7.1 Microbiological Spectrum and Pathogenesis

Primary Pathogens:

• Neisseria gonorrhoeae

• Chlamydia trachomatis

Secondary/Co-pathogens:

• Anaerobic bacteria (Bacteroides, Prevotella)

• Gram-negative rods

• Mycoplasma genitalium

• Respiratory pathogens (Haemophilus influenzae)

7.2 Diagnostic Criteria Refinement

CDC Minimum Criteria with Modifications

Major Criteria (Must Have Both):

1. Lower abdominal tenderness

2. Cervical motion tenderness OR uterine/adnexal tenderness

Supportive Criteria (Increase Specificity):

• Oral temperature >38.3°C (101°F)

• Abnormal cervical mucopurulent discharge

• Presence of WBC on wet prep

• Elevated ESR/CRP

• Laboratory documentation of cervical infection

Differential Diagnosis Considerations

• Ectopic pregnancy

• Appendicitis

• Ovarian torsion

• Hemorrhagic ovarian cyst

• Endometriosis

• Irritable bowel syndrome

7.3 Treatment Protocols: Detailed Regimens

Inpatient Parenteral Therapy

Regimen A:

• Cefotetan 2g IV every 12 hours OR Cefoxitin 2g IV every 6 hours

• PLUS Doxycycline 100 mg IV/oral every 12 hours

• Transition to Oral: 24 hours after clinical improvement

Regimen B:

• Clindamycin 900 mg IV every 8 hours

• PLUS Gentamicin loading dose (2 mg/kg), then maintenance (1.5 mg/kg) every 8 hours

• Advantage: Better anaerobic coverage for tubo-ovarian abscess

Outpatient Management Criteria

Suitable Candidates:

• Mild-moderate clinical severity

• Low risk of non-compliance

• No nausea/vomiting

• Ability to follow up within 48-72 hours

Regimen:

• Ceftriaxone 500 mg IM (single dose) – increased dose for gonorrhea resistance concerns

• PLUS Doxycycline 100 mg orally twice daily for 14 days

• PLUS Metronidazole 500 mg orally twice daily for 14 days

7.4 Complication Management

Tubo-Ovarian Abscess (TOA)

• Imaging: TVUS for diagnosis, CT/MRI for complex cases

• Medical Management: IV antibiotics for 48-72 hours, then oral completion

• Intervention Indications:

  • Rupture (surgical emergency)

  • Failure to improve after 72 hours of antibiotics

  • Size >8 cm

• Procedures: Image-guided drainage vs. surgical exploration

Fitz-Hugh-Curtis Syndrome

• Presentation: Right upper quadrant pain with PID

• Pathophysiology: Perihepatitis from ascending infection

• Diagnosis: Clinical, confirmed by laparoscopic “violin string” adhesions

• Treatment: Extended antibiotic course (14-21 days)

7.5 Follow-Up and Partner Management

Patient Monitoring:

• Clinical re-evaluation within 48-72 hours

• Test-of-cure for gonorrhea/chlamydia at 3-4 weeks

• Screening for reinfection at 3-6 months

Partner Management:

• Expedited partner therapy where permitted

• Treat all sexual partners within 60 days prior to diagnosis

• Abstinence until patient and partners complete treatment

• PID – Investigations (Based on RCOG GTG & BASHH 2019)

  🧪 1. Diagnosis is primarily clinical

  • PID is a clinical diagnosis — investigations are supportive.

  • Do not delay treatment while awaiting test results.

  🧬 2. Microbiological investigations

  • Endocervical and vaginal swabs should be taken before starting antibiotics, if possible:

    • NAAT (Nucleic Acid Amplification Test) for:

      • Chlamydia trachomatis

      • Neisseria gonorrhoeae

    • Microscopy, culture, and sensitivity for:

      • Mycoplasma genitalium (if available)

      • Trichomonas vaginalis (if symptomatic or high-risk)

      • Bacterial vaginosis and aerobic vaginitis (if discharge present)

  • Consider urine NAAT if cervical swabs are not feasible.

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  💉 3. Blood tests

  • Full Blood Count (FBC) – may show raised WBC.

  • CRP / ESR – non-specific but raised in moderate–severe infection.

  • Pregnancy test (β-hCG) – mandatory to exclude ectopic pregnancy.

  • HIV and syphilis testing – recommended for all women with PID (BASHH).

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  🩻 4. Imaging

  • Pelvic ultrasound (preferably transvaginal) if:

    • Diagnosis uncertain,

    • Adnexal mass or abscess suspected,

    • No improvement after 48–72 hours of antibiotics.

    • Look for tubo-ovarian abscess, hydrosalpinx, or free pelvic fluid.

  • MRI – highly sensitive for complicated PID or diagnostic uncertainty.

  • CT – if alternative diagnosis (e.g., appendicitis) is suspected.

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  🔬 5. Laparoscopy

  • Gold standard for definitive diagnosis, but not first-line/ unless high risk patient.

  • Indicated when:

    • Diagnosis is uncertain,

    • No response to therapy,

    • Alternative pelvic pathology suspected (e.g., endometriosis, appendicitis).

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  💊 6. Partner testing and screening

  • Screen and treat sexual partners for chlamydia and gonorrhoea.

  • Offer contact tracing and test of cure as per BASHH protocols.

For BASHH guideline on PID click below button