# Presentation: 653144

## Pelvic Inflammatory Disease (PID)

## Learning Objectives

- Upon completion of this content, the learner will be able to:
- Describe the epidemiology of PID in the U.S.
- Describe the pathogenesis of PID.
- Discuss the clinical manifestations of PID.
- Identify the clinical criteria used in the diagnosis of PID.
- List CDC-recommended treatment regimens for PID.
- Summarize appropriate prevention counseling messages for a patient with PID.
- Describe public health measures to prevent PID.

## Lessons

- Epidemiology: Disease in the U.S.
- Pathogenesis
- Clinical manifestations
- PID diagnosis
- Patient management
- Prevention

## Lesson I: Epidemiology: Disease in the U.S.

## Pelvic Inflammatory Disease

- Clinical syndrome associated with ascending spread of microorganisms from the vagina or cervix to the endometrium, fallopian tubes, ovaries, and contiguous structures.
- Comprises a spectrum of inflammatory disorders including any combination of endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis.

- Epidemiology

## Incidence and Prevalence

- Occurs in approximately 1 million U.S. women annually.
- Annual cost exceeds $4.2 billion.
- Surveillance and reporting limited by insensitive and nonspecific diagnosis and underreporting.
- Hospitalizations declined through the 80s and early 90s; have remained constant since 1995.
- Reported number of initial visits to physicians’ offices has remained unchanged since 1998.

- Epidemiology

## Pelvic inflammatory disease — Hospitalizations of women 15 to 44 years of age: United States, 1980–2002

- Note: The relative standard error for the estimates of the overall total number of PID cases range from 6% to 18%.
- SOURCE: National Hospital Discharge Survey (National Center for Health Statistics, CDC)

- Epidemiology

## Pelvic inflammatory disease — Initial visits to physicians’ offices by women 15-44 years of age: United States, 1980–2003 

- SOURCE: National Disease and Therapeutic Index (IMS Health)

- Pelvic inflammatory disease — Initial visits to physicians’ offices by women 15-44 years of age: United States, 1980–2003

- Epidemiology

## Risk Factors

- Adolescence
- History of PID
- Gonorrhea or chlamydia, or a history of gonorrhea or chlamydia
- Male partners with gonorrhea or chlamydia
- Multiple partners
- Current douching
- Insertion of IUD
- Bacterial vaginosis
- Demographics (socioeconomic status)
- Oral contraceptive use (in some cases)

- Epidemiology

## Normal Cervix with Ectopy

*Source*: Seattle STD/HIV Prevention Training Center at the University of Washington/
- Claire E. Stevens

- Epidemiology

## Lesson II: Pathogenesis

## Microbial Etiology 

- Most cases of PID are polymicrobial
- Most common pathogens:
*N. gonorrhoeae*:  recovered from cervix in 30%-80% of women with PID
*C. trachomatis*:  recovered from cervix in 20%-40% of women with PID
*N. gonorrhoeae* and *C. trachomatis *are present in combination in approximately 25%-75% of patients

- Pathogenesis

## Pathway of Ascendant Infection

*Cervicitis*

*Endometritis*

*Salpingitis/ oophoritis/ tubo-ovarian abscess*

*Peritonitis*

- Pathogenesis

## Normal Human Fallopian Tube Tissue

*Source*: Patton, D.L. University of Washington, Seattle, Washington

- Pathogenesis

## C. trachomatis Infection (PID)

*Source*: Patton, D.L. University of Washington, Seattle, Washington

- Pathogenesis

## Lesson III: Clinical Manifestations

## PID Classification

**Overt**
**40%**

- Clinical Manifestations

## Sequelae

- Approximately 25% of women with a single episode of PID will experience sequelae, including ectopic pregnancy, infertility, or chronic pelvic pain
- Tubal infertility occurs in 50% of women after three episodes of PID

- Clinical Manifestations

## Lesson IV: PID Diagnosis

## Minimum Criteria in the Diagnosis of PID

- Uterine/adnexal tenderness or
- Cervical motion tenderness

- Diagnosis

## Additional Criteria to Increase Specificity of Diagnosis

- Temperature >38.3°C (101°F)
- Abnormal cervical or vaginal mucopurulent discharge
- Presence of WBCs on saline wet prep
- Elevated erythrocyte sedimentation rate (ESR)
- Elevated C-reactive protein (CRP)
- Gonorrhea or chlamydia test positive

- Diagnosis

## Mucopurulent Cervical Discharge(Positive swab test) 

*Source*:Seattle STD/HIV Prevention Training Center at the University of Washington/
- Claire E. Stevens and Ronald E. Roddy

- Diagnosis

## More Specific Criteria

- Endometrial biopsy
- Transvaginal sonography or MRI
- Laparoscopy

- Diagnosis

## Lesson V: Patient Management

## General PID Considerations

- Regimens must provide coverage of *N. gonorrhoeae*, *C. trachomatis*, anaerobes, Gram-negative bacteria, and streptococci
- Treatment should be instituted as early as possible to prevent long term sequelae

- Management

## Criteria for Hospitalization

- Inability to exclude surgical emergencies
- Pregnancy
- Non-response to oral therapy
- Inability to tolerate an outpatient oral regimen
- Severe illness, nausea and vomiting, high fever or tubo-ovarian abscess
- HIV infection with low CD4 count

- Management

## Oral Regimens

**CDC-recommended oral regimen A**
- Ofloxacin 400 mg orally 2 times a day for 14 days, OR
- Levofloxacin 500 mg orally 2 times a day for 14 days
*With or Without*
- Metronidazole 500 mg orally 2 times a day for 14 days
**CDC-recommended oral regimen B**
- Ceftriaxone 250 mg IM in a single dose, OR
- Cefoxitin 2 g IM in a single dose and Probenecid 1 g orally in a single dose, OR
- other parenteral third-generation cephalosporin (e.g., Ceftizoxime, Cefotaxime)
- PLUS Doxycycline 100 mg orally 2 times a day for 14 days
*With or Without*
- Metronidazole 500 mg orally 2 times a day for 14 days

- Management

## Follow-Up

- Patients should demonstrate substantial improvement within 72 hours.
- Patients who do not improve usually require hospitalization, additional diagnostic tests, and surgical intervention.
- Some experts recommend rescreening for *C. trachomatis* and *N. gonorrhoeae* 4-6 weeks after completion of therapy in women with documented infection with these pathogens.

- Management

## Parenteral Regimens

**CDC-recommended parenteral regimen A**
- Cefotetan 2 g IV every 12 hours, OR
- Cefoxitin 2 g IV every 6 hours
- PLUS doxycycline 100 mg orally or IV every 12 hours
**CDC-recommended parenteral regimen B**
- Clindamycin 900 mg IV every 8 hours
- PLUS gentamicin loading dose IV of IM (2 mg/kg), followed by maintenance dose (1.5 mg/kg) every 8 hours.  Single daily gentamicin dosing may be used.

- Management

## Parenteral Regimens (continued)

- Continue either of these regimens for at least 24 hours after substantial clinical improvement, then
- Complete a total of 14 days therapy with
- Doxycycline (100 mg orally twice a day) with regimen A or with
- Doxycycline or Clindamycin (450 mg orally 4 times a day), if using regimen B

- Management

## Alternative Parenteral Regimen

**CDC-recommended alternative parenteral regimen**
- Ofloxacin 400 mg IV every 12 hours, or
-  Levofloxacin 500 mg IV once daily
*With or Without*
- Metronidazole 500 mg IV every 8 hours, or
- Ampicillin/Sulbactam 3 g IV every 6 hours
- PLUS Doxycycline 100 mg orally or IV every 12 hours

- Management

## Lesson VI: Prevention

## Screening

- To reduce the incidence of PID, screen and treat for chlamydia.
- Annual chlamydia screening is recommended for:
- Sexually active women 25 and under
- Sexually active women >25 at high risk
- Screen pregnant women in the 1st trimester.

- Prevention

## Partner Management

- Male sex partners of women with PID should be examined and treated if they had sexual contact with the patient during the 60 days preceding the patient’s onset of symptoms.

- Prevention

## Partner Management (continued)

- Male partners of women who have PID caused by *C. trachomatis* or *N. gonorrhoeae* are often asymptomatic.
- Sex partners should be treated empirically with regimens effective against both *C. trachomatis* and *N. gonorrhoeae*, regardless of the apparent etiology of PID or pathogens isolated from the infected woman.

- Prevention

## Reporting

- Report cases of PID to the local STD program in states where reporting is mandated.
- Gonorrhea and chlamydia are reportable in all states.

- Prevention

## Patient Counseling and Education 

- Nature of the infection
- Transmission
- Risk reduction
- Assess patient's behavior-change potential
- Discuss prevention strategies
- Develop individualized risk-reduction plans

- Prevention

## Case Study

## History: Jane Wheels

- 24-year-old female who presents reporting lower abdominal pain, cramping, slight fever, and dysuria for 4 days
- P 1001, LMP 2 weeks ago (regular without dysmenorrhea). Uses oral contraceptives (for 2 years).
- Reports gradual onset of symptoms of lower bilateral abdominal discomfort, dysuria (no gross hematuria), abdominal cramping and a slight low-grade fever in the evenings for 4 days. Discomfort has gradually worsened.
- Denies GI disturbances or constipation. Denies vaginal d/c.
- States that she is happily married in a monogamous relationship. Plans another pregnancy in about 6 months. No condom use.
- No history of STDs. Reports occasional yeast infections.
- Douches regularly after menses and intercourse; last        douched this morning.

- Case Study

## Physical Exam

- Vital signs: blood pressure 104/72, pulse 84, temperature 38°C, weight 132
- Neck, chest, breast, heart, and musculoskeletal exam within normal limits. No flank pain on percussion. No CVA tenderness.
- On abdominal exam the patient reports tenderness in the lower quadrants with light palpation. Several small inguinal nodes palpated bilaterally.
- Normal external genitalia without lesions or discharge.
- Speculum exam reveals minimal vaginal discharge with a small amount of visible cervical mucopus.
- Bimanual exam reveals uterine and adnexal tenderness as well as pain with cervical motion. Uterus anterior, midline, smooth, and not enlarged.

- Case Study

## Questions

- What should be included in the differential diagnosis?
- What laboratory tests should be performed or ordered?

- Case Study

## Laboratory

**Results of office diagnostics: **
- Urine pregnancy test: negative
- Urine dip stick for nitrates: negative
- Vaginal saline wet mount: vaginal pH was 4.5. Microscopy showed WBCs >10 per HPF, no clue cells, no trichomonads, and the KOH wet mount was negative for budding yeast and hyphae.
- What is the presumptive diagnosis?
- How should this patient be managed?
- 5.  What is an appropriate therapeutic regimen?

- Case Study

## Partner Management

**Sex partner:  Joseph (spouse)**
- First exposure: 4 years ago
- Last exposure: 1 week ago
- Frequency: 2 times per week
- 	(vaginal only)
- 6.  How should Joseph be managed?

- Case Study

## Follow-Up

- On follow up 3 days later, Jane was improved clinically. The culture for gonorrhea was positive. The nucleic acid probe (DNA-probe) for chlamydia was negative.
- Joseph (Jane’s husband) came in with Jane at follow-up. He was asymptomatic but did admit to a "one-night stand" while traveling. He was treated. They were offered HIV testing which they accepted.
- Who is responsible for reporting this case to the local health department?
- 8. What are appropriate prevention counseling recommendations for this patient?

- Case Study