Internal Medicine

0521779407-17 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 21:18

1148 Pelvic Inflammatory Disease

➣Elevated CRP

➣Positive GC or CT test

■Definitive criteria:

➣Histopathologic evidence of endometritis

➣Abnormal imaging study (US, CT, or MRI)

➣Laparoscopic abnormalities

Treatment Options

Now often treated as outpatient, but low threshold to admit if adoles-

cent, appears acutely ill, or does not tolerate or respond to oral treat-

ment. Should return for evaluation in 24–72 h.

Parenteral Regimens:

A. Cefotetan OR Cefoxitin; PLUS Doxycycline

B. Clindamycin PLUS Gentamicin

■Continue parenteral regimen for 24 h after clinical improvement,

then change to Doxycycline to complete 14 days of therapy; add

Clindamycin or Metronidazole if tubo-ovarian abscess present

■Alternative parenterals: Ofloxacin PLUS Metronidazole; Ampi-

cillin/Sulbactam PLUS Doxycycline; Ciprofloxacin PLUS Doxy-

cycline PLUS Metronidazole Oral Regimens: A. Ofloxacin PLUS

Metronidazole B. Ceftriaxone OR Cefoxitin PLUS Probenecid OR

other third-generation cephalosporin; PLUS Doxycycline

■Consider adding Metronidazole if bacterial vaginosis present

■Alternative oral regimens: Amoxacillin/clavulanate PLUS Doxycycl-

ine; insufficient data to recommend Azithromycin

Side Effects & Contraindications

■Cefotetan: side effects: disulfiram-like reaction with alcohol,

diarrhea; contraindicated in penicillin allergy; pregnancy=B

■Ceftriaxone: side effects: pain with IM injection, phlebitis, diarrhea,

cholestasis; contraindicated with penicillin allergy; pregnancy=B

■Clindamycin: side effects: diarrhea,C. difficile colitis, rash, GI into-

lerance; caution in pregnancy but no risk with extensive experience

■Doxycycline: side effects: GI distress, photosensitivity, erosive

esophagitis; contraindicated in pregnancy (D) and growing children

■Gentamicin: side effects: nephrotoxicity, ototoxicity, vestibular

toxicity; contraindicated in pregnancy (C); avoid in renal or hepatic

insufficiency

■Metronidazole: side effects: disulfiram-like reaction with alcohol,

GI distress, headache, metallic taste; pregnancy=B; avoid in first

trimester