Pelvic Inflammatory Disease

20 y/o F with h/o repeat gonorrhea/chlamydia infections presents with lower abdominal pain. Reports unprotected sex with multiple partners. Fever, mucopurulent cervical discharge, cervical motion tenderness on exam.

• Diagnosis

  • Perform saline wet mount to evaluate for bacterial vaginosis and trichomonas

  • Obtain vaginal swab for chlamydia/gonorrhea NAAT, trichomonas NAAT

  • Obtain syphilis RPR, HBsAG, HIV ELISA

• Treatment

  • Outpatient (empiric):

    • Ceftriaxone IM 250 mg x 1 dose, doxycycline PO 100 mg BID x 14 days

    • Add metronidazole PO 500 mg BID x 14 days for any of the following: History of uterine instrumentation within previous 3 weeks, evidence of bacterial vaginosis/trichomonas on exam

  • Inpatient

    • Admit to hospital for any of the following reasons: Pregnant, severe abdominal pain, unable to tolerate PO due to vomiting, failure of outpatient therapy, hemodynamic instability (e.g. meets SIRS criteria)

    • Start cefoxitin IV 2g q6h, doxycycline IV 100 mg q12h and transition to oral therapy after > 24 hours of clinical improvement

Notes

• Diagnosis

  • Overall, diagnosis is clinical (81% sensitive)

    • Ultrasound sensitivity: 30%

    • Abdominal/pelvic CT sensitivity: Poor

  • Send vaginal trichomoniasis swab as wet mount sensitivity is poor (51%–65%) versus NAAT (~100%)

  • Syphilis RPR (as compared to VDRL) reduces false positive results

• Additional reading: Acute Pelvic Inflammatory Disease: Diagnostic Performance of CT