pid

PID is the general description given to inflammation caused by infection in the upper genital tract in females and includes salpingitis, endometritis, oophoritis, myometritis (uterine wall), and parametritis (broad ligament and uterine serosa).
99% of acute PID arises from ascending organisms from the vagina and cervix, the other 1% is “secondary PID” due to spread of infection from outside the genital tract such as from a ruptured appendix or intraabdominal abscess.
90% of primary PID is said to be venereal (sexually transmitted infections (STDs/STIs)) with the main organisms being:
- Chlamydia trachomatis
- Neisseria gonorrhoeae (gonococcus)
  - was a very uncommon cause of PID in Western society in the 1990's but is on the rise again.
  - suspect if either:
    - PID occurs within 1 week of menstruation
    - partner has documented gonorrhoea
    - endocervical exudate contains intracellular gram-negative diplococci in 3 or more leukocytes.
- anaerobic and aerobic organisms are often cultured in pelvic abscesses in patients with acute PID, but usually play secondary roles
- Mycoplasma hominis and Ureaplasma urealyticum may play secondary roles
- rarely tuberculosis (TB)
10% of primary PID is non-venereal
- usually iatrogenic - as a complication of D&C, endometrial biopsies, hysterosalpingogram, IUCD insertion
- may arise from septic miscarriages or retained products of conception.

multiple sexual partners → 3-4x risk, especially if new partners in past 30 days
age < 30yrs
early coitrarche
menstruation
- acute PID is unusual in women who are pregnant, premenarchal or post-menopausal
- risk for PID appears higher when intercourse occurs during menses
PH PID → 2-3x risk of another episode
contraceptive method:
- condom use may be partly protective:
  - some studies have suggested no correlation between condom use and acute PID in adolescents - but is that because reported use was inaccurate?
other factors not fully researched:
- alcohol intake prior to sex - maybe it impairs judgement or allows forgetting to use condom
- substance abuse

highest risk in 1st month following IUCD insertion
retained products of conception
- risk of PID: 1% spontaneous miscarriages; 0.5% legal termination of pregnancy; >10% for illegal abortions;
uterine procedures in 4weeks prior

cervical swabs for Chlamydia and gonococcus PCR (or consider 1st stream urin PCR taken > 2hrs after last micturition)
exclude pregnancy
remember to treat partner(s)
the following are from Aust. Therapeutic Guidelines as at May 2009.
NB. where adherence to 2 weeks of doxycycline (or roxithromycin in pregnant or breastfeeding women) is unlikely, there are theoretical grounds to indicate they may be replaced by adding a second dose of azithromycin 1 g orally on day 8, although no satisfactory clinical trial data are available.

azithromycin 1g o single dose, PLUS
ceftriaxone 250mg im single dose for gonorrhoea, PLUS
doxycycline 100mg bd for 14 days (if pregnant or breastfeeding use roxithromycin 300mg daily for 14 days instead), PLUS
metronidazole 400mg bd for 14 days

doxycycline 100mg bd for 14 days (if pregnant or breastfeeding use roxithromycin 300mg daily for 14 days instead), PLUS
cetriaxone 1g iv daily, PLUS
metronidazole 500mg iv bd
continue until there is substantial clinical improvement, then use oral doxycycline plus metronidazole (as for mild-moderate infection)

gentamicin 4 to 6 mg/kg IV, daily (adjust dose for renal function), PLUS
clindamycin 600 mg IV, 8-hourly
continue until there is substantial clinical improvement, then use oral doxycycline plus metronidazole (as for mild-moderate infection)