Pelvic Inflammatory Disease

Background:
 Pelvic Inflammatory Disease (PID): a spectrum of inflammatory disorders of the upper
female genital tract, including any combination of the following:
o Endometritis: inflammation of the uterine lining
o Salpingitis: inflammation of the fallopian tubes
o Tubo-ovarian abscess: an abscess formed as a result of infection of the fallopian
tube and ovary
o Pelvic peritonitis: inflammation of the peritoneum in the pelvic area
 Organisms implicated in PID:

Common Historic Association/Vaginal Flora Possible Association

N. gonorrhoeae* G. vaginalis T. vaginalis
C. trachomatis* H. Influenzae M. hominis
-------- Streptococcus agalactiae U. urealyticum
-------- Strict and facultative anaerobes M. genitalium
-------- Enteric gram-negative rods Cytomegalovirus (CMV)

Diagnosis:
 Difficult due to variability in signs and symptoms associated with PID.
 Those with PID may experience non-specific symptoms or be asymptomatic as a whole.
 Lack of test that demonstrates both sensitivity and specificity.
o Sensitivity: a test’s ability to designate an individual with a disease as positive
o Specificity: a test’s ability to designate an individual with the absence of a
disease as a negative.
 Minimum clinical criteria for diagnosis of PID upon pelvic examination:

Cervical Motion Uterine Adnexal

Tenderness Tenderness Tenderness

 Additional criteria to enhance the specificity of a PID diagnosis from pelvic examination:

Oral Temperature > 38.3°C (> 101°F) Elevated C-reactive protein

Abnormal cervical discharge/friability Elevated erythrocyte sedimentation rate
Abundant WBCs in vaginal fluid Documentation of cervical infection*
First Line Treatment Regimens (Parenteral):
 Three Agent Regimen:
o Ceftriaxone 1 g IV every 24 hours PLUS
o Doxycycline 100 mg PO or IV every 12 hours PLUS
o Metronidazole 500 mg PO or IV every 12 hours
 Two Agent Regimens:
o Cefotetan 2 g IV every 12 hours PLUS
o Doxycycline 100 mg PO or IV every 12 hours
OR
o Cefoxitin 2 g IV every 6 hours PLUS
o Doxycycline 100 mg PO or IV every 12 hours

Alternative Treatment Regimens:

 Ampicillin-sulbactam 3 g IV every 6 hours PLUS
 Doxycycline 100 mg PO or IV every 12 hours
OR

 Clindamycin 900 mg IV every 8 hours PLUS

 Gentamicin loading dose IV or IM 2mg/kg, maintenance dose of 1.5 mg/kg every 8
hours

IM or PO Treatment:
 Ceftriaxone 500 mg IM in a single dose PLUS
 Doxycycline 100 mg PO twice daily x 14 days PLUS
 Metronidazole 500 mg PO twice daily x 14 days
OR
 Cefoxitin 2 g IM x 1 dose WITH Probenecid 1 g PO x 1 dose (concurrent) PLUS
 Doxycycline 100 mg twice daily x 14 days PLUS
 Metronidazole 500 mg twice daily x 14 days
OR

 Parenteral third-generation cephalosporin PLUS

 Doxycycline 100 mg twice daily x 14 days PLUS
 Metronidazole 500 mg twice daily x 14 days
 Lyme Disease, Human Granulocytic Anaplasmosis,
Babesiosis
Prevention of Tick Bites:

No vaccines DEET Permethrin

Removal of Ticks:

DO NOT:

 Light the tick on fire before

removal
 Apply noxious chemicals to
the tick before removal

https://www.hopkinsallchildrens.org/Patients-Families/Health-Library/HealthDocNew/Tick-
Removal-A-Step-by-Step-Guide

Lyme Disease:
Vector: Blacklegged Tick
Signs/Symptoms:

Bull’s-Eye Rash Severe Headache/Neck Stiffness

Facial Palsy Joint Swelling
Heart Palpitations CNS Inflammation
Nerve Pain Fever/Fatigue

 Bites: Treatment vs. Prophylaxis

o Prophylactic antibiotics against Lyme Disease should only be given if a bite is
identifiable as a high risk bite: Doxycycline 200 mg x 1 dose within 72 hours of
tick removal.

Tick Attached
Blacklegged Tick Highly Endemic Area
> 36 hours
  First Line Oral Treatment Agents:
o Doxycycline 100 mg twice daily
o Amoxicillin 500 mg three times daily
o Cefuroxime 500 mg twice daily
 Treatment Durations:
o Erythema Migrans (Bull’s-eye rash): 14 days
 10 days for doxycycline
o Acute Neurologic Disease: 14-21 days
o Arthritis without Neurologic Involvement: 28 days
 cefuroxime use off-label
 Alternative Oral Agents:
o Azithromycin: 500 mg daily for 7 days
 CNS Involvement
o IV therapy is preferred (ceftriaxone, cefotaxime, penicillin G)
o Duration: 14-28 days

Human Granulocytic Anaplasmosis (HGA)

Vector: Lonestar Tick + Blacklegged Tick
Signs/Symptoms:

Lab abnormalities (leukopenia,

Nausea/Vomiting/Diarrhea
thrombocytopenia, elevated liver enzymes)
Fever/Chills Severe Headaches/Confusion
Muscle Aches Loss of Appetite
Rash (children) – red splotches/pinpoint dots Meningoencephalitis
Respiratory Failure Bleeding

 Bite Treatment:
o Doxycycline 100 mg twice daily for 10 days
 Alternative Agent:
o Rifampin 300 mg twice daily for 10 days (off-label)
 Ineffective against Rocky Mountain Spotted Fever or Lyme Disease
 Shown effective vs. HGA in laboratory settings per CDC – clinical
evaluation is lacking.
Babesiosis
Vector: Blacklegged Tick
Signs/Symptoms:
Fevers/Chills/Sweats/Fatigue Myalgia/Headache
GI Symptoms (anorexia, nausea/vomiting) Dark Urine
Thrombocytopenia, disseminated intravascular
Mild splenomegaly, hepatomegaly, or jaundice
coagulation

 Bite Treatment (Preferred Regimen; 2020 IDSA Guidelines):

o Azithromycin 500 mg x 1 dose followed by 250 mg daily for 7-10 days
PLUS
o Atovaquone 750 mg twice daily for 7-10 days

 Alternative Agents (historically preferred regimen):

o Clindamycin 600 mg every 8 hours for 7-10 days
PLUS
o Quinine 650 mg every 6-8 hours for 7-10 days

 High Risk Patients:

o Azithromycin dosing: may increase up to 1 gram daily
o Duration: May extend duration for > 6 weeks (including 2 weeks after resolution of
parasitemia)

St. Louis Encephalitis

Vector: Culex species mosquito
Similar infections: Japanese encephalitis, Powassan Virus, West Nile Virus
Signs/Symptoms:

Fatigue Headache
Nausea/Vomiting Body Aches
Dizziness Agitation/Confusion
Temors Coma

 The majority of patients will undergo spontaneous recovery, without progression from
asymptomatic or flu-like symptoms to severe encephalitis
 Treatment: symptom management (rest, fluids, OTC pain management)