Nejm 1994;330:115

Cause:(Med Let 1999;41:86) Chlamydia causes over half of mild cases (Ann IM 1981;95:685; Nejm 1980;302:1063) (Chlamydial Atypical Pneumonias and URIs), maybe most; Neisseria gonococcus(15%), anaerobes, mycoplasma. All via sexual intercourse, esp with multiple partners; IUD use previously thought to incr risk (Nejm 1985;312:937, 941, 984), now felt to have minimal effect

Pathophys:Lower genital tract infections ascend cervical canal usually just before or during menses, to tubes and ovaries

Sx: Pain in lower abdomen, constant or colicky; dyspareunia; dysuria; tenesmus; dysmenorrhea; nausea and vomiting; anorexia

Si:Adnexal mass (20%) and tenderness or pain on cervical motion ("Chandelier si"); fever; cervical discharge

Infertility (15+% with each episode); ectopic pregnancy; pelvic abscess; septic thrombophlebitis; surgical excision of reproductive organs

r/o endometriosis, adenomyosis, ectopic pregnancy

Lab:

Bact: GC culture, chlamydia screens

Hem:WBC elevated; ESR elevated in 1/3; the higher the ESR, the more likely sterility

Noninv:Laparoscopy if dx unclear or improvement slow

Xray:Pelvic ultrasound; CT scan for possible abscess

Rx:

Prevent w condom use (Am J Pub Hlth 1990;80:964); bcp's help (Jama 1984;251:2553)

Screen asx women for chlamydia if expected prevalence is >7%, reduces PID by 1/2 (Nejm 1996;334:1362); or perhaps all women and maybe men under age 25 yr w PCR techniques (Pelvic Inflammatory Disease) (Nejm 1998;339:739, 768)

of disease (Med Let 1999;41:86); pain and tenderness is adequate indication to initiate rx (Mmwr 1993;42:76)

• Outpatients:
• 1st, ceftriaxone 250 mg im × 1 then doxycycline 100 mg bid × 14 d
• 2nd, ofloxacin 400 mg po bid + metronidazole 500 mg po bid × 2 wk
• Inpatients: hospitalize if
• Diagnosis is unclear,
• Mass is present,
• Unable to keep po meds down,
• Peritoneal si's present,
• Outpt rx failure, or
• If expect poor compliance
• Rx w:
• 1st: Doxycycline 100 mg q 12 hr iv + cefoxitin 2 gm iv q 6 h ("FoxyDoxy") or cefotetan 2 gm iv q 12 hr until better, then doxycycline 100 mg po bid × 14 d
• 2nd: Gentamicin 2 mg/kg iv × 1 then 1.5 mg/kg iv q 8 h + clindamycin 900 mg iv q 8 h until better, then f/u w po doxycycline × 14 d
• 3rd: Levofloxacin 500 mg pd iv/po, or ofloxacin 400 mg po q 12 hr + metronidazole 500 mg iv 8 h; amp/sulbactam 3 gm iv q 6 h + doxycycline 100 mg iv q 12 h; all followed by doxy × 14 d

Rx of partners for gc if culture is positive, otherwise just for chlamydia