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pelvic inflammatory disease (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:
    • 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
  • 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.

risk factors for venereal PID

  • 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

risk factors for non-venereal PID

  • 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

management of sexually acquired PID

  • 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.

mild-moderate infection

severe infection

  • 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)
patients with immediate penicillin hypersensitivity can be given this regime instead:
  • 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)
pid.txt · Last modified: 2012/01/16 05:00 by

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