients who do not improve within 3 days of therapy may require hospitalization, additional diagnostic tests, and/or surgical intervention.
  • Women with documented chlamydial or gonococcal infections have a high rate of reinfection within 6 months of treatment.
  • Repeat testing of all women who have been diagnosed with chlamydia or gonorrhea is recommended between 3 and 6 months after treatment, regardless of whether their sexual partners were treated.

Treatment of Sexual Partners

  • Male partners of women who have PID are often asymptomatic.
  • Both symptomatic and asymptomatic sexual partners of patients with pelvic inflammatory disease should be also be evaluated and, if necessary, treated.

References

  1. ↑ 1.0 1.1 Ness RB, Soper DE, Holley RL, Peipert J, Randall H, Sweet RL, Sondheimer SJ, Hendrix SL, Amortegui A, Trucco G, Songer T, Lave JR, Hillier SL, Bass DC, Kelsey SF (2002). "Effectiveness of inpatient and outpatient treatment strategies for women with pelvic inflammatory disease: results from the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) Randomized Trial". Am. J. Obstet. Gynecol. 186 (5): 929–37. PMID 12015517.
  2. ↑ 2.0 2.1 2.2 Workowski KA, Bolan GA (2015). "Sexually transmitted diseases treatment guidelines, 2015". MMWR Recomm Rep. 64 (RR-03): 1–137. PMID 26042815.
  3. ↑ 3.0 3.1 Brunham RC, Gottlieb SL, Paavonen J (2015). "Pelvic inflammatory disease". N. Engl. J. Med. 372 (21): 2039–48. doi:10.1056/NEJMra1411426. PMID 25992748.
  4. ↑ Ford GW, Decker CF (2016). "Pelvic inflammatory disease". Dis Mon. 62 (8): 301–5. doi:10.1016/j.disamonth.2016.03.015. PMID 27107781.

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