​Kembara Xtra - Medicine - Pelvic Inflammatory Disease

​Kembara Xtra - Medicine - Pelvic Inflammatory Disease 
The uterus, fallopian tubes, ovaries, and surrounding pelvic tissues are all included in the upper female genital tract, which is affected by pelvic inflammatory disease (PID), an infectious and inflammatory condition. The most typical form of PID is an escalating polymicrobial infection brought on by sexually transmitted pathogens (1).
Salpingitis, which affects future fertility, is the most clinically important diagnostic factor. Mild to moderate PID is infection and inflammation in the absence of a tubo-ovarian abscess (TOA). Due to inconsistent definitions and criteria, the lack of a single conclusive diagnostic test, and the wide range of symptoms and signs, diagnosing severe disease can be difficult. Severe disease is described as having significant systemic symptoms OR the presence of a TOA.
PID patients frequently experience vague or subtle symptoms.


Epidemiology 

Age range most common: 15 to 29 years
Incidence
PID accounts for 18 out of every 10,000 hospital discharges in the United States for gynecologic admissions (2).
Prevalence
The estimated lifetime PID prevalence in sexually active cisgender women between the ages of 18 and 44 is 4.4%.
Since 1995, the lifetime prevalence has steadily dropped (4).
 Black women had a greater lifetime prevalence of STIs compared to white women (2.7% vs. 6.0%). Lifetime prevalence among individuals with a previous STI was comparable across racial groups (10% vs. 10.3%). This gap shows that black individuals may be more likely to have had an undiagnosed STI or to not have received treatment for an infection that was symptomatic at the time, leading to PID.

Pathophysiology and Etiology 
PID is brought on by several organisms. Cervicitis typically precedes polymicrobial illness in most situations. 50% of women who test positive for a microorganism have acute PID.
Mixed infections happen frequently. Common vaginal bacteria include Prevotella, peptostreptococci, Gardnerella vaginalis, Escherichia coli, and Haemophilus influenzae. Other genital tract mycoplasmas include Neisseria gonorrhoeae, Chlamydia trachomatis, and Mycoplasma genitalium.
● Bacterial vaginosis is linked to a large number of nongonococcal, nonchlamydial microorganisms recovered from the upper vaginal tract in acute PID.
The cervix, endometrium, salpinx, peritoneal cavity, lymphatic spread by infection of the parametrium (from an IUD), and the uncommon hematogenous route are all potential ascent routes from the lower genital tract.
75% of cases happen within 7 days after menstruation, when cervical mucous encourages the ascent of bacteria.

Risk Elements 

Age under 25 and sexual activity; first sexual activity before age 15; new or multiple partners; inconsistent condom use; gynecological procedures that breach the cervical wall, such as endometrial biopsy, curettage, hysterosalpingography, hysteroscopy, in vitro fertilization, and IUD insertion in the previous six weeks; other factors linked to PID, such as:
- Some methods of birth control, such oral contraceptive tablets and spermicidal creams, change the vaginal pH and flora, which raises the risk of STIs.
- Previous PID history; 20–25% of cases will reoccur.
- Cervical ectopy - Previous C. trachomatis infection; 10–40% will experience PID.
- Gonococcal cervicitis history; 10–20% of patients will develop PID.

Basic Prevention 

 Education campaigns regarding condoms and other barrier contraceptives, as well as other safe sex practices.
The U.S. Preventive Services Task Force advises annual chlamydia screening for all sexually active women under the age of 25 and for those under the age of 25 who are at higher risk (new sex partner/multiple sex partners). Chlamydia testing may help prevent PID cases thanks to the following factors: routine STI screening during pregnancy; early medical attention for genital sores or unusual discharge; and moderate-quality evidence.

Accompanying Conditions 
In a patient with a pelvic abscess and an IUD, suspect an Actinomyces infection that needs to be treated with penicillin.
Although uncommon, adnexal abscess rupture can be fatal.
There must be early surgical exploration.
Fitz-Hugh-Curtis (FHC) syndrome, also known as chlamydial or gonococcal perihepatitis, can occur with PID. 10% of PID cases are complicated by FHC syndrome, which is characterized by severe pleuritic right upper quadrant pain.
Women with PID are more likely to develop plasma cell endometritis; the severity of the symptoms is correlated with the density of the infiltration of plasma cells.


When compared to laparoscopy, the positive predictive value of a clinical diagnosis ranges from 65 to 90% for the diagnosis of PID. The CDC advises empiric treatment for PID in at-risk females who have lower abdomen or pelvic pain with an unidentified cause and at least one of the following symptoms:
Tenderness in the following areas: - Adnexal tenderness - Cervical motion tenderness
Additional criteria that increase specificity include a fever of 101 degrees or higher, new or abnormal cervical mucopurulent discharge, cervical friability, the presence of abundant WBCs on wet prep, elevated C-reactive protein (CRP), elevated ESR, and laboratory evidence of genitourinary infection with N. gonorrhoeae or C. trachomatis. The criteria that are the most specific for identifying PID are endometritis, thickened, fluid-filled

History 

Lower abdominal/pelvic discomfort that is dull, painful or crampy, bilateral, and continuous. This pain is made worse by movement, exercise, or coitus.
Fever, chills, leg cramps, and dyspareunia
Low back pain and discomfort while urinating
About 40% of cases of unexpected vaginal bleeding, frequently postcoital, are documented.
IUD insertion during the last 21 days; recent hysterosalpingogram (HSG) or other surgery that breaks the uterine barrier


Clinical examination: evidence of cervicitis with or without vaginal discharge; fever; lower abdomen pain; cervical motion soreness


Differential diagnosis: Endometriosis/dysmenorrhea; Appendicitis; Constipation; Gastroenteritis; Ectopic pregnancy; Ovarian tumor/torsion; Hemorrhagic/ruptured ovarian cyst; Diverticulitis; UTI/pyelonephritis; Nephrolithiasis

Laboratory Results 

Initial examinations (lab, imaging)
Chlamydia and gonorrhea testing (urine or cervical swab nucleic acid amplification test [NAAT] and/or ligase chain reaction); a negative result does not rule out PID. Pregnancy test to rule out ectopic pregnancy and problems of an intrauterine pregnancy.
 Urinalysis Saline vaginal fluid microscopy (for WBC) HIV and syphilis screening tests
While not necessary for diagnosis, transvaginal ultrasonography may reveal thicker, fluid-filled tubes (hydrosalpinges), free fluid, or TOA.
Child Safety Considerations
Think about child sexual abuse who exhibits PID signs.
Tests in the Future & Special Considerations
Outpatient follow-up ultrasonography for adnexal abscess resolution


Laparoscopy should only be performed in the following circumstances: - Patients with competing diagnoses (such as appendicitis) - Patients who have failed outpatient treatment - Patients who have not improved after 72 hours of inpatient care
 An infrequently recommended endometrial biopsy reveals endometritis and plasma cells. 

Management To reduce the chance of reinfection, patients are advised to postpone sexual activity until they and their partners have received treatment.
Inform patients and partners of any potential long-term effects.
 Outpatient care is advised, if clinically necessary.
The following is a list of requirements for hospitalization and parenteral therapy.

General Actions 
Regardless of test results, treatment should address the main pathogens (CT, NG, and polymicrobial infections with anaerobic coverage). IUD removal is NOT necessary for mild PID.

First Line of Medicine

Long-acting cephalosporin, macrolide or tetracycline, and metronidazole are the prescribed medications for outpatient therapy.
Metronidazole 500 mg twice day for 14 days, along with Ceftriaxone 500 mg IM single dosage and Doxycycline 100 mg PO BID. Patients over 300 lb require 1 g of ceftriaxone.
The CDC no longer advises using fluoroquinolones to treat gonococcal infections, including PID, due to the development of fluoroquinolone-resistant gonococci.
Next Line
It is advised to collect a culture swab for resistance testing and repeat CT/NG tests for confirmation of treatment success two weeks after the end of the treatment since gonococci are showing signs of emerging resistance (5).
Cefoxitin 2 g IM single dose, probenecid 1 g PO, or cefotaxime (1 g IM) or ceftizoxime (1 g IM) taken concurrently in single dosage, as well as doxycycline 100 mg PO BID for 14 days AND metronidazole 500 mg PO BID for 14 days make up the outpatient treatment regimen.
Skin testing is crucial to confirm or rule out penicillin allergy in people who have experienced recorded severe allergic reactions to the drug.
- Third-generation cephalosporins have little penicillin cross-reactivity.
- Clindamycin 900 mg IV every eight hours PLUS a maintenance dosage of gentamicin (1.5 mg/kg body weight) every eight hours; a single daily dose of (3 to 5 mg/kg body weight) may be used in place of the combination.
If a patient's sex partner had contact with them during the previous 60 days, they should be referred for treatment under special consideration.
Where possible, expedited partner therapy should be used.
- Despite having a higher risk of TOA, HIV-infected individuals with acute PID should be treated similarly to non-HIV-infected patients.

Reserved surgical procedures for medical treatment failures and probable burst adnexal abscess with acute surgical abdomen

Admission 

If any of the following apply, hospitalization criteria (5)[C]:
- It is impossible to rule out surgical emergencies (like appendicitis).
- Pregnancy - Failing to respond clinically to oral antibiotics after 72 hours
The CDC advises the following treatment plans for inpatient PID therapy:
- Parenteral protocol A
Doxycycline 100 mg PO or IV every 12 hours along with cefotetan 2 g IV q12h or cefoxitin 2 g IV q6h
 24 hours of parenteral treatment following clinical improvement. When possible, it is best to take doxycycline orally because it has a similar bioavailability when taken intravenously. Doxycycline should be taken for a total of 14 days (3).
- Parenteral protocol B
Clindamycin 900 mg IV every eight hours in addition to gentamicin loading dosage IV or IM (2 mg/kg of body weight), followed by maintenance dose (1.5 mg/kg) every eight hours, or a single daily dose of 3 to 5 mg/kg, might be used instead (3).
After 24 hours of clinical recovery, parenteral therapy may be stopped; instead, oral therapy with the previously indicated doses of doxycycline or clindamycin should be continued for a total of 14 days.
PID is uncommon in pregnant patients, although it necessitates hospitalization. Parenteral regimen C: Ampicillin/sulbactam 3 g IV every 6 hours plus doxycycline 100 mg PO or IV every 12 hours. Azithromycin plus a second-generation cephalosporin should replace doxycycline.


Patient Follow-Up Monitoring
72-hour follow-up is advised, especially for patients with moderate or severe clinical presentation (3).
 Keep an eye out for any symptoms (fever, stomach pain, and tenderness with cervical mobility) that get worse.
In 3 to 6 months, repeat the gonorrhea and chlamydia tests.
 Use serial ultrasounds to monitor the size and location of adnexal abscesses.

Modification of Lifestyle 

 Refraining from any kind of sexual activity until the patient's or partner's treatment is finished.
It should be promoted to use condoms consistently and correctly.
Patients who meet the requirements should be given the HPV and hepatitis B vaccinations.
Encourage thorough STI screening.
 Patients who present with a new STI or PID should be offered HIV preexposure prophylaxis (PrEP); IUD implantation presents a minimal risk of PID in the presence of a prior/current STI diagnosis.
GOOD PROGNOSIS IF EARLY EFFECTIVE THERAPY AND FURTHER INFECTION IS AVOIDED: PID has a significant morbidity; around 20% of affected patients become infertile, 40% suffer chronic pelvic pain, and 1% have an ectopic pregnancy.
Negative prognosis and postponed therapy
PID caused by nongonococcal, nonchlamydial organisms is more severe and has a poorer prognosis for future fertility.

Complications 
7–16% of individuals had TOA prior to presentation; 33% of patients with PID were hospitalized
20 to 25 percent of individuals experience recurrent infections.
Patients with a history of PID have a 7–10-fold greater risk of ectopic pregnancy.
 Following 1, 2, and 3 episodes of PID, tubal infertility occurred in 8%, 19.5%, and 40% of patients, respectively.
20% of the time, adhesions, chronic salpingitis, or recurrent infections are the cause of chronic pelvic pain.
Following the resolution of PID, the fallopian tube fills with sterile fluid and blocks, causing pain and sterility.

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