Management of pelvic inflammatory disease
Pelvic inflammatory disease (PID) is an ascending infection that may involve one or all organs of the upper genital track such as endometrium, fallopian tubes, ovaries, as well as surrounding peritoneum (Black, 2014). About 2.5 million American women have PID, which is one of the preventable causes of infertility (New Analysis Look, 2017). “Presence of an STI, previous pelvic infections, unprotected sexual intercourse, sexual intercourse at an early age and multiple sexual partners are risk factors for PID. Less commonly, instrumentation of the cervix and/or the uterus can result in endogenous bacteria inoculating the endometrium and consequently leading to PID” (Kochhar, 2014).
While chlamydia trachomatis and Neisseria gonorrhoeae are the most common causes, other cervical, enteric, bacterial vaginosis-associated, such as Gardnerella vaginalis and respiratory pathogens, including Mycobacterium tuberculosis, , Haemophilus influenzae, and Streptococcus agalactias may be involved (Simmons, 2015). In a 2015 meta-analysis, M. genitalium infections were associated with an increase in PID and treatment of this infection is challenging because rates of resistance are high. Research indicates that a single 1-gram dose of azithromycin is more effective against M. genitalium than doxycycline. Cure rates for moxifloxacin range from 70-100% (AHC Media, 2018). Around 10% of untreated chlamydial infections progress to PID and untreated gonococcal infection may present even higher risk, 10-18% (CDC, 2018).
PID is a major concern because it can result in inflammation and scarring, leading to damage of fallopian tubes, elevating the risk of infertility and ectopic pregnancy (CDC, 2018). Untreated PID can also lead to chronic pelvic pain and intra-abdominal infections. The danger is also in potential lack of symptoms, which can lead to advance and irreversible damage to reproductive organs. When symptoms occur, they are most often in the form of lower abdominal and/or pelvic pain, change in vaginal discharge including color, amount, and odor, dysuria, pain with intercourse, fever, have cervical motion, uterine, or adnexal tenderness on exam, presence of large numbers of WBC on saline microscopy of vaginal fluid, and elevated erythrocyte sedimentation rate and c-reactive protein (CDC, 2018). The diagnosis is done primarily clinically with mild to moderate disease treatment should be started as early as possible to minimize the risk of future ectopic pregnancy and tubal infertility.
Antibiotic regimens for the treatment of PID should cover C trachomatis, N gonorrhoeae, anaerobes, Gram-negative aerobes and streptococci. This provides treatment which will cover the most likely STIs as well as endogenous vaginal and lower gastrointestinal flora (Kocchlar, 2014). The CDC recommends the following for first-line treatment for outpatient therapy: Doxycycline 100 mg orally twice a day for 14 days with ceftriaxone 250 mg intramuscularly (IM) for one dose or cefoxitin 2 g IM with probenecid 1g orally for one dose. Additionally, metronidazole is recommended for 14 days in the setting of bacterial vaginosis, trichomoniasis, or recent uterine instrumentation (CDC, 2015). Hospitalization for parenteral antibiotics is recommended in patients who are pregnant or severely ill, in whom outpatient treatment has failed. It is important to test and treat sex partner as well to prevent recurrent infection (Black, 2014). The rate of PID has declined somewhat, perhaps due to earlier identification and treatment of chlamydia and gonorrhea infection and availability of single-dose therapies that increase adherence to treatment (CDC, 2018). However, the CDC (2015) warns that antibiotic treatment won’t reverse any scarring that infection already has caused. This finding emphasizes the importance of immediate care if a woman experiences pelvic pain or other symptoms of PID.
AHC MEDIA. (2018). Radar Is Up for Rising of Mycoplasma Genitalium. Contraceptive Technology Update, 39(9), N.PAG.
Black, A. (2014). Management of pelvic inflammatory disease. Nurse Prescribing, 12(9), 443-450.
Center for Disease Control and Prevention. (2015, June 4). 2015 Sexually transmitted diseases treatment guidelines: pelvic inflammatory disease. Retrieved from https://www.cdc.gov/std/tg2015/pid.htm
Center for Disease Control and Prevention. (2018, October 8). Sexually transmitted diseases surveillance 2018: STDs in women and infants. Retrieved from https://www.cdc.gov/std/stats18/womenandinf.htm#pid
Kochhar, S. (2014). Pelvic inflammatory disease: a common cause of morbidity. Independent Nurse, 3.
New Analysis Looks at Pelvic Inflammatory Disease. (2017). Contraceptive Technology Update, 38(4), 1–3.
Simmons, S. (2015). Understanding pelvic inflammatory disease. Nursing, 45(2), 65–66. https://doi-org.wilkes.idm.oclc.org/10.1097/01.NURSE.0000458943.04114.6e
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