Pelvic Inflammatory Disease (PID)

N73.0-1/N73.9

DESCRIPTION

PID includes salpingitis with or without oophoritis and, as precise clinical localisation is often difficult, denotes the spectrum of conditions resulting from infection of the upper genital tract.

Sequelae include:

  • recurrent infections if inadequately treated,
  • infertility,
  • increased probability of ectopic pregnancy, and
  • chronic pelvic pain.
Stage Manifestations
Stage I - cervical motion tenderness and/or uterine tenderness and/or adnexal tenderness
Stage II - as stage I, plus pelvic peritonitis
Stage III - as stage II, plus
- tubo-ovarian complex or abscess
Stage IV - generalised peritonitis
- ruptured tubo-ovarian complex
- septicaemia

GENERAL MEASURES

Hospitalise all patients with stage II–IV PID for parenteral antibiotic therapy.
Frequent monitoring of general abdominal and pelvic signs is essential.
Admission for parenteral therapy, observation, further investigation and/or possible surgical intervention should also be considered in the following situations:

  • a surgical emergency cannot be excluded
  • lack of response to oral therapy
  • clinically severe disease
  • presence of a tubo-ovarian abscess
  • intolerance to oral therapy
  • pregnancy

Further Investigation

All sexually active patients should be offered:

  • a pregnancy test
  • screening for sexually transmitted infections including HIV

Perform a pregnancy test, as an ectopic pregnancy forms part of the differential diagnosis.
Note: Remove IUDs and provide alternative contraception.

In stage III, surgery is indicated if:

  • the diagnosis is uncertain,
  • there is no adequate response after 48 hours of appropriate therapy,
  • the patient deteriorates on treatment, or
  • there is a large or symptomatic pelvic mass after 6 weeks.

MEDICINE TREATMENT

Stage I

  • Azithromycin, oral, 1 g as a single dose

LoEII [9]

AND

  • Ceftriaxone, IM, 250 mg as a single dose.
    • Dissolve ceftriaxone, IM, 250 mg in 0.9 mL lidocaine 1% without adrenaline (epinephrine).

LoEIII [10]

AND

  • Metronidazole, oral, 400 mg 12 hourly for 7 days.

LoEIII [11]

Severe penicillin allergy: (Z88.0)

  • Azithromycin, oral, 2 g as a single dose

LoEI [12]

AND

  • Metronidazole, oral, 400 mg 12 hourly for 7 days.

Stage II–IV

  • Ceftriaxone, IV, 1 g daily

AND

  • Metronidazole, IV, 500 mg 8 hourly.

Continue intravenous therapy until there is definite clinical improvement (within 24-48 hours). Thereafter, change to:

  • Amoxicillin/clavulanic acid, oral, 875/125 mg 12 hourly to complete 10 days therapy.

LoEIII [13]

AND

To treat chlamydia: A56.1+(N74.4*)

  • Azithromycin, oral, 1 g, as a single dose.

Note: The addition of metronidazole to amoxicillin/clavulanic acid is unnecessary as amoxicillin/clavulanic acid has adequate anaerobic cover.


Severe penicillin allergy: (Z88.0)

  • Clindamycin, IV, 600 mg 8 hourly.

AND

  • Gentamicin, IV, 6 mg/kg daily (see GENTAMICIN, IV for guidance on prescribing).

Continue intravenous therapy until there is definite clinical improvement (within 24-48 hours). Thereafter, change to:

  • Clindamycin, oral, 450 mg 8 hourly.

AND

  • Ciprofloxacin, oral, 500 mg 12 hourly to complete 10 days therapy.

LoEIII [14]

To treat chlamydia:A 56.1+(N74.4*)

  • Azithromycin, oral, 1 g, as a single dose.

Note: The addition of metronidazole to clindamycin is unnecessary as clindamycin has adequate anaerobic cover.

REFERRAL

Stages III and IV should be managed in consultation with a gynaecologist.