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INTRODUCTION
An upper genital tract infection that causes :
Uterus ( Endometritis) Fallopian tubes (Salpingitis) Ovaries (oophoritis), Pelvic peritonitis Tubo-ovarian abscess
A common and serious complication of STDs . Due to : ascending spread of microorganisms from vagina & endocervix to endometrium, tubes, contiguous structures Incidence acute PID 1-2% of young sexually active women each year
Anaerobic bacterial species found in the vagina, particularly Bacteroides spp., Anaerobic gram-positive cocci, (Peptostreptococci), E. coli Mycoplasma hominis
RISK FACTORS
Age < 25 are more likely to develop PID than those older (Age of 1st intercourse)
Multiple sex partners Frequency of sex intercourse MS 33% nulliparous Douching regularly IUD (Dec in : barrier and OC methods )
SYMPTOMS
lower abdomen pain, usually bilateral lower back pain Dyspareunia pain during or after sex bleeding between periods or after sex Menometrorrhagia sense of pressure or swelling in the lower abdomen fever (often with chills) feeling tired or unwell abnormal vaginal discharge nausea, vomiting and dizziness leg pain increased period pain increased pain at ovulation dysuria, frequently urination
INVESTIGATION
- Laboratory studies : CBC ,ESR , CRP
Laboratory may be entirely normal An elevated leukocyte count does not distinguish PID from other diagnoses - Vaginal & cervical swab : Cervical cultures for gonorrhea or Chlamydia require 3-7 days for results -ve gram smear not R/O PID - Imaging studies : U/S, CT, MRI Pelvic ultrasonography can detect pelvic abscesses - HIV and syphilis testing should be recommended
- Laparoscopy
most accurate method for confirm PID all pt. with uncertain dx, not response to Rx
CLINICAL CRITERIA
Major criteria Minor criteria
Gram stain of Neisseria gonorrhoeae, The bacteria are diplococci association with host pmn's (polymorphonuclear leukocytes).
DIFFERENTIAL DIAGNOSIS
Appendicitis Gastroenteritis Cholecystitis Irritable bowel syndrome Ectopic pregnancy Hemorrhagic ovarian cyst Ovarian torsion Endometriosis Nephrolithiasis Somatization
s/s ; RUQ pain, pleuritic pain, tenderness at RUQ on palpation of the liver mistaken dx ; acute cholecystitis, pneumonia
( Fitz-Hugh-Curtis syndrome)
Perihepatic adhesions (arrow) usually associated with pelvic gonorrhoeal or chlamydial infection (Fitz-Hugh-Curtis syndrome).
REGIMEN B
Ceftriaxone 250 mg IM in a single dose + Doxycycline 100 mg orally twice a day for 14 days WITH OR WITHOUT Metronidazole 500 mg orally twice a day for 14 days 2. Cefoxitin 2 g IM single dose and Probenecid, 1 g orally administered concurrently single dose + Doxycycline 100 mg orally twice a day for 14 days WITH OR WITHOUT Metronidazole 500 mg orally twice a day for 14 days 3. Third-generation cephalosporin + Doxycycline 100 mg orally twice a day for 14 day WITH OR WITHOUT Metronidazole 500 mg orally twice a day for 14 days
Levofloxacin 500 mg once daily for 14 days OR Ofloxacin 400 mg twice daily for 14 days
INPATIENT TREATMENT
Regimen A
Doxycycline 100 mg
Cefoxitin 2 g IV every 6 hours + orally or IV every 12 hours
REGIMEN B
Clindamycin 900 mg IV every 8 hours
Gentamicin loading dose (2 mg/kg ) IV or IM followed by a maintenance 14 days dose (1.5 mg/kg) every 8 hours
SURGERY
Laparoscopy
consider in all pt with ddx of PID & without contraindication R/O surgical emergency surgical emergencies failure medical treatment
Laparotomy for
Evidence of current / previous abscess Acute exacerbation of PID with bilateral TOA
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