Pelvic infections

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Chapter 11 Pelvic infections

Yasmin Jayasinghe

Definition. Pelvic inflammatory disease (PID) is an upper genital tract infection. This includes infection of the uterus, fallopian tubes and other pelvic viscera.

Causes of infection

• organisms introduced to the upper genital tract via procedures such as insertion of an intrauterine contraceptive device, and dilatation and curettage

• motile organisms: spermatozoa acting as carriers of organisms

• coital uterine contractions enhancing the spread of organisms

• spread from other organs (e.g. appendix)

• association with other disease: tuberculosis, schistosomiasis

Risk factors

• increased risk in adolescents and young women due to sexual behaviours and immaturity of the cervical epithelium with wide transformation zone

• early sexual debut, multiple partners, lack of condoms or contraception

• increased risk with sexual activity during menses

Microbiology

It is a polymicrobial infection.

Tubal cultures

Table 11.1 lists the microbiological aetiology of PID.

Table 11.1 Microbiological aetiology of PID

Aetiology	Incidence
Chlamydia trachomatis	40%–60%
Neisseria gonorrhoea	15%–18%
Mycoplasma species	10%–15%
Anaerobic facultative bacteria: Escherichia coli, group B streptococcus (GBS), Bacteroides species, Peptostreptococcus species, Staphylococcus aureus	30%

Neisseria gonorrhoea

• gram-negative diplococcus which invades the columnar epithelium; infection usually occurs in the first half of the menstrual cycle

• incubation period: usually 2–7 days

• period of communicability: months in untreated individuals

Diagnosis

Definitive diagnosis is by culture.

• Collect microbiological swabs from the endocervix (or posterior fornix if pregnant), urethra, rectum and throat.

• Send slide for gram stain, and then place second swab into Amies +/– charcoal transport medium.

• Conduct polymerase chain reaction (PCR) test on endocervical specimens (95% sensitivity, 100% specificity). In women, PCR testing of first pass urine (10–20 mL at least 1 hour after passing urine) is less sensitive (around 50%), and, if positive, should be followed up by collection of further endocervical specimens for PCR and culture, prior to antibiotic therapy. Treatment can be commenced before these repeat results are obtained.

Treatment

• ceftriaxone 500 mg intramuscular injection immediately, mixed with 2 mL 1% lignocaine or ciprofloxacin 500 mg orally; single dose in areas where there is no resistance

• coinfection with Chlamydia may occur, so always cover for both

• a notifiable disease

Chlamydia trachomatis

• It is an obligate intracellular organism.

• Its lifecycle has two stages: (a) an infectious and metabolically inactive elementary body which penetrates the cell wall by endocytosis, where it is transformed into (b) the reticulate body, which reproduces by binary fission to form new elementary bodies in the vacuole, which eventually ruptures to release the organism.

• It is the most common notifiable sexually transmitted disease (STD). Incidence is 2.5%–14% in STD clinic patients, 5% in family planning clients and up to 15% in commercial sex workers.

• The incubation period is poorly defined: 7–14 days or longer.

• The period of communicability is unknown: perhaps months to years.

Diagnosis

• endocervical swab into PCR transport tube (or send as dry swab) or first void urine PCR

• both have comparable sensitivity: 87%–99% sensitivity, >95% specificity

Treatment

• first-line azithromycin 1 g orally, single dose, or

• doxycycline 100 mg orally twice daily for 7 days, or

• erythromycin 500 mg orally four times a day for 7 days

• a notifiable disease

Mycoplasma genitalium

• Mycoplasma genitalium is strongly associated with PID and is best detected by PCR, to distinguish from other Mycoplasma species.

• Mycoplasma hominis and Ureaplasma urealyticum are associated with bacterial vaginosis, possibly PID, but also may be non-pathogenic commensals.

• Treatment of choice is azithromycin.

Anaerobes: Bacteroides and Peptostreptococcus species

Treat with metronidazole 400 mg three times a day for 7 days.

Diagnosis of PID

Presentation. It may be acute, subacute or subclinical. Most women with endocervical chlamydial or gonorrhoeal infection are asymptomatic.

Symptomatic PID

• Symptoms are acute pelvic pain, febrile illness, vaginal discharge, postcoital or intermenstrual bleeding; less frequent symptoms include urethral syndrome (dysuria and pyuria), bartholinitis, perihepatitis and proctitis.

• Signs are fever, abdominal tenderness, adnexal tenderness or mass, uterine or cervical motion tenderness, cervical inflammation and vaginal discharge.

• The Centers for Disease Control and Prevention (CDC) 2006 guidelines recommend that empiric treatment be undertaken in sexually active women with lower abdominal pain if they meet at least one of the following criteria: cervical motion, uterine or adnexal tenderness.

• Laparoscopy is the gold standard for diagnosis, and is useful in unwell subjects where diagnosis is unclear, or there is no improvement with antibiotics, and for surgical intervention.

• Findings include erythema and oedema of tubes, purulent discharge, pyosalpinx, tubo-ovarian abscess and pelvic adhesions.

Management of PID

Principles

• broad spectrum antibiotics for 14 days: cure rates of over 90%

• investigation and empiric treatment of sexual partners

• notifiable diseases must be reported to Department of Health

• counsel regarding safe sexual practices

• advise avoidance of sexual intercourse for duration of treatment

• test of cure is not cost-effective where the above advice has been followed; however, may provide reassurance

Outpatient treatment for mild–moderate PID

Outpatient treatment for mild–moderate PID is safe and efficacious.

• azithromycin 1 g orally, immediately

• plus metronidazole 400 mg orally twice daily for 14 days

• plus doxycycline 100 mg orally twice daily for 14 days

• plus ceftriaxone 500 mg intramuscular injection with 2 mL 1% lignocaine if suspect gonorrhoea

Inpatient treatment for severe PID

• cefotaxime 1 g intravenously (IV) 8 hourly, or cefoxitin 2 g IV 6 hourly, or ceftriaxone 1 g IV daily

• plus metronidazole 500 mg IV 8 hourly

• plus doxycycline 100 mg orally twice daily, or roxithromycin 150 mg orally twice daily or 300 mg orally daily as a single dose, until the patient is afebrile and improved; then continue doxycycline or roxithromycin for 2–4 weeks

Outpatient treatment of mild–moderate procedure-related PID

• doxycycline 100 mg orally twice daily for 2–4 weeks, or

• amoxycillin 500 mg orally three times a day, plus metronidazole 400 mg orally three times a day for 2–4 weeks

Inpatient treatment of severe septicaemic procedure-related PID

• amoxycillin 2 g IV 4 hourly, plus gentamicin 1.5 mg/kg IV 8 hourly, plus metronidazole 500 mg IV 8 hourly until afebrile; then doxycycline 100 mg orally twice daily for 2 weeks

Actinomyces israelii

• This is a gram-positive, non-acid, mycelium-bearing, anaerobic fungus. It is a normal commensal of mouth and gastrointestinal and genital tract.

• Actinomyces-like organisms (ALOs) may be identified on cervical smears, but this is not diagnostic of pelvic disease.

• They are found in women with and without an intrauterine device (IUD).

• If a woman is symptomatic, or has a pelvic mass, the IUD should be removed, and treatment with antibiotics penicillin, tetracycline or erythromycin, plus or minus surgical intervention, is required.

• There is no evidence to support the routine removal of an IUD in an asymptomatic woman.

Toxic shock syndrome (TSS)

• historically associated with use of superabsorbant tampons in presence of exotoxin producing Staphylococcus aureus colonisation

• non-menstrual TSS related to infected wounds, foreign bodies

• menstrual TSS declining, annual incidence 1–2 in 100,000, with a 3% case fatality rate

• incidence of non-menstrual TSS remains relatively constant, with a 6% case fatality rate

Aetiology

• caused most commonly by S. aureus, which produces TSS toxin 1 (TSST-1); accounts for 90% of menstrual cases and 60% of non-menstrual cases of TSS or S. aureus producing enterotoxin B

• can also be caused by Streptococcus pyogenes (group A streptococcus), non-group A beta-haemolytic streptococcus, and Streptococcus viridans (more fulminant disease with higher mortality)

Presentation

• fever, hypotension

• erythroderma of palms, soles, hands, desquamation, multiorgan dysfunction including coagulopathy, renal failure, adult respiratory distress syndrome, and abnormalities in electrolytes and liver biochemistry

Investigations

• full septic and biochemical screen

• isolation of TSST-1 pathognomonic for S. aureus TSS

Management

• resuscitate, ventilate if required

• intravenous antibiotics

• remove tampon if present

• open and debride infected wounds

Further reading and references

Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2006. MMWR Recommendations and Reports. 2006;55(No. RR–11):1-77.

Cook R.L., Hutchison S.L., Østergaard L., et al. Systematic review: noninvasive testing for Chlamydia trachomatis and Neisseria gonorrhoeae. Annals of Internal Medicine. 2005;142(11):914-925.

FFPRHC Guidance. The copper intrauterine device as long-term contraception. Journal of Family Planning and Reproductive Health Care. 2004;30(1):29-42.

Gainer J., Yost M. Critical care infectious disease. Obstetrics and Gynecology Clinics of North America. 2003;30:695-709.

Ness R.B., Soper D.E., Holley R.L., et al. Effectiveness of inpatient and outpatient treatment strategies for women with pelvic inflammatory disease: results from the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) Randomized Trial. American Journal of Obstetrics and Gynecology. 2003;186(5):924-937.

Sexual Health Society of Victoria. National management guidelines for sexually transmissible infections. Royal Australian College of General Practitioners. 2008. 18 December. Available: www.racp.edu.au

Victorian Department of Health. Blue book. Available www.health.vic.gov.au/ideas/bluebook/, 2009.

Westrom L., Joesoef R., Reynolds G., et al. Pelvic inflammatory disease and infertility. A cohort study of 1844 women with laparoscopically verified disease and 657 control women with normal laparoscopic results. Journal of Sexually Transmitted Diseases. 1992;19(4):185-192.

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