PELVIC INFLAMMATORY DISEASE (PID)

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DESCRIPTION

PID includes salpingitis with or without oöphoritis and, as precise clinical localisation is often difficult, denotes the spectrum of conditions resulting from infection of the upper genital tract.

Sequelae include:

»     recurrent infections if inadequately treated,

»      infertility,

»             increased probability of ectopic pregnancy, and »       chronic pelvic pain.

Stage   Manifestations
Stage I » cervical motion tenderness and/or uterine tenderness and/or adnexal tenderness
Stage II » as stage 1, plus pelvic peritonitis
Stage III » as stage II, plus
  » tubo-ovarian complex or abscess
Stage IV » generalised peritonitis
  » ruptured tubo-ovarian complex
  » septicaemia

GENERAL MEASURES

Hospitalise all patients with stage II–IV PID for parenteral antibiotic therapy. Frequent monitoring of general abdominal and pelvic signs is essential.

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Note:

Remove IUCDs.

Test and, if necessary, treat patient for syphilis and offer HIV testing.

Perform a pregnancy test as an ectopic pregnancy forms part of the differential diagnosis.

 

In stage III, surgery is indicated if:

»     the diagnosis is uncertain,

»    there is no adequate response after 48 hours of appropriate therapy,

»     the patient deteriorates on treatment, or

»    after 4–6 weeks there still is a large or symptomatic pelvic mass.

MEDICINE TREATMENT

STAGE I

  • Doxycycline, oral, 100 mg 12 hourly for 10 days. PLUS
  • Ceftriaxone, IM, 250 mg as a single dose. PLUS
  • Metronidazole, oral, 400 mg 12 hourly for 10 days.

STAGE II–IV

  • Ceftriaxone, IV, 250 mg as a single dose.
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Followed by:

  • Benzylpenicillin (Penicillin G), IV, 2 million units 6 hourly.

PLUS

  • Gentamicin, IV, 6 mg/kg daily.

PLUS

  • Metronidazole, IV, 500 mg 8 hourly.

 

Continue intravenous therapy until there is definite clinical improvement.

Thereafter, change to:

  • Amoxicillin/clavulanic acid, oral, 875/125 mg 12 hourly to complete 10 days’ therapy.

PLUS

To treat chlamydia:

  • Doxycycline, oral, 100 mg 12 hourly for 10 days.

Note:

The addition of metronidazole to amoxicillin/clavulanic acid is unnecessary as amoxicillin/clavulanic acid has adequate anaerobic cover.

Penicillin allergy:

  • Ceftriaxone 250 mg IV as a single dose.

If severe penicillin allergy: Ciprofloxacin, oral, 500 mg.

PLUS

  • Clindamycin, IV, 600 mg 8 hourly. PLUS
  • Gentamicin, IV, 6 mg/kg daily.

Continue intravenous therapy until there is definite clinical improvement.

Thereafter, change to:

  • Doxycycline, oral, 100 mg 12 hourly for 10 days.
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PLUS 

Metronidazole, oral, 400 mg 8 hourly for 10 days.

REFERRAL

»      Stages III and IV should be managed in consultation with a gynaecologist.

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