Pelvic Inflammatory Disease Treatment & Management

The treatment of pelvic inflammatory disease (PID) addresses the relief of acute symptoms, eradication of current infection, and minimization of the risk of long-term sequelae. These sequelae, including chronic pelvic pain, ectopic pregnancy, tubal factor infertility (TFI), and implantation failure with in vitro fertilization attempts, may occur in up to 25% of patients.^[39]

From a public health perspective, treatment is aimed at the expeditious eradication of infection in order to reduce the risk of transmission of infection to new partners and to identify and treat current and recent partners to further help prevent sexually transmitted infection (STI).

Early diagnosis and treatment appears to be critical in the preservation of fertility. Current guidelines suggest that empirical treatment should be initiated in at-risk women who exhibit lower abdominal pain, adnexal tenderness, and cervical motion tenderness. Due to diagnostic difficulties and the potential for serious sequelae, the Centers for Disease Control and Prevention (CDC) advises that physicians maintain a low threshold for aggressive patient treatment, with overtreatment preferred to no or delayed treatment.

Therapy using antibiotics alone is successful in 33-75% of cases. If surgical treatment is warranted, the current trend in therapy is conservation of reproductive potential with simple drainage, adhesiolysis, and copious irrigation or unilateral adnexectomy, if possible. Further surgical therapy is needed in 15-20% of cases so managed.

Most patients with PID are managed as outpatients, but physicians should consider hospitalization for patients with the following conditions, although no clear data suggest that these patients benefit from hospitalization:

• Uncertain diagnosis
• Pelvic abscess on ultrasonographic scanning
• Pregnancy
• Failure to respond to outpatient management
• Inability to tolerate outpatient oral antibiotic regimen
• Severe illness or nausea and vomiting precluding outpatient treatment
• Immunodeficiency (eg, patients with HIV infection who have a low CD4 count, or patients using immunosuppressive medications)
• Failure to improve clinically after 72 hours of outpatient therapy

Worldwide, more than 90% of individuals with PID who are HIV positive are treated as outpatients.^[40] A 2006 study of HIV-infected women in Nairobi, with investigators blinded to patient HIV status, demonstrated that severe PID was more common in all women who were HIV positive. This group, irrespective of CD4 count, took longer to achieve clinical improvement; however, no change in antibiotic regimen was necessary.^[41]

Most patients show clinical response within 48-72 hours after medical therapy. If the patient continues to have fever, chills, uterine tenderness, adnexal tenderness, and cervical motion tenderness, consider other possible causes and a diagnostic laparoscopy.

Admission of persons infected with HIV and of adolescents should be reviewed on an individual basis. Admission decisions are based on the following factors:

• Diagnostic certainty
• Illness severity
• Likelihood of compliance with outpatient regimen
• Whether or not the patient is pregnant
• Coexisting immunosuppression or illness
• Major fertility issues
• Risk factors for significant anaerobic infection (eg, IUD use, recent pelvic procedure, presence of TOA)

The following consultations may be helpful:

• Obstetrician/gynecologist
• Surgeon (especially if appendicitis or another intra-abdominal process cannot be excluded)
• Infectious disease consultant (especially in patients who are HIV positive and may be on highly active antiretroviral treatment [HAART])

Treatment initiated in the emergency department, clinic, or office setting should be expeditiously begun and should include empirical broad-spectrum antibiotics to cover the full complement of common causes. All regimens must be effective against Chlamydia trachomatis and Neisseria gonorrhoeae, as well as against gram-negative facultative organisms, anaerobes, and streptococci.

A number of studies (1992-2006) have demonstrated the effectiveness of a variety of parenteral and oral regimens in the elimination of acute symptoms and in microbiologic cure.^[32] No differences in outcome were identified between inpatient and outpatient management in a large, randomized, multicenter, NIH-sponsored clinical study that effectively compared inpatient and outpatient oral and parenteral antibiotic regimens in the documented elimination of endometrial and tubal infection.^[42]

Physicians should be aware of current guidelines and current national and local patterns of drug resistance in their patient populations to avoid inappropriate treatment.^[43] If an IUD is present, it should be removed after the initiation of antibiotic treatment.

Patients on an intravenous PID regimen can be transitioned to oral antibiotics 24 hours after clinical improvement. These should be continued for a total of 14 days. Oral therapy usually involves doxycycline (Vibramycin); however, azithromycin (Zithromax, Zmax) can also be used.^[44] In patients who have developed TOA, oral therapy should include clindamycin (Cleocin) or metronidazole (Flagyl). (See Medication.)

All patients should be reevaluated in 72 hours for evidence of clinical improvement and compliance with their antibiotic regimen. Multiple studies have shown poor compliance with doxycycline therapy, and approximately 20-25% of patients have never filled their prescriptions.

Patients who do not improve in 72 hours should be reevaluated for possible laparoscopic or surgical intervention and for reconsideration of other possible diagnoses. Laparoscopic pelvic lavage, abscess drainage, and adhesion lysis may be necessary.

Most TOAs (60-80%) resolve with antibiotic administration. If patients do not respond appropriately, laparoscopy may be useful for identifying loculations of pus requiring drainage. An enlarging pelvic mass may indicate bleeding secondary to vessel erosion or a ruptured abscess. Unresolved abscesses may be drained percutaneously via posterior colpotomy, via CT or ultrasonographic guidance, laparoscopically, or by laparotomy.

The advantages of laparoscopy include direct visualization of the pelvis and more accurate bacteriologic diagnosis if cultures are obtained. However, laparoscopy is not always available in acute PID. In addition, this procedure is costly and requires general anesthesia. It should be used if the diagnosis is in doubt. However, if operative laparoscopy is used early in the course of the disease, copious irrigation and separation of thin adhesions by blunt dissection may prevent later sequelae.

Laparotomy is usually reserved for surgical emergencies, such as abscesses that have ruptured or that have not responded to medical management and laparoscopic drainage, and for patients who are not candidates for laparoscopic management. Treatment is guided by intraoperative findings and the patient's desire for fertility maintenance. Treatment may involve unilateral salpingo-oophorectomy or hysterectomy and bilateral salpingo-oophorectomy. Ideally, surgery is performed after the acute infection and inflammation have resolved. In patients with recurrent PID, dense pelvic adhesions may render surgery difficult.

Randomized, controlled trials suggest that preventing chlamydial infection reduces the incidence of PID.^[45] In addition, all sexual partners of women with PID should be treated empirically for C trachomatis and N gonorrhoeae if they have had sexual contact with the patient in the 60 days preceding the onset of her symptoms. Additionally, the 2010 CDC guidelines recommend that if a patient last had sexual intercourse more than 60 days before onset of symptoms or diagnosis, the most recent sex partner should be treated. Urethral gonococcal or chlamydial infection in the partner is highly likely and is frequently asymptomatic in men. Even in clinical settings where men do not receive treatment, arrangements for care or referral of male sex partners should be made. Regardless of whether a woman’s sex partners were treated, women diagnosed with chlamydial or gonococcal infection should follow up with repeat testing within 3-6 months, as these women have a high rate of reinfectionwithin6months of treatment.^[36]

Improved education, routine screening, diagnosis, and empirical treatment of these infections should decrease the incidence and prevalence of these processes and the incidence of long-term sequelae. Education should concentrate on strategies to prevent PID and STIs, including reducing the number of sexual partners, avoiding unsafe sexual practices, and routinely using appropriate barrier protection. Adolescents should be advised to delay the onset of sexual activity until age 16 years or older, as they are at an increased risk for PID.

Women with PID should be counseled to abstain from sexual activity, or be educated to strictly and appropriately use barrier protection, until their symptoms and those of their partner^[36] have fully abated and they have completed their entire treatment regimen.

Based on published data, the US Preventive Services Task Force (USPSTF) recommends screening for chlamydia in all sexually active, nonpregnant women up to age 25 years and in nonpregnant women aged 25 years or older who are at increased risk (grade A recommendation), as well as in all pregnant women up to age 25 years and in pregnant women aged 25 years or older who are at increased risk (grade B recommendation). The USPSTF recommends against routine screening for women aged 25 years and older, whether or not they are pregnant, if they are not at increased risk (grade C recommendation).

The USPSTF does not provide recommendations for chlamydia screening in men, due to insufficient evidence regarding benefits and risks.^[46] However, a 2008 demonstration project suggested that the combination of partner notification and the screening of men with a relatively high prevalence of chlamydia and a larger number of partners would be more cost-effective than expanding screening to low-risk women.^[47]

Patients treated for STIs and PID may be noncompliant with medication regimen because of low medical literacy and may not understand their diagnosis. These individuals frequently do not follow up or notify partners. Patients should be fully educated about these issues, as well as about the advisability of testing and treatment for other STIs, including HIV, hepatitis, and syphilis. In particular, the 2010 CDC guidelines state that HIV testing should be offered to all women diagnosed with acute PID.^[36]