PID Curriculum

Pelvic Inflammatory Disease (PID)

PID Curriculum

Learning Objectives
Upon completion of this content, the learner will be able to: 1. 2. Describe the epidemiology of PID in the U.S. Describe the pathogenesis of PID.

3.
4. 5.

Discuss the clinical manifestations of PID.

Identify the clinical criteria used in the diagnosis of PID. List CDC-recommended treatment regimens for PID.

6.
7.

Summarize appropriate prevention counseling messages for a patient with PID.

Describe public health measures to prevent PID.
2

PID Curriculum

Lessons
I. II. III. IV. V. VI. Epidemiology: Disease in the U.S. Pathogenesis Clinical manifestations PID diagnosis Patient management Prevention
3

PID Curriculum

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

PID Curriculum

Epidemiology

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.
5

PID Curriculum

Epidemiology

Incidence and Prevalence

Occurs in approximately 1 million U.S. women annually. Annual cost exceeds $4.2 billion. No national surveillance or reporting requirements exist, and national estimates are limited by insensitive clinical diagnosis criteria. Rates of hospitalization has decreased 16% from 1985-2001. Ambulatory data also support a decrease in PID rates. PID cases are more likely to be diagnosed in ambulatory settings. The reported number of initial visits to physicians offices for PID generally declined from 1998 and 2007.
6

PID Curriculum

Pelvic inflammatory disease Hospitalizations of women 15 to 44 years of age: United States, 19972006 Hospitalizations (in thousands)
75 60 45 Acute, Unspecified Chronic 30 15 0 1997 98 99 2000 01 02 03 04 05 06

Note: The relative standard error for these estimates of the total number of acute unspecified PID cases ranges from 11.9% to 17.2%. The relative standard error for these estimates of the total number of chronic PID cases ranges from 11% to 18%. Data only available through 2006.
SOURCE: National Hospital Discharge Survey (National Center for Health Statistics, CDC)

PID Curriculum

Pelvic inflammatory disease Initial visits to physicians offices by women 15 to 44 years of age: United States, 19972007
Visits (in thousands) 300 240 180 120 60 0 1998 99 2000 01 02 03 04 05 06 07

Note: The relative standard error for these estimates ranges from 21.6% to 29.3%
8
SOURCE: National Disease and Therapeutic Index (IMS Health)

PID Curriculum

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 Oral contraceptive use (in some cases) Demographics (socioeconomic status)
9

PID Curriculum

Epidemiology

Normal Cervix with Ectopy

Source: Seattle STD/HIV Prevention Training Center at the University of Washington/

Claire E. Stevens
10

PID Curriculum

Lesson II: Pathogenesis

11

PID Curriculum

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
12

PID Curriculum

Pathogenesis

Pathway of Ascendant Infection

Cervicitis
Endometritis Salpingitis/ oophoritis/ tuboovarian abscess Peritonitis
13

PID Curriculum

Pathogenesis

Normal Human Fallopian Tube Tissue

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

14

PID Curriculum

Pathogenesis

C. trachomatis Infection (PID)

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

15

PID Curriculum

Lesson III: Clinical Manifestations

16

PID Curriculum

Clinical Manifestations

PID Classification
Subclinical/ silent 60% Mild to moderate symptoms 36%
Overt
40%

Severe symptoms 4%
17

PID Curriculum

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 8% of women after 1 episode of PID, in 20% of women after 2 episodes, and in 50% of women after 3 episodes.
18

PID Curriculum

Lesson IV: PID Diagnosis

19

PID Curriculum

Diagnosis

Minimum Criteria in the Diagnosis of PID

Uterine tenderness, or Adnexal tenderness, or Cervical motion tenderness

20

PID Curriculum

Diagnosis

Additional Criteria to Increase Specificity of Diagnosis

Temperature >38.3C (101F) Abnormal cervical or vaginal mucopurulent discharge Presence of abundant numbers of WBCs on saline microscopy of vaginal secretions Elevated erythrocyte sedimentation rate (ESR) Elevated C-reactive protein (CRP) Gonorrhea or chlamydia test positive
21

PID Curriculum

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
22

PID Curriculum

Diagnosis

More Specific Criteria

Endometrial biopsy Transvaginal sonography or MRI Laparoscopy

23

PID Curriculum

Lesson V: Patient Management

24

PID Curriculum

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

25

PID Curriculum

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

26

PID Curriculum

Management

Oral Regimens
CDC-recommended oral regimen A
Ceftriaxone 250 mg IM in a single dose, PLUS Doxycycline 100 mg orally 2 times a day for 14 days Metronidazole 500 mg orally 2 times a day for 14 days Cefoxitin 2 g IM in a single dose and Probenecid 1 g orally in a single dose, PLUS Doxycycline 100 mg orally 2 times a day for 14 days Metronidazole 500 mg orally 2 times a day for 14 days Other parenteral third-generation cephalosporin (e.g., Ceftizoxime, Cefotaxime), PLUS Doxycycline 100 mg orally 2 times a day for 14 days
27

With or Without

CDC-recommended oral regimen B

With or Without

CDC-recommended oral regimen C

With or Without

Metronidazole 500 mg orally 2 times a day for 14 days

PID Curriculum

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 re-screening for C. trachomatis and N. gonorrhoeae 4-6 weeks after completion of therapy in women with documented infection due to these pathogens. All women diagnosed clinical acute PID should be offered HIV testing.
28

PID Curriculum

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 or IM (2 mg/kg), followed by maintenance dose (1.5 mg/kg) every 8 hours. Single daily gentamicin dosing may be substituted.

29

PID Curriculum

Management

Alternative Parenteral Regimen

Ampicillin/Sulbactam 3 g IV every 6 hours, PLUS Doxycycline 100 mg orally or IV every 12 hours.

It is important to continue either regimen A or B or alternative regimens for at least 24 hours after substantial clinical improvement occurs and also to complete a total of 14 days therapy with: Doxycycline 100mg orally twice a day OR Clindamycin 450mg orally four times a day.

30

PID Curriculum

Lesson VI: Prevention

31

PID Curriculum

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.

32

PID Curriculum

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 patients onset of symptoms.

33

PID Curriculum

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.
34

PID Curriculum

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.

35

PID Curriculum

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

36

PID Curriculum

Case Study

37

PID Curriculum

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 38 douched this morning.

PID Curriculum

Case Study

Physical Exam
Vital signs: blood pressure 104/72, pulse 84, temperature 38C, 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.
39

PID Curriculum

Case Study

Questions
1. What should be included in the differential diagnosis? 2. What laboratory tests should be performed or ordered?

40

PID Curriculum

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.

3. What is the presumptive diagnosis? 4. How should this patient be managed? 5. What is an appropriate therapeutic regimen?
41

PID Curriculum

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?
42

PID Curriculum

Case Study

Follow-Up
On follow up 3 days later, Jane was improved clinically. The culture for gonorrhea was positive. The nucleic acid acid amplification test (NAAT) for chlamydia was negative. Joseph (Janes 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.

7. Who is responsible for reporting this case to the local health department?

8. What are appropriate prevention counseling recommendations for this patient?

43