Pelvic Inflammatory Disease

Infections génitales hautes

The pelvic infections are bacterial infections of the uterus (endometritis) and / or the fallopian tubes (salpingitis), which may be complicated by peritonitis, pelvic abscess or sepsis.

The choice of antibiotic therapy considers the context of infection: in to childbirth or abortion (puerperal sepsis) or outside this context (sexually transmitted infection).

In case of suspicion of peritonitis or pelvic abscess, ask for a surgical opinion.

The expectation of surgical opinion must not delay antibiotic therapy.

Pelvic Inflammatory DiseaseClinical signs:

Infections sexually transmitted:

Diagnosis can be difficult because the clinical manifestations are varied.

– Suggestive symptoms are abdominal pain, abnormal vaginal discharge, fever, dyspareunia, menometrorrhagia, dysuria.

– Infection is probable when one or more of these symptoms are associated with one or more of these signs: pain in the cervical motion, palpation of the annexes, painful abdominal mass.

Infections in to childbirth or abortion:

– The clinical picture is often typical with, within 2 to 10 days after childbirth (caesarean or vaginal) or abortion (spontaneous or induced)

• Fever, usually high

• abdominal-pelvic pain

• Lochia foul or purulent

• Uterus big, soft and / or painful examination

– Search for a retained placenta.

– In the forms debutantes, fever may be absent or moderate and mild abdominal pain.

Treatment:

– Hospitalization criteria:

• Patient whose appearance suggests a severe or complicated infection (p. Ex. Peritonitis, abscesses, septicemia)

• Uncertainty about the diagnosis (p. Ex. Suspected ectopic pregnancy, appendicitis)

• Failure to follow an oral outpatient treatment

• No improvement after 48 hours of outpatient treatment or degradation within 48 hours

– The other patients can be treated as outpatients. They should be systematically reviewed in the third day of treatment to assess clinical improvement (reduction of pain, absence of fever). If it is difficult to organize systematic monitoring, ask these patients to re-check after 48 hours of treatment if their condition does not improve, or before if their condition deteriorates.

Infections Sexually Transmitted (IST):

– Antibiotic treatment: treatment combines 3 antibiotics to cover the most common causative organisms: gonorrhea, chlamydia and anaerobic bacteria.

• In-patient:

cefixime PO: 400 mg single dose or ceftriaxone IM: 250 mg single dose

+ Doxycycline PO: 200 mg / day in 2 divided doses for 14 days 1

+ Metronidazole PO: 1 g / day in 2 divided doses for 14 days

• In hospital:

ceftriaxone IM: 250 mg / once daily

+ Doxycycline PO: 200 mg / day in 2 divided doses for 14 days 1

+ Metronidazole PO or IV: 1 g / day in 2 divided doses or infusions

Continue triple antibiotic therapy 24 to 48 hours after the regression of symptoms (disappearance of fever, pain mitigation) and continue doxycycline (or erythromycin) + metronidazole to complete 14 days of treatment.

– Remove intrauterine device if this (offer another method).

– Analgesic treatment adapted to the intensity of pain.

– Processing partner in a single dose treatment of gonorrhea and chlamydia, whether symptomatic or not (as inurethral discharge).

Infections in to childbirth or abortion:

– Antibiotic treatment: treatment should cover the most common causative organisms: anaerobic bacteria, Gram-negative, Streptococcus.

• In-patient (forms beginners only):

Amoxicillin / clavulanic acid (co-amoxiclav) PO (the dose is expressed in amoxicillin): 3 g / day in 3 divided doses for 7 days

or amoxicillin PO: 3 g / day in 3 divided doses + metronidazole PO: 1.5 g / day in 3 divided doses for 7 days

• In hospital:

Amoxicillin / clavulanic acid (co-amoxiclav) IV (the dose is expressed in amoxicillin): 3 g / day in 3 injections +gentamicin IM: 5 mg / kg / once daily

or ampicillin IV: 6 g / day in 3 injections

+ Metronidazole IV: 1.5 g / day in 3 infusions

+ Gentamicin IM: 5 mg / kg / once daily

The co-amoxiclav or amoxicillin + metronidazole PO (as for outpatient treatment) can be given as soon as the condition of the patient improves and can tolerate oral medication. Antibiotic therapy was stopped 48 hours after resolution of fever and pain mitigation.

1* In pregnant / breastfeeding: erythromycin PO: 2 g / day in 2 or 4 doses for 14 days in sexually transmitted IGH, azithromycin in a single dose is sufficient to treat chlamydia.

In case of allergy to penicillin, clindamycin use (2700 mg / day in 3 divided doses or injections) + gentamicin (5 mg / kg / once daily).

– In case of a retained placenta, perform digital curettage or manual vacuum aspiration after 24 hours of antibiotic therapy (refer to guide Obstetrics, MSF).

– Analgesic treatment adapted to the intensity of pain.

– In case of worsening or persistent fever after 48-72 hours of treatment, consider a complication requiring additional treatment (eg drainage of a pelvic abscess..), Otherwise change antibiotic therapy (ceftriaxone + metronidazole + doxycycline, as an STI treated in hospital).