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Acute pelvic inflammatory disease

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 Review Article
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Acute pelvic inflammatory disease

Donald E. Greydanus1, Flora Bacopoulou2
1
Department of Pediatric & Adolescent Medicine, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI, USA;
2
Center for Adolescent Medicine and UNESCO Chair on Adolescent Health Care, First Department of Pediatrics, School of Medicine, National
and Kapodistrian University of Athens, Aghia Sophia Children’s Hospital, Athens, Greece
Contributions: (I) Conception and design: All authors (II) Administrative support: All authors; (III) Provision of study materials or patients: None;
(IV) Collection and assembly of data: All authors; (V) Data analysis and interpretation: All authors; (VI) Manuscript writing: All authors; (VII) Final
Approval of manuscript: All authors.
Correspondence to: Donald E. Greydanus. Department of Pediatric & Adolescent Medicine, Western Michigan University Homer Stryker M.D.
School of Medicine, 1000 Oakland Drive, Kalamazoo, MI 49008-1284, USA. Email: [email protected].

Abstract: Pelvic inflammatory disease (PID) is an upper genital tract infection in females that is typically
acquired via sexual activity. It usually is initiated by the presence of Chlamydia trachomatis and/or Neisseria
gonorrhoeae and escalates into a polymicrobial infection from local genital tract flora. Research identifies
various known risk factors including young age, immunopathology and others. This article reviews the
epidemiology, differential diagnosis, management, and concepts of prevention for PID.

Keywords: Pelvic inflammatory disease (PID); genital infection; sexually transmitted disease (STD); adolescents;
sexual activity

Received: 03 June 2019; Accepted: 01 July 2019; published: 30 July 2019.

doi: 10.21037/pm.2019.07.05
View this article at: http://dx.doi.org/10.21037/pm.2019.07.05

Introduction in the lower genital tract that ascend to infect the

uterus, fallopian tubes and ovaries. PID often becomes
Pelvic inflammatory disease (PID) is a major sexually
a polymicrobial infection due to the presence of various
transmitted disease typically involving sexually active
vaginal-cervical endogenous microbes (1,2).
adolescent and young adult females (1). Its presentation can
be confusing with an extensive differential diagnosis. This
discussion considers principles of PID management based Epidemiology
on guidelines from the United States Centers for Disease There are approximately one million PID cases that are
Control and Prevention (U.S. CDC) and the World identified each year in the U.S. and approximately one-
Health Organization (WHO). Specific factors need specific third are diagnosed in adolescent females. After a steady
consideration in the management of PID; these include the decline in initial office visit for PID until 2014, a rising
presence of human immunodeficiency virus infection, use trend is recently reported (Figure 2). Finding precise PID
of intrauterine devices (IUDs), incarceration, and sexual epidemiologic figures can be challenging due to differences
violence. in surveillance in various regions as well as countries,
natural variation in PID prevalence, and difficulty of
distinguishing cervicitis from overt PID (1,3,4).
Definition

PID is generally a sexually transmitted disease characterized

Pathophysiology
by upper genital tract infection in females (1) (Figure 1). It
is often initiated by the presence of Neisseria gonorrhoeae (N. Classic PID is an infection that begins in the cervical-
gonorrhoeae) and/or Chlamydia trachomatis (C. trachomatis) vaginal region and ascends to the upper genital tract

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Page 2 of 10 Pediatric Medicine, 2019

Female reproductive system Table 1 Microbes associated with in pelvic inflammatory disease
Chlamydia trachomatis
Uterus Endometrium
Neisseria gonorrhoeae
Fallopian tube
Gardnerella vaginalis

Haemophilus influenzae

Bacteroides species (B. fragilis, bivius, disiens)

Mycoplasma genitalium
Ovary
Group B streptococcus (S. agalactiae)
Vagina Cervix
Coliforms (Enterobacteriaceae)
Myometrium
Peptostreptococcus

Streptococcus faecalis

Figure 1 Female reproductive system. Source: https://www. Ureaplasma urealyticum

womenshealth.gov/files/images/female-reproductive-system.jpg Neisseria meningitides
accessed 5/31/2019. A federal government website managed by the
Mycoplasma hominis
Office on Women’s Health in the Office of the Assistant Secretary
for Health at the U.S. Department of Health and Human Services. Enterococcus

Cytomegalovirus

Other anaerobes
200
Visits (in thousands)

150

100
adhesions (6).
50 Studies reveal that C. trachomatis-induced PID is more
0 frequent in the 16- to 24-year old female [versus Neisseria
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 gonorrhoeae (N. gonorrhoeae) initiation] (3). Microbiology
Year
findings of PID research show that C. trachomatis is found
Figure 2 Pelvic inflammatory disease—initial visits to physicians’ in up to 43% (10–43%) of PID cases and N. gonorrhoeae
offices among women aged 15–44 years, United States, 2007–2016. is noted in up to 50% (25–50%). Other microbes are seen
Source: National Disease and Therapeutic Index, IMS Health, in 30% of PID cases; these include enteric and respiratory
Integrated Promotional Services™, IMS Health Report, 1966– microbes, cervical pathogens (i.e., Mycoplasma genitalium),
2016. Content source: Division of STD Prevention, National bacterial vaginosis agents, and other bacteria (i.e., anaerobic
Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, and facultative) (Table 1).
Centers for Disease Control and Prevention (https://www.cdc.
gov/std/stats17/figures/a.htm, accessed 5/31/2019). STD, sexually
Risk factors
transmitted disease; TB, tuberculosis.
Research has identified a number of risk factors in PID
development that include young age (i.e., adolescence or
resulting in a combination of features; these include acute young adulthood), ectropion of young adolescent females,
salpingitis, perihepatitis, endometritis, oophoritis, pelvic immature immune system, multiple coital partners,
peritonitis and/or tubo-ovarian abscess (TOA) (1,2,5). ineffective condom usage, past PID, presence of bacterial
Scarring, adhesions and obstruction of the fallopian tubes vaginosis, vaginal douching, coitus during menstruation,
may result from PID-induced inflammation. Loss of the and history of non-barrier contraception (1).
ciliary epithelial cells of the fallopian tube impairs ovum The highest PID prevalence is found in adolescent
transport and augments the risk for infertility as well as females 15 to 19 years of age who initiate their coital
ectopic pregnancy; chronic pelvic pain may develop due to experience early in adolescence (Figure 3), have multiple

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Pediatric Medicine, 2019 Page 3 of 10

Table 2 Factors associated with C. trachomatis-induced fallopian and young adults may be reluctant to seek timely medical
tube damage care if there is a history of sexual violence. Psychological
Stimulation of the innate immune receptor with Toll-like receptor 1 support is needed by caring and understanding health
Anti-C trachomatis antibodies (i.e., 60-kDa heat shock protein 60) care professionals to provide beneficial support in such
+ potentially difficult circumstances.
CD4 T cell responses

Immune responses of TH1

Incarceration
Immune responses of TH17
C. trachomatis, Chlamydia trachomatis. Adolescents in jail or jail-like facilities have an increased
incidence of C. trachomatis, N. gonorrhoeae, PID and other
sexually transmitted infections (STIs) (1). Thus, it is
coital partners, and fail to utilize effective contraception important to provide robust STI screening programs to
or contraceptive methods in a recommenced manner (1,7). these youths with appropriate treatment as well (18).
An additional risk factor for young adolescent females is
the presence of immature cervix that contains columnar
Lesbian, bisexual, and transgender youth
epithelium transitional zone that can be a positive milieu for
N. gonorrhoeae and C. trachomatis. Other youth who may be reluctant to seek healthcare for
Trauma to the endocervical canal from an IUD may their sexuality issues include those who identify as lesbian,
facilitate the ascent of microorganisms into the endometrial bisexual and transgender; also, medical practitioners may
cavity. Multifilament IUD tails strings were implicated assume that some of these persons are not at risk for PID
earlier with increased risk for infection; however, current (19,20). Thus, medical practitioners caring for all youth
research reveals that PID risks do not rise with insertion must be vigilant for the health care needs of all their young
of monofilament tail string IUDs (1,8). Even so, expert patients and obtain a careful as well as detailed history on
recommendations for the placement of IUDs in adolescent their medical needs (21).
females usually state that C. trachomatis and N. gonorrhoeae
screening occur when inserting the IUD (9,10). HIV
Complicating the PID in the adolescent females is their
immature immune system; this includes the immaturity of Females diagnosed with PID should be screened for other
antibody and CD4+ T cell responses that fail to eliminate STIs including HIV and also for being victims of sexual
C. trachomatis and the resultant potential for a silent violence (22,23). Management of females with PID in
infection (11). Chronic fallopian tube damage can result women with HIV is similar to those without associated
from chronic inflammation due to various factors that HIV; however, some data suggests that this combination of
include cell-autonomous immunity and the effects of disorders may induce an increase in concomitant infection
interstitial or stromal cells (i.e., telocytes) (Table 2) (1,12-14). with certain microbes (i.e., streptococci, Mycoplasma hominis)
Not only can repeated C. trachomatis infection lead as well as increased risk for TOA (24).
to fallopian tube damage, but tubal injury may occur
from N. gonorrhoeae via release of lytic transglycosylases Clinical features
(LTg) (1). LTgA and LTgD can induce the development
A wide variety of symptoms can be seen in females with PID
and release of peptidoglycans that can damage fallopian
and thus, accurate diagnosis can be clinically challenging (1).
tube cells (15,16).
Patients may exhibit few or no symptoms, whereas others
have acute, serious illness. The most common presenting
Specific considerations complaint is lower abdominal pain. Gonorrheal PID is
the most severe form whereas chlamydial PID is more
Sexual violence
likely to be subclinical with little or no symptoms, but with
Individuals may be hesitant to get medical care if they have potentially adverse long-term consequences (6). In a sample
been victims of sexual violence including rape (17). Medical of endometrial biopsies, 13% females with PID were
practitioners should understand that these adolescents diagnosed with subclinical PID (25,26). Although sparse

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Page 4 of 10 Pediatric Medicine, 2019

30.0 bleeding and/or dyspareunia (1-3,5). Others include fever,

n=1,171 chills, and protean gastrointestinal symptoms (i.e., nausea,
Lifetime PID prevalence

25.0 23.6

20.0
emesis, constipation, and diarrhea). The condition can
also manifest with an acute abdominal crisis with rebound
15.0
tenderness and reduced bowel sounds. A pelvic examination
10.0 8.9
may reveal cervical motion tenderness and there may or
4.9 4.6
5.0 2.7 may not be uterine or adnexal tenderness (1-3,5).
0.0 Studies reveal that about 4% (3–10%) of those with
<12 12–13 14–15 16–17 ≥18 PID also have Fitz-Hugh-Curtis syndrome (perihepatitis)
Age at sexual debut in years
due to the spread of the lower genital tract inflammation/
Figure 3 Prevalence of self-reported lifetime PID and age of infection in the paracolic gutter that induces inflammation
sexual debut. In NHANES 2013–2014, 1,171 sexually experienced of the liver’s Glisson’s capsule and local peritoneum (1).
women 18–44 years of age were interviewed regarding a lifetime Perihepatitis symptomatology includes fever, nausea,
diagnosis of PID. This graph shows the correlation of age of sexual emesis, abdominal pain (right upper quadrant pain), right
debut and lifetime prevalence of PID. Source: US Centers for pleural effusion and/or right shoulder pain (1,27-31). In
Disease Control and Prevention: Kreisel K, Torrone E, Bernstein such cases there is typically right upper quadrant tenderness
K, et al. Prevalence of Pelvic Inflammatory Disease in Sexually but no lower abdominal pain. Medical practitioners should
Experienced Women of Reproductive Age - United States, 2013- consider perihepatitis (Fitz-Hugh-Curtis syndrome) in sexually
2014. MMWR Morb Mortal Wkly Rep 2017;66:80-3. PID, pelvic active females who have right upper quadrant pain (32). Severe
inflammatory disease; NHANES, National Health and Nutrition infection with N. gonorrhoeae may progress to disseminated
Examination Survey. gonococcal infection (Figure 5).

Diagnosis

Diagnostic criteria for PID from the U.S. CDC are listed
in Table 3 that include minimal criteria, additional criteria
and specific criteria (24) (Figure 6). All females suspected of
PID should be tested for N. gonorrhoeae and C. trachomatis
infection using nucleic acid amplification tests. Although
the diagnosis of PID in most cases is based on clinical
findings, when indicated, it can be aided by the following:
laparoscopy (81% sensitivity versus 100% specificity),
magnetic resonance imaging, transvaginal sonography (30%
Figure 4 Chlamydia trachomatis infection. This image depicts a sensitivity versus 67% specificity), and endometrial biopsy
colposcopic view of a female patient’s cervix, which had manifested (74% sensitivity versus 84% specificity) (1,24,32).
signs of erosion and erythema, due to a Chlamydia trachomatis The diagnosis of PID in emergency rooms and clinics is
infection. If left untreated, chlamydia infection can cause severe, often based on clinical criteria, with or without additional
costly reproductive, and other health problems. Both short- and laboratory and imaging tests (33). Clinical findings have
long-term consequences can ensue, including pelvic inflammatory a sensitivity of 87% and a specificity of 50% versus 83%
disease (PID), infertility, and potentially fatal, ectopic tubal sensitivity and 26% specificity of endometrial culture
pregnancies. (1,2,24,32).
Table 4 lists the differential diagnosis of PID and reveals
the clinical challenge that can arise in a sexually active
symptoms may be seen in PID, its classic presentation is female with PID-like symptoms. Many possibilities must
vaginal (cervical) discharge (Figure 4) and lower abdominal be considered including genitourologic, gynecologic,
(lower quadrant; pelvic) pain (1). gastrointestinal, rheumatologic, hematologic and others
Other features of PID include vaginal bleeding, urinary (1,24,32). A pregnancy test should be performed to exclude
symptoms (i.e., dysuria, urinary frequency), post-coital the possibility of ectopic pregnancy. An augmented level of

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Pediatric Medicine, 2019 Page 5 of 10

Table 3 U.S. CDC 2015 Diagnostic criteria for pelvic inflammatory disease (24)
Category of criteria Specific criteria data

Minimal criteria (≥1) Cervical motion tenderness, or uterine tenderness, or adnexal tenderness

Additional criteria Oral temperature over 101 ℉ (over 38.3 ℃)

(≥1 to support minimal criteria for PID)
Abnormal cervical mucopurulent discharge or cervical friability

Presence of abundant numbers of WBC on saline microscopy of vaginal fluid

Elevated erythrocyte sedimentation rate

Elevated C-reactive protein; and

Laboratory documentation of cervical infection with N. gonorrhoeae or C. trachomatis

Most specific criteria Endometrial biopsy with histopathological evidence of endometritis

Findings of PID on laparoscopy

Ultrasound (transvaginal) or magnetic resonance imaging showing fallopian tubes that are
thick and filled with fluid; may be free fluid in the pelvis or a tubo-ovarian complex; or

Doppler studies suggestive of pelvic infection via tubal hyperemia

U.S. CDC, United States Centers for Disease Control and Prevention; PID, pelvic inflammatory disease.

Figure 6 Gram stain positive for N gonorrhoeae. This Gram-

stained photomicrograph reveals the presence of intracellular
Gram-negative, Neisseria gonorrhoeae diplococcal bacteria, amongst
numerous white blood cells (WBCs) known as polymorphonuclear
leukocytes, or PMNs (https://phil.cdc.gov/Details.aspx?pid=15018,
Figure 5 Cutaneous gonococcal lesion. This patient presented accessed 5/31/2019).
with a cutaneous gonococcal lesion due to a disseminated Neisseria
gonorrhoeae bacterial infection. Though a sexually transmitted
disease, if a gonorrhoeae infection is allowed to go untreated, the In virginal adolescents, PID may originate from the lower
Neisseria gonorrhoeae bacteria responsible for the infection can genital tract, urinary tract, gastrointestinal tract and may be
become disseminated throughout the body, forming lesions in associated with genital or other anomalies (39).
extra-genital locations (https://phil.cdc.gov/Details.aspx?pid=6384,
accessed 5/31/2019).
Treatment

serum procalcitonin can be a marker for TOA (34). Medical Treatment of PID involves an early diagnosis along with
practitioners must also consider that PID can develop in the recognized protocols such as the 2001 WHO (40)
non-sexually active females in uncommon cases (35-38). (Table 5) or the 2015 CDC sexually transmitted diseases

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Page 6 of 10 Pediatric Medicine, 2019

Table 4 Differential diagnosis of pelvic inflammatory disease guidelines (Table 6) (24). Such antibiotic courses cover
Acute intermittent porphyria various microbes seen in PID such as C. trachomatis, N.
Adnexal torsion
gonorrhoeae, Mycoplasma genitalium, and various facultative/
anaerobic bacteria (1,24). Use of these recommended
Appendicitis
antibiotics should lead to observable symptomatology
Constipation improvement in two to three days that includes no fever,
Cystitis (urinary tract infection) reduction in abdominal pain (tenderness, rebound), and
reduced pelvic pain (less cervico-utero-adnexal motion
Diverticulitis
tenderness). Table 7 lists indications for hospitalization.
Dysmenorrhea Intravenous antibiotics can be converted to oral
Endometriosis administration after 24 hours of improvement. The use of
Ectopic pregnancy metronidazole can also treat bacterial vaginosis that may
also be present (1). Oral use of doxycycline is preferred
Fallopian tube torsion
since intravenous administration of this antibiotic can be
Functional abdominal pain quite painful (1).
Gastroenteritis (as due to Yersinia enterocolitica or A variety of problems arise in treatment including
Campylobacter fetus) increasing bacterial resistance to antibiotics, i.e., quinolone-
Genital trauma resistant N. gonorrhoeae (QRNG) and reduced efficacy
of third-generation cephalosporins (1,41). Therefore,
Henoch-Schonlein syndrome
quinolones are no longer recommended for the treatment
Hemolytic-uremic syndrome of gonorrhoeae (41,42). The ease of travel across regions and
Inflammatory bowel disease countries has led to continuous changes in other bacteria
Irritable bowel disease as well—such as the prevalence and antibiotic resistances
of Mycoplasma genitalium, Ureaplasma urealyticum and
Lead intoxication
others (43-45). Complicating this picture is the failure
Lupus serositis of some medical practitioners to follow established
Meckel’s diverticulum guidelines (46-49).
Mesenteric lymphadenitis
Careful management of PID is important to reduce
discomfort, improve symptoms as soon as possible, and
Mesenteric vascular disease
potentially reduce the complications that include chronic
Ovarian cyst (with or without torsion or rupture) pelvic pain, ectopic pregnancy and infertility (1,26,50). In
Ovarian neoplasm (including teratoma rupture) the classic research of Weström et al. dealing with a large
cohort of women, laparoscopic evaluations revealed a PID-
Ovulation (Mittelschmerz)
associated infertility rate of 16% (versus 2.7% in controls);
Pelvic adhesions
also, 9.1% of post-PID pregnancy were ectopic pregnancies
Pregnancy complication (versus 1.4% of controls) (50).
Pyelonephritis According to the WHO (51) and CDC (52) Medical
Eligibility Criteria for Contraceptive Use, there is
Reiter’s syndrome
insufficient evidence to recommend removal of the IUD
Septic abortion in the case of acute PID. However, close clinical follow-
Sickle cell crisis up is recommended if the IUD is left in place (53). Patients
Urethritis with PID should be tested for other STIs (including HIV).
Sexual partner/s should be evaluated and treated when
Ureterocele
indicated. The U.S. CDC recommends treatment of the
Urolithiasis PID patient’s sexual partner (s) over the past 2 months even

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Pediatric Medicine, 2019 Page 7 of 10

Table 5 Antibiotic management of PID (2001 WHO Model Prescribing Information: Drugs used in Bacterial Infections) (40)
Type of patient Recommended antibiotics

Ambulatory patients Ceftriaxone 250 mg IM in a single dose followed by doxycycline 100 mg orally every 12 hours for 10 days
(contraindicated during pregnancy), plus metronidazole 400–500 mg orally every 8 hours for 10 days
(contraindicated during pregnancy)

Hospitalized patients with Ceftriaxone 25 mg IM every 12 hours for at least 4 days (or for 48 hours after clinical improvement occurs),
moderate or severe disease followed by doxycycline 100 mg orally every 12 hours for 10–14 days (contraindicated during pregnancy)

Hospitalized patients with Gentamicin 5–7 mg/kg IV or IM every 24 hours or 1.5–2.0 mg/kg IV or IM every 8 hours for at least 4 days
very severe disease (or for 48 hours after clinical improvement occurs; contraindicated during pregnancy; plus clindamycin
900 mg IV every 8 hours for at least 4 days (for 48 hours after clinical improvement occurs) followed by
doxycycline 100 mg orally every 12 hours for 10–14 days (contraindicated during pregnancy)
PID, pelvic inflammatory disease; IM, intramuscular; IV, intravenous.

Table 6 Antibiotic management of PID: U.S. CDC 2015 STI guidelines

Method of delivery Recommended antibiotics

Oral/intramuscular Ceftriaxone 250 mg IM in a single dose or cefoxitin 2 g IM in a single dose and probenecid 1 g orally
concurrently or other parenteral third generation cephalosporin (as ceftizoxime or cefotaxime); plus doxycycline
100 mg orally twice a day for 14 days with or without metronidazole 500 mg orally twice a day for 14 days

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

Regimen B: clindamycin 900 mg IV every 8 hours plus gentamicin loading dose IV or IM (2 mg/kg body weight)
followed by a maintenance dose (1.5 mg/kg) every 8 hours. Single daily dosing (3–5 mg/kg) can be substituted

Alternative: ampicillin/Sulbactam 3 g IV every 6 hours plus doxycycline 100 mg orally or IV every 12 hours
U.S. CDC, United States Centers for Disease Control and Prevention; STI, sexually transmitted infection; PID, pelvic inflammatory disease;
IM, intramuscular; IV, intravenous.

Table 7 Considerations for hospital-based treatment for PID Prevention

High fever
Various STI/PID screening programs have been utilized
Intractable nausea or vomiting around the world over the past few decades such as that
(including loss of medications due to vomiting)
of the annual C. trachomatis screening recommended by
Inability to follow outpatient protocols the U.S. Preventive Service Task Force (USPSTF) for
Pregnancy all sexually active females under age 26 years of age (54).
Medical practitioners can also recommend screening
Possibility of appendicitis or other surgical emergency
utilizing the “self-taken swab” that is done by the person
Tubo-ovarian abscess being screened in which the examination of the swab can
Failure of oral antimicrobial therapy detect both C. trachomatis and N. gonorrhoeae with nucleic
PID, pelvic inflammatory disease. acid amplification technology (55,56). One study noted a
56% lowering of PID incidence in sexually active females (18
to 34 years of age) who received appropriate C. trachomatis
though they may be asymptomatic; principles of expedited screening (57). Limitations to such success of screening
partner therapy (EPT) are suggested (1,24). The treated programs may occur if the screening is limited, medical
PID patient should be seen in 3 to 6 months post-treatment practitioners are not motivated to provide/encourage such
and provided with further sexuality education (1,24). policies, or public health officials in various countries view

© Pediatric Medicine. All rights reserved. Pediatr Med 2019;2:36 | http://dx.doi.org/10.21037/pm.2019.07.05

Page 8 of 10 Pediatric Medicine, 2019

Table 8 Strategies for prevention of pelvic inflammatory disease

Education to delay adolescent coital activity

Education about correct condom use

Education of potential cause of abdominal pain and need for medical evaluation in such situations

Comprehensive sexuality education in schools

Include sexuality education to those at high-risk for STIs—runaway teens, incarcerated teens

Further research on immunological defenses for infections

Further research on vaccines for STIs (as C. trachomatis and N. gonorrhoeae)

STI, sexually transmitted infection; C. trachomatis, Chlamydia trachomatis; N. gonorrhoeae, Neisseria gonorrhoeae.

such programs as too costly (58-60). Table 8 lists other References

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doi: 10.21037/pm.2019.07.05
Cite this article as: Greydanus DE, Bacopoulou F. Acute
pelvic inflammatory disease. Pediatr Med 2019;2:36.

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