Other causative pathogens: Peptostreptococcus, Bacteroides, Atopobium, Leptotrichia and Clostridium species, Mycoplasma hominis, Ureaplasma urealyticum
In addition, approx. 15% of the pathogens involved are of respiratory or intestinal origin: Haemophilus influenzae, Streptococcus pneumoniae, group A Streptococcus, Staphylococcus aureus and Campylobacter species.
PID is usually caused by several microbes at the same time.
Chronic PID
Mycobacterium tuberculosis (countries with risk of tuberculosis)
Actinomyces (patients often have an IUD; the infection is often found in a Pap smear test)
Clinical picture
Course of disease in acute PID
Typically begins after menstruation or after a procedure, such as the insertion of an IUD (risk increased for up to 3 weeks).
The infection ascends via the cervical canal to the uterus where it causes inflammation of the uterine mucosa, or endometritis, and to the fallopian tubes where it causes inflammation of the fallopian tubes, or salpingitis, inflammation of the fallopian tubes and ovaries, or salpingo-oophoritis, or accumulation of pus in the fallopian tubes, or pyosalpinx.
Perihepatitis, or superficial inflammation of the fibrous capsule of the liver (tunica fibrosa hepatis), and periappendicitis may also occur in association with PID. A tubo-ovarian abscess and peritonitis may develop in severe cases.
The severity of symptoms varies: the disease may have very mild symptoms or be nearly asymptomatic (particularly chlamydia) or present as a septic disease with impairment of the patient's general condition.
Findings
Tenderness of the lower abdomen on palpation
Uterine and adnexal tenderness in pelvic examination
Mucopurulent or bloody cervical discharge visible in the speculum examination
Findings: thickening of the walls of the fallopian tubes, fluid accumulation in the fallopian tubes, fluid in Douglas' pouch, abscess in the abdominal cavity or an ovary, thickening and increased vasculature of the endometrium
Treatment primarily against chlamydia: 100 mg doxycycline twice daily for 14 days and 400 mg or 500 mg metronidazole three or two times daily, respectively, for 14 days.
A non-optimal alternative for patients with allergy, for example, is 500 mg ciprofloxacin three times daily and 400 mg metronidazole three times daily.
When gonorrhoea is diagnosed (obvious purulent discharge from the cervix, urine gonococcal nucleic acid detection positive), a gonococcal culture sample should be taken for antimicrobial susceptibility testing. Without waiting for the result, the treatment may be started with a single dose of 250 mg ceftriaxone i.m. and, additionally, 100 mg oral doxycycline twice daily for 14 days.
If chlamydial and gonococcal infections can be excluded and the infection occurs after the insertion of an IUD, for example, it is usually a mixed infection caused by normal vaginal flora and can be treated with a combination of cephalexin (500 mg three, or 750 mg two times daily) and metronidazole (500 mg two, or 400 mg three times daily).
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