Pelvic Inflammatory Disease: Diagnosis and Treatment in the Emergency Department (Infectious Disease CME and Pharmacology CME)

Table of Contents

 

About This Issue

Recent research has shown that pelvic inflammatory disease is no longer necessarily a sequela of sexually transmitted infection, and as the pathogens have evolved, current guidelines have changed. Swift, empiric treatment is necessary to avoid life-threatening and fertility-threatening complications of PID. In this issue, you will learn:

The pathogens currently primarily responsible for PID.

The CDC’s clinical diagnosis of PID and the 3 criteria that should prompt empiric treatment.

The historical findings that suggest PID and can indicate mild, moderate, or severe and complicated PID.

The involvement of Neisseria gonorrhoeae and Chlamydia trachomatis in PID and how testing for these STIs will inform diagnosis.

Which laboratory tests are needed, and which tests can be misleading.

What ultrasound, CT, and MRI may – and may not – show.

The latest drug therapy recommendations: oral, IV, IM – and when to discharge, observe, or admit.

The importance of prompt follow-up.

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal of the Literature
6. Etiology and Pathophysiology
   1. Pelvic Inflammatory Disease Pathogens
      1. Pelvic Examination
7. Differential Diagnosis
8. Prehospital Care
9. Emergency Department Evaluation
   1. History
      1. Pelvic Examination
   2. Physical Examination
10. Diagnostic Studies
    1. Laboratory Testing
    2. Imaging
11. Treatment
    1. Mild to Moderately Severe Pelvic Inflammatory Disease
    2. Patients With Antibiotic Allergies
    3. Severe Pelvic Inflammatory Disease
    4. Observation and Admission for Inpatient Therapy
12. Treatment of Special Populations
    1. Pregnant Patients
    2. Adolescent Patients
    3. Transgender Male Patients
    4. Patients With HIV
    5. Patients With an Intrauterine Device
    6. Partner Treatment
13. Quality Improvement and Additional Considerations
14. Controversies and Cutting Edge
    1. Mycoplasma genitalium
    2. Addition of Metronidazole to the Standard Treatment Regimen
    3. Drug-Resistant Organisms
    4. Patients With Suspected Treatment Failure
    5. Point-of-Care Testing in Low-Resource Settings
15. Disposition and Transition of Care
16. Summary
17. Time- and Cost-Effective Strategies
18. 5 Things That Will Change Your Practice
19. Risk Management Pitfalls in Pelvic Inflammatory Disease
20. Case Conclusions
21. Clinical Pathway for Determining Need for Admission and Treatment of Pelvic Inflammatory Disease
22. Tables and Figures
23. References

Abstract

Pelvic inflammatory disease is associated with complications that include infertility, chronic pelvic pain, ruptured tubo-ovarian abscess, and ectopic pregnancy. The diagnosis may be delayed when the presentation has nonspecific signs and symptoms. Even when properly diagnosed, pelvic inflammatory disease is often treated suboptimally. This review provides evidence-based recommendations for the diagnosis, treatment, disposition, and follow-up of patients with pelvic inflammatory disease. Arranging follow-up of patients within 48 to 72 hours and providing clear patient education are fundamental to ensuring good patient outcomes. Emerging issues, including new pathogens and evolving resistance patterns among pelvic inflammatory disease pathogens, are reviewed.

Case Presentations

A 30-year-old woman presents with abdominal pain…

• You note mild left adnexal tenderness without cervical motion tenderness or adnexal masses. Her laboratory test results are notable for a urinalysis that is positive for small leukocyte esterase and nitrite-negative, and a wet mount is without clue cells, yeast, or Trichomonas vaginalis. The patient denies any urinary complaints or flank pain.
• The patient’s ultrasound results contain the radiologist’s impression: “No radiological etiology of patient’s abdominal pain is found.” You review the chart and confirm there is no concern for any nongynecological etiologies for her pain.
• As the patient asks, “Why am I having this pain? Can I just go home?” you wonder if there is something else you should do…

A 22-year-old woman returns for re-evaluation 1 week after starting treatment for pelvic inflammatory disease…

• The patient was given 500 mg ceftriaxone IM in the ED followed by doxycycline 100 mg orally twice daily and metronidazole 500 mg twice daily. She does not have access to primary care and was instructed to return to the ED for repeat evaluation after 2 days, but she did not return because of a work conflict.
• She continues to complain of nonspecific left lower abdominal pain. She states that the pain may be a bit more intense, but it has not changed in quality, position, or associated features.
• On your physical examination, the patient has left lower quadrant abdominal tenderness without guarding or rebound. Bimanual examination reveals mild left adnexal tenderness without a palpable mass. She states that she has been fully compliant with the doxycycline and metronidazole. She has not had intercourse since her diagnosis. Her previous records show a reassuring pelvic ultrasound, urinalysis, urine culture, and a negative HIV test.
• You are surprised to find that her gonorrhea/chlamydia nucleic acid amplification test from a cervical specimen showed no evidence of infection. After being told about her negative gonorrhea and chlamydia tests, she asks if she can stop taking the antibiotics…

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Clinical Pathway for Determining Need for Admission and Treatment of Pelvic Inflammatory Disease

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Tables and Figures

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

11. * Workowski KA, Bachman LH, Chan PA, et al. Sexually transmitted infections treatment guidelines, 2021. MMWR Recomm Rep. 2021;70(4):1-180. (CDC guidelines) DOI: 10.15585/mmwr.rr7004a1

17. Ross J, Cole M, Evans C, et al. United Kingdom national guideline for the management of pelvic inflammatory disease (2019 interim update). 2019. Accessed November 10, 2022. (Guideline)

27. * Wiesenfeld HC, Meyn LA, Darville T, et al. A randomized controlled trial of ceftriaxone and doxycycline, with or without metronidazole, for the treatment of acute pelvic inflammatory disease. Clin Infect Dis. 2021;72(7):1181-1189. (Randomized double-blind placebo-controlled trial; 233 patients) DOI: 10.1093/cid/ciaa101

68. * Simms I, Warburton F, Weström L. Diagnosis of pelvic inflammatory disease: time for a rethink. Sex Transm Infect. 2003;79(6):491-494. (Retrospective; 623 patients) DOI: 10.1136/sti.79.6.491

92. * Tomas ME, Getman D, Donskey CJ, et al. Overdiagnosis of urinary tract infection and underdiagnosis of sexually transmitted infection in adult women presenting to an emergency department. J Clin Microbiol. 2015;53(8):2686-2692. (Prospective; 264 patients) DOI: 10.1128/JCM.00670-15

94. * Lee MH, Moon MH, Sung CK, et al. CT findings of acute pelvic inflammatory disease. Abdom Imaging. 2014;39(6):1350-1355. (Prospective; 231 patients) DOI: 10.1007/s00261-014-0158-1

127. *Goyal M, Hersh A, Luan X, et al. National trends in pelvic inflammatory disease among adolescents in the emergency department. J Adolesc Health. 2013;53(2):249-252. (Retrospective NAHMCS database study) DOI: 10.1016/j.jadohealth.2013.03.016

145. *Marrazzo J. Molecular characterization of microbes in the female upper genital tract: a valiant quest to “redefine” pelvic inflammatory disease. J Infect Dis. 2021;224(12 Suppl 2):S36-S38. (Review) DOI: 10.1093/infdis/jiab301

146. *Mitchell C. To effectively treat pelvic inflammatory disease, look beyond coverage for gonorrhea and chlamydia. Clin Infect Dis. 2021;72(7):1190-1191. (Review) DOI: 10.1093/cid/ciaa103

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Keywords: pelvic, cervical, uterus, adnexa, STI, endometritis, salpingitis, tubo-ovarian abscess, Fitz-Hugh-Curtis, ectopic, infertility, gonorrhea, chlamydia