CDC Pelvic Inflammatory Disease 2010 STD Treatment Guidelines

PID comprises a spectrum of inflammatory

disorders of the upper female genital tract

Including any combination of endometritis,

salpingitis, tubo-ovarian abscess, and pelvic
peritonitis

CDC Pelvic Inflammatory Disease 2010 STD Treatment Guidelines

Sexually transmitted organisms, especially N.

gonorrhoeae and C. trachomatis, are
implicated in many cases

However, microorganisms that comprise the

vaginal flora (e.g., anaerobes, G. vaginalis,
Haemophilus influenzae, enteric Gramnegative rods, and Streptococcus agalactiae)
also have been associated with PID

CDC Pelvic Inflammatory Disease 2010 STD Treatment Guidelines

In addition, cytomegalovirus (CMV), M.

hominis, U. urealyticum, and M. genitalium
might be associated with some cases of PID

All women who have acute PID should be

tested for N. gonorrhoeae and C. trachomatis
and should be screened for HIV infection.

CDC Pelvic Inflammatory Disease 2010 STD Treatment Guidelines

Acute PID is difficult to diagnose because of

the wide variation in the symptoms and signs.

Many women with PID have subtle or mild

symptoms.

Delay in diagnosis and treatment probably

contributes to inflammatory sequelae in the
upper reproductive tract

Laparoscopy can be used to obtain a more

accurate diagnosis of salpingitis and a more
complete bacteriologic diagnosis.

However, this diagnostic tool frequently is not

readily available, and its use is not easy to justify
when symptoms are mild or vague.

Moreover, laparoscopy will not detect endometritis

and might not detect subtle inflammation of the
fallopian tubes

Diagnosis of PID is usually based on clinical

findings

Because of the difficulty of diagnosis and the

potential for damage to the reproductive health
of women (even by apparently mild or subclinical
PID), health-care providers should maintain a low
threshold for the diagnosis of PID

CDC Pelvic Inflammatory Disease 2010 STD Treatment Guidelines

Sexually active young women and other

women at risk for STDs if they are
experiencing pelvic or lower abdominal pain

If no cause for the illness other than PID can

be identified

If one or more of the following minimum

criteria are present on pelvic examination

Minimum criteria on pelvic examination

Cervical motion tenderness

or
Uterine tenderness
or
Adnexal tenderness

CDC Pelvic Inflammatory Disease 2010 STD Treatment Guidelines

The requirement that all three minimum criteria

be present before the initiation of empiric
treatment could result in insufficient sensitivity
for the diagnosis of PID.

The presence of signs of lower-genitaltract

inflammation (predominance of leukocytes in
vaginal secretions, cervical exudates, or cervical
friability), in addition to one of the three
minimum criteria, increases the specificity of the
diagnosis.

One or more of the following additional criteria

can be used to enhance the specificity of the
minimum criteria and support a diagnosis of PID

CDC Pelvic Inflammatory Disease 2010 STD Treatment Guidelines

Oral temperature >101 F (>38.3 C)

Abnormal cervical or vaginal mucopurulent
discharge
Presence of abundant numbers of WBC on
saline microscopy of vaginal fluid
Elevated ESR
Elevated C-reactive protein
Laboratory documentation of cervical infection
with N. gonorrhoeae or C. trachomatis.

Endometrial biopsy with histopathologic evidence

of endometritis

Transvaginal sonography or magnetic resonance

imaging techniques showing thickened, fluid filled
tubes with or without free pelvic fluid or tuboovarian complex, or Doppler studies
suggesting pelvic infection (e.g., tubal hyperemia)

Laparoscopic abnormalities consistent with PID.

Patients should demonstrate substantial

clinical improvement within 3 days after
initiation of therapy.

Patients who do not improve within this period

usually require hospitalization, assessment of
the antimicrobial regimen, additional
diagnostic tests, and surgical intervention.

CDC Pelvic Inflammatory Disease 2010 STD Treatment Guidelines

Repeat testing of all women who have been

diagnosed with chlamydia or gonorrhea is
recommended 36 months after treatment,
regardless of whether their sex partners were
treated.

All women diagnosed with acute PID should be

offered HIV testing.

CDC Pelvic Inflammatory Disease 2010 STD Treatment Guidelines

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.
the patients most recent sex partner,
If a patients last sexual intercourse was
>60 days before onset of symptoms or
diagnosis
CDC - Pelvic Inflammatory Disease - 2010 STD Treatment Guidelines

Evaluation and treatment are imperative because

of the risk for reinfection of the patient and the
strong likelihood of urethral gonococcal or
chlamydial infection in the sex partner
Male partners of women who have PID caused by
C. trachomatisand/orN. gonorrhoeaefrequently
are asymptomatic.
should be treated empirically with regimens
effective against both of these infections,
regardless of the etiology of PID or pathogens
isolated from the infected woman.
CDC - Pelvic Inflammatory Disease - 2010 STD Treatment Guidelines

Arrangements should be made to provide

care or appropriate referral for male sex
partners of women who have PID.
Patients should be instructed to abstain
from sexual intercourse until therapy is
completed and until they and their sex
partners no longer have symptoms
CDC - Pelvic Inflammatory Disease - 2010 STD Treatment Guidelines

Screening and treating sexually active

women for chlamydia reduces their risk for
PID
Although BV is associated with PID,
whether the incidence of PID can be
reduced by identifying and treating women
with BV is unclear
CDC - Pelvic Inflammatory Disease 2010 STD Treatment Guidelines

Provide sexual health education

Avoid Risks
eg. multiple partners, unprotected sex
Protections : condom
STD Screening including : Syphilis AIDs HepB
Prevention of post PID complication
eg. ectopic pregnancy, Infertility
3,2551
. .

Because of the high risk for maternal morbidity and

preterm delivery, pregnant women who have
suspected PID should be hospitalized and
treated with parenteral antibiotics.
CDC - Pelvic Inflammatory Disease - 2010 STD Treatment Guidelines

PID in pregnancy is associated with an increase in

both maternal and fetal morbidity, therefore
parenteral therapy is advised although none of the
suggested evidence based regimens are of proven
safety in this situation.
The risk of giving any of the recommended
antibiotic in very early pregnancy (prior to a
pregnancy test becoming positive) is justified by
the need to provide effective therapy and the
low risk to the foetus .
UK National Guideline for the Management of Pelvic Inflammatory Disease 2011

The risk for PID associated with IUD use is

primarily confined to the first 3 weeks after
insertion and is uncommon thereafter
Evidence is insufficient to recommend that
the removal of IUDs in women diagnosed with
acute PID.
However, caution should be exercised if the
IUD remains in place, and close clinical followup is mandatory
CDC - Pelvic Inflammatory Disease - 2010 STD Treatment Guidelines

In the past, Clinicians generally removed IUDs to

optimize the treatment of PID. This was primarily based
on concerns that as a foreign body, removal of the
IUD enhanced clinical response.

randomized study of 46 women in Sweden, Soderberg,

and Lindgren reported no differences in response to
treatment whether the IUD was removed or left in place

randomized trial from Turkey, noted that clinical

improvement (e.g., absence of pelvic pain, vaginal
discharge, and pelvic tenderness) was more common in
the group whose IUDs were removed.

If the provider elects to leave the IUD in place while PID

is being treated, close clinical follow up is important
Infectious Diseases in Obstetrics and Gynecology Volume 2011
Review Article : Treatment of Acute Pelvic InflammatoryDisease
Richard L. Sweet Department of Obstetrics and Gynecology, University of California

Differences in the clinical manifestations of PID

between HIV-infected women and HIV-negative women have
not been well delineated.

more comprehensive observational and controlled studies

now have demonstrated that HIV-infected women with PID
have similar symptoms when compared with uninfected
controls
: except, they were more likely to have a TOA

both groups of women responded equally well to standard

parenteral and oral antibiotic regimens.

Regardlesss of these data, whether the management of

immunodeficient HIV-infected women with PID requires more
aggressive interventions (e.g., hospitalization or
parenteral antimicrobial regimens) has not been
determined.
CDC - Pelvic Inflammatory Disease - 2010 STD Treatment Guidelines

microbiologic findings for HIV-positive and HIVnegative women were similar

except HIV-infected women had higher rates of
concomitantM. hominis, candida, streptococcal, and
HPV infections and HPV-related cytologic
abnormalities.
CDC - Pelvic Inflammatory Disease - 2010 STD Treatment Guidelines