Journal Article:

PID_nejmra1411426

Summary:

Daniel DeMarco                                  Journal Article Assignment                 Rotation #4: OB/GYN

 

Pelvic Inflammatory Disease

Robert C. Brunham, MD, Sami L. Gottlieb MD, MSPH, and Jorma Paavonen, MD

New England Journal of Medicine

 

What is it?:

• Infection-induced inflammation of female upper reproductive tract (endometrium, fallopian tubes, ovaries, pelvic peritoneum)

 

Spread of Infection?:

• Inflammation from vagina or cervix to upper genital tract
• Endometritis = intermediate stage

 

Diagnostic Hallmarks?:

• Pelvic tenderness (cervical motion tenderness, adnexal tenderness, or uterine compression tenderness) + inflammation of lower genital tract (cervical mucopus, cervical friability, inc. leukocytes on wet mount)
• Abrupt onset severe lower abdominal pain during or shortly after menses = classic symptom
• Other symptoms: pelvic pain of varying severity, abnormal vaginal discharge, intermenstrual or postcoital bleeding, dyspareunia, dysuria; +/- fever; +/- RUQ pain due to Fitz-Hugh-Curtis Syndrome (inflammation/adhesion formation in liver capsule)
• 75% of women w/ clinical diagnosis of PID have laparoscopic confirmation of salpingitis (tubal and uterine inflammation, exudate, adhesions, or abscess)

 

Range of Clinical Symptoms?:

• Subtle at times, clinically silent, subclinical

 

Why do we care about PID?:

• Long-term reproductive disability (infertility, ectopic pregnancy, chronic pelvic pain)
• Though rates have been decreasing in North America and Western Europe, areas like Sub-Saharan Africa highly affected
• Public health efforts have proven to decrease rates = WE CAN DO BETTER by controlling Chlamydia trachomatis and Neisseria gonorrhoeae; treated patients have suboptimal reproductive outcomes, subclinical PID = poorly controlled
• 5 million C. trachomatis and N. gonorrhoeae infections globally every year

 

Types of PID?:

• Acute = <30d duration
  • >85% = STD (N gonorrhoeae, C trachomatis, Mycoplasma genitalium) or BV-associated microbes (peptostreptococcus spp., bacteroides spp., atopobium spp., leptotrichia spp., hominis, Ureaplasma urealyticum, clostridia spp.)
  • 15% = respiratory ( influenzae, S pneumoniae, Group A streptococci, S aureus)/enteric (E. coli, Bacteroides fragilis, group B streptococci, campylobacter spp.) organisms that colonize lower GI tract
• Subclinical = may be 2x as common as acute PID (GC)
• Chronic = >30d
  • Chronic infection due to Mycobacterium tuberculosis or actinomyces species

 

Risks for PID?:

• Untreated chlamydial infections → approx 15% lead to PID; Gonorrhea maybe higher…
• Sexual intercourse, retrograde menstruation: movement of organisms from lower genital → upper genital tract

 

Complications of PID?:

• fibrinous/suppurative inflammatory damage along epithelial surface of fallopian tubes and peritoneal surface of tubes/ovaries, loss of ciliated epithelial cells along fallopian tube, pelvic and peritoneal adhesions → scarring, adhesions, partial/total obstruction of fallopian tubes, impaired ovum transport, tubalfactor infertility, ectopic pregnancy, chronic pelvic pain
• Repeated infections inc. risks of above complications, delayed care also has worse long-term outcomes

 

In Whom is the Clinical Vignette Most Likely to Occur?:

• Sexually active young and adolescent women

 

Sensitivity/Specificity?:

• Pelvic tenderness = high sensitivity (>95%) for PID; poor specificity

 

Labs/Diagnostic Imaging?:

• Laparoscopy = standard for diagnosis of PID; though may not detect endometritis or early tubal inflammation
• Transcervical endometrial aspiration with histopathological findings of increased numbers of plasma cells and neutrophils = more commonly used confirmation test
  • Downside = invasive, skill for interpretation, delayed diagnosis
• Transvaginal ultrasound (TVUS) and MRI show thickened, fluid-filled tubes = highly specific
  • TVUS sensitivity = fair (not optimal)
  • MRI sensitivity = high
    • Downside = expensive, not typically available
  • Power Doppler Studies = inc. fallopian-tube blood flow

 

DDx?:

• Alternative diagnoses in 10-25% of those thought to have PID
  • Ovarian cyst
  • Endometriosis
  • Ectopic pregnancy
  • Acute appendicitis

 

Work Up for Patient with Suspected PID?:

• Cervical or vaginal nucleic acid amplification tests (NAAT) for GC and Chlamydia
• Vaginal fluid wet mount = inc. leukocytes, signs of BV (clue cells), elevated pH, amine odor with KOH (“whiff test”)
• Pregnancy test (r/o Ectopic Pregnancy)
• HIV test (HIV inc. risk of tuboovarian abscess (TOA)
• ESR/CRP (if elevated may increase specificity of diagnosis)

 

Treatment of PID?:

• What pathogens are covered?
  • GC/Chlamydia
  • +/- cover anaerobes (BV)
  • ? genitalium
• Outpatient: mild to moderate PID
  • Doxycycline 100mg bid x 2wk +/- metronidazole 500mg bid x 2wk plus one of:
    • Ceftriaxone 250mg IM
    • Cefoxitin 2g IM with probenacid 1g orally
    • Parenteral third-generation cephalosporin (cefotaxime or ceftizoxime)
  • Inpatient: moderate to severe PID +/- TOA
    • One of:
      • Cefotetan 2g IV q12h + doxycycline 100mg po or IV q12h
      • Cefoxitin 2g IV q6h + doxycycline 100mg po or IV q12h
      • Clindamycin 900mg IV q8h + gentamicin 3 to 5 mg/kg IV once daily → particularly useful if TOA
    • Removal of IUD does not hasten clinical resolution (may delay it); therefore, just leave it in place
    • >90% of patients will have a clinical response to aforementioned treatment; though long-term outcomes still not desirable
    • Prompt evaluation and empirical treatment of sexual partners (prevent reinfection)

 

Prevention?:

• High-income countries = programs implemented = decreased GC/Chlamydia
• Data from RCTs show that screening for and treating trachomatis can reduce a woman’s risk of PID by approximately 30-50% over 1 year
• Screening recommendations:
  • USPSTF, CDC = screen all sexually active women younger than 25yo and older women at inc. risk of infection (multiple/new partners)
• Comprehensive sex education, promotion of use of condoms

 

The Future?:

• Develop accurate noninvasive/minimally invasive tests to confirm infection of fallopian tubes or inflammatory changes predicting poor reproductive outcomes
• Biomarkers of immune response to infection that predict tubalfactor infertility (CA-125, E-cadherin occasionally used presently…)
• Immunohistochemical analysis/flow cytometry to define patterns (of endometrial biopsy) that correlate with infection
• Development of inexpensive, point-of-care diagnostic tests (particularly for low-resource settings)
• ?cephalosporin-resistant GC on the horizon
• ?vaccination against GC/Chalmydia