Pelvic Inflammatory Disease 2

MEDICATION
See Medical Care for treatment regimens.
Drug Category: Antibiotics -- Therapy must be comprehensive and cover all likely pathogens in the context of this clinical setting.
Drug Name
Cefoxitin (Mefoxin) -- Second-generation cephalosporin indicated for infections with gram-positive cocci and gram-negative rods. Infections caused by cephalosporin- or penicillin-resistant gram-negative bacteria may respond to cefoxitin.
Adult Dose
2 g IV q6h
Pediatric Dose
80-160 mg/kg/d IV divided q4-6h; higher doses for severe or serious infections; not to exceed 12 g/d
Contraindications
Documented hypersensitivity
Interactions
Probenecid may increase effects; coadministration with aminoglycosides or furosemide may increase nephrotoxicity (closely monitor renal function)
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged use or repeated treatment; caution in patients with previously diagnosed colitis
Drug Name
Cefotetan (Cefotan) -- Second-generation cephalosporin indicated for infections caused by susceptible gram-positive cocci and gram-negative rods. Dose and route of administration depend on condition of patient, severity of infection, and susceptibility of causative organism.
Adult Dose
2 g IV q12h
Pediatric Dose
20-40 mg/kg per dose IV/IM q12h for 5-10 d
Contraindications
Documented hypersensitivity
Interactions
Consumption of alcohol within 72 h may produce disulfiramlike reactions; may increase hypoprothrombinemic effects of anticoagulants; coadministration with potent diuretics (eg, loop diuretics) or aminoglycosides may increase nephrotoxicity
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Reduce dosage by one half if CrCl is 10-30 mL/min and by one fourth if CrCl <10 mL/min; bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged or repeated therapy
Drug Name
Doxycycline (Vibramycin) -- Inhibits protein synthesis and, thus, bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria.
Adult Dose
100 mg PO/IV q12h
Pediatric Dose
<8>8 years: 2-5 mg/kg/d qd or divided bid; not to exceed 200 mg/d
Contraindications
Documented hypersensitivity; severe hepatic dysfunction
Interactions
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of PO contraceptives, causing breakthrough bleeding and increased risk of pregnancy
Pregnancy
D - Unsafe in pregnancy
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning facilities; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (<8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines
Drug Name
Clindamycin (Cleocin) -- Lincosamide for treatment of serious skin and soft tissue staphylococcal infections. Also effective against aerobic and anaerobic streptococci (except enterococci). Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest.
Adult Dose
900 mg IV q8h; if administered with ofloxacin, 450 mg PO qid for 14 d
Pediatric Dose
8-20 mg/kg/d PO as hydrochloride and 8-25 mg/kg/d as palmitate tid/qid20-40 mg/kg/d IV/IM tid/qid
Contraindications
Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis
Interactions
Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects; antidiarrheals may delay absorption
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis by allowing overgrowth of Clostridium difficile
Drug Name
Metronidazole (Flagyl) -- Imidazole ring–based antibiotic active against various anaerobic bacteria and protozoa. Used in combination with other antimicrobial agents (except for C difficile enterocolitis).
Adult Dose
Loading: 15 mg/kg, or 1 g for 70-kg adult, IV over 1 hMaintenance: 6 h following loading dose, infuse 7.5 mg/kg, or 500 mg for 70-kg adult, over 1 h q6-8h; not to exceed 4 g/dIf administered with ofloxacin PO: 500 mg PO bid for 14 d
Pediatric Dose
Administer as in adults
Contraindications
Documented hypersensitivity
Interactions
May increase toxicity of anticoagulants, lithium, and phenytoin; cimetidine may increase toxicity; disulfiramlike reaction may occur with PO ethanol
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Adjust dose in hepatic disease; monitor for seizures and development of peripheral neuropathy
Drug Name
Meropenem (Merrem) -- Bactericidal broad-spectrum carbapenem antibiotic that inhibits cell wall synthesis. Effective against most gram-positive and gram-negative bacteria.
Adult Dose
1 g IV q8h
Pediatric Dose
40 mg/kg IV q8h
Contraindications
Documented hypersensitivity
Interactions
Probenecid may inhibit renal excretion of meropenem, increasing meropenem levels
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Pseudomembranous colitis and thrombocytopenia may occur, requiring immediate discontinuation of medication
Drug Name
Ceftriaxone (Rocephin) -- Third-generation cephalosporin with broad-spectrum gram-negative activity. Lower efficacy against gram-positive organisms and higher efficacy against resistant organisms. Arrests bacterial growth by binding to 1 or more penicillin-binding proteins.
Adult Dose
250 mg IM once
Pediatric Dose
50-75 mg/kg/d IV/IM q12h; not to exceed 2 g/d
Contraindications
Documented hypersensitivity
Interactions
Probenecid may increase levels; coadministration with ethacrynic acid, furosemide, or aminoglycosides may increase nephrotoxicity
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Adjust dose in renal impairment; caution in breastfeeding women and in people with allergy to penicillin
Drug Name
Ofloxacin (Floxin) -- Penetrates prostate well and is effective against N gonorrhea and C trachomatis.A pyridine carboxylic acid derivative with broad-spectrum bactericidal effect.
Adult Dose
400 mg PO q12h for 14 d
Pediatric Dose
<18>18 years: Administer as in adults
Contraindications
Documented hypersensitivity
Interactions
Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; ciprofloxacin reduces therapeutic effects of phenytoin; probenecid may increase ciprofloxacin serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal impairment; superinfections may occur with prolonged or repeated antibiotic therapy
Drug Name
Gentamicin (Gentacidin, Garamycin) -- Aminoglycoside antibiotic for gram-negative coverage. Used in combination with an agent against gram-positive organisms and one that covers anaerobes. Dosing regimens are numerous. Adjust dose based on CrCl and changes in volume of distribution. Follow each regimen by at least a trough level drawn on the third or fourth dose (0.5 h before dosing); may draw a peak level 0.5 h after 30-min infusion.
Adult Dose
Loading: 2 mg/kg IV/IMMaintenance: 1.5 mg/kg IV/IM q8h
Pediatric Dose
<5>5 years: 1.5-2.5 mg/kg per dose IV/IM q8h or 6-7.5 mg/kg/d divided q8h; not to exceed 300 mg/d
Contraindications
Documented hypersensitivity; non–dialysis-dependent renal insufficiency
Interactions
Coadministration with other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; aminoglycosides enhance effects of neuromuscular blocking agents; thus, prolonged respiratory depression may occur; coadministration with loop diuretics may increase auditory toxicity; irreversible hearing loss of varying degrees may occur (monitor regularly)
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (not on dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment Drug Category: Uricosuric agents -- Reduce clearance of some types of antibiotics, increasing their plasma levels.
Drug Name
Probenecid -- Inhibits tubular secretion of penicillin and usually increases penicillin plasma levels by any route the antibiotic is administered. Adjuvant to therapy with penicillin, ampicillin, methicillin, oxacillin, cloxacillin, or nafcillin. Two- to 4-fold elevation of penicillin plasma levels demonstrated.
Adult Dose
1 g PO once
Pediatric Dose
<2>2 years: Not established
Contraindications
Documented hypersensitivity; blood dyscrasia; uric acid kidney stones; coadministration of ketorolac
Interactions
Salicylates at high dosages and nitrofurantoin may decrease effects; increases levels/toxicity of methotrexate, beta-lactam antibiotics, acyclovir, thiopental, clofibrate, dyphylline, pantothenic acid, ketorolac, benzodiazepines, rifampin, sulfonamide, dapsone, zidovudine, and sulfonylureas
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Crosses placental barrier; caution in history of peptic ulcer FOLLOW-UP
Further Inpatient Care:
Most patients clinically respond within 48-72 hours after medical therapy. If the patient continues to have fever, chills, uterine tenderness, adnexal tenderness, and cervical motion tenderness, consider other possible causes.
Further Outpatient Care:
Perform a follow-up examination 48-72 hours after prescribing outpatient therapy to ensure clinical improvement. If the patient continues to have fevers, chills, uterine tenderness, adnexal tenderness, and cervical motion tenderness, consider hospitalization.
Male sex partners of women with PID should be examined and treated if they have had sexual contact with the patient during the 60 days preceding the onset of symptoms in the patient.
In/Out Patient Meds:
See Medical Care.
Deterrence/Prevention:
Randomized controlled trials suggest that preventing chlamydial infection reduces the incidence of PID. Other methods of preventing PID and STD include reducing the number of sexual partners, avoiding unsafe sexual practices, and using condoms with spermicide. Use of mechanical barriers with spermicide also decreases the risk of acquiring STDs.
Notification of the female sex partners of men infected with Chlamydia trachomatis is recommended.
Complications:
Tuboovarian abscess is one of the major complications of acute PID, and it occurs in up to 15-30% of women requiring hospitalization for treatment of PID.
Prognosis:
Therapy using antibiotics alone is successful in 33-75% of cases. If surgical therapy is warranted, the current trend in therapy is conservation of reproductive potential with simple drainage, adhesiolysis, and copious irrigation or unilateral adnexectomy, if possible. Further surgical therapy is needed in 15-20% of cases so managed.
Chronic pelvic pain occurs in approximately 25% of patients with a history of PID. This pain is thought to be related to cyclic menstrual changes, but it also may be the result of adhesions or hydrosalpinx.
Impaired fertility is a major concern in women with a history of PID. The rate of infertility increases with the number of episodes of infection.
The risk of ectopic pregnancy is increased in women with a history of PID. Ectopic pregnancy is a direct result of damage to the fallopian tube.
Patient Education:
Asking women about high-risk sexual behavior is important.
Encourage screening tests for those at risk.
Ensure that male sex partners are evaluated and treated.
Counsel women about safe sex practices.
MISCELLANEOUS
Medical/Legal Pitfalls:
A frequent cause of litigation is failure to diagnose. The physician should always clearly document the patient's symptoms, as well as the physical examination and results of laboratory and radiological studies. Documenting the diagnosis, treatment plan, and disposition of the case is equally important. If the patient is referred to other services for consultation, a copy of the consulting physician's note should be attached to the medical record.
Special Concerns:
Women with HIV infection who have PID have similar symptoms when compared to women who do not have HIV. However, women with HIV infection are more likely to have tuboovarian abscess.