A longitudinal study of pelvic inflammatory disease.

OBJECTIVE: To study the microbiology and long term prognosis of pelvic inflammatory disease (PID). DESIGN: A prospective study of women with laparoscopically confirmed PID. SETTING: Teaching hospital in central London. SUBJECTS: 23 women with PID. OUTCOME MEASURES: Microbiological investigations at the time of diagnosis and at follow up; subsequent fertility and the occurrence of pelvic pain. RESULTS: PID diagnosed by laparoscopy was regarded as moderate to severe in 15 cases. Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma hominis and Ureaplasma urealyticum or a combination of these micro-organisms were detected most frequently in the cervix, less often in the endometrium and least in the tubes, C. trachomatis being the micro-organism found most commonly in the tubes. There was serological evidence of acute chlamydial infection in 13 of 20 cases in which paired sera were available and a serological response to M. hominis in 9 of 12 cases in which it was possible to evaluate the results. On the basis of microbiological and serological results, C. trachomatis appeared to be the most important aetiological agent in 10 cases, N. gonorrhoeae in four cases, M. hominis in three cases and U. urealyticum in none; in five cases, two of these micro-organisms appeared to be of equal importance. After 1 to 3 years, 33% of the women were having difficulty conceiving and 56% continued to complain of pelvic pain. CONCLUSION: It is difficult to be certain of the infectious cause of PID in any given case. However, the evidence that N. gonorrhoeae and C. trachomatis are pathogens is very strong. M. hominis may be responsible for a few cases on its own or together with other micro-organisms.     

Levofloxacin plus metronidazole in uncomplicated pelvic inflammatory disease: A preliminary study

Objective

Uncomplicated pelvic inflammatory disease (PID) is a common disease caused by numerous pathogens: sexually transmitted infections (such as Chlamydia trachomatis, Neisseria gonorrhoeae and Mycoplasma genitalium), anaerobes, and other organisms from the vaginal flora. It is currently treated by oral route and most present protocols recommend ofloxacin plus metronidazole (MET). The CDC 2006 Guidelines suggested that levofloxacin (LEV) can be a substitute for ofloxacin. This study aimed to evaluate the efficacy and safety of LEV–MET in the treatment of uncomplicated PID.

Study design

The first 40 cases of uncomplicated PID were prospectively evaluated (June 2006 to December 2007). Diagnosis was based on the clinical signs and microbial findings. If present (N = 8), IUD were removed and cultured. Treatment consisted of LEV 500 mg OD + MET 500 mg BID by oral route for 14 days. Visits took place at the end of therapy (EOT) and at follow-up (FU) 4–6 weeks later. The endpoints were clinical resolution (at the EOT and FU) and bacteriological eradication (at the EOT).

Results

10 cases of bacterial vaginosis were found and 35 pathogens (E. coli: 12, anaerobes: 5; C. trachomatis: 5; M. hominis: 5; U. urealyticum: 3; others: 5) were isolated in the cervix. 37 patients were evaluable at the EOT: 27 were clinically cured and 10 significantly improved; all pathogens were eradicated. At FU, all 35 evaluable patients were clinically cured. Drug-related adverse events (AEs) occurred in 9 cases: 1 patient discontinued (myalgia and tendonitis) while other AEs consisted of nausea or diarrhea.

Conclusion

This preliminary study has shown that a 14-day course of oral LEV–MET is effective and well-tolerated in the treatment of outpatients with uncomplicated PID.     

Long-term sequelae of acute pelvic inflammatory disease. A retrospective cohort study.

OBJECTIVE: Our objective was to prospectively assess the frequency and predictors of long-term sequelae of acute pelvic inflammatory disease. STUDY DESIGN: We performed a retrospective cohort study of 140 women admitted for treatment of pelvic inflammatory disease to San Francisco General Hospital in 1985, locating and interviewing 51 women by telephone a median of 37 months later. RESULTS: Twelve (24%) women had pelvic pain for 6 months or more after hospitalization, 22 (43%) had subsequent episode(s) of pelvic inflammatory disease, and 40% were involuntarily infertile. A history of pelvic inflammatory disease prior to admission was associated with infertility (p = 0.05), chronic pelvic pain (p = 0.03), and pelvic inflammatory disease subsequent to hospitalization (p = 0.06). Longer duration of abdominopelvic pain before admission and younger age at the time of first sexual intercourse were associated with both infertility (p = 0.02, p = 0.04) and subsequent pelvic inflammatory disease (p = 0.04, p = 0.0008). CONCLUSIONS: Further studies are needed to more accurately assess the incidence and predictors of long-term sequelae of pelvic inflammatory disease. A reduction in adverse outcome will require more stringent efforts at education and reduction of risk-taking behaviors.     

Adnexitis and pelvic inflammatory disease

Pelvic inflammatory disease and upper genital tract infection describe inflammatory changes in the upper female genital tract of any combination: endometritis, salpingitis, tubo-ovarian abscess, peritonitis in the small pelvis. The International Infectious Disease Society for Obstetrics and Gynecology recommends a revision of the CDC guidelines taking into account the type of germ or the triggering agent and the seriousness of the disease. Infections with Chlamydia trachomatis and Neisseria gonorrhoeae are increasing worldwide. They are one of the main causes of tubal sterility, chronic abdominal pain and ectopic pregnancies. More than 30% of the infections are subclinical and asymptomatic. Therefore it is most recommendable to generally screen young, sexually active women with any of the risks mentioned above. Antibiotic therapy should be started as early as possible, in case of doubt even probatively, and should cover a broad spectrum of germs. C. trachomatis and N. gonorrhoeae should be treated according to resistance testing. In uncomplicated cases, hospitalization is unnecessary, ambulant therapy is sufficient.     

Ultrasonographic evaluation of pelvic inflammatory disease

The relative frequencies of various sonographic patterns and features of pelvic inflammatory disease (PID) were examined in retrospective analyses of sonograms in 36 proven cases. The original sonographic reports correctly predicted PID in 34/36 patients (sensitivity = 94.4%). Two cases were found to be tubo-ovarian abscess although at first they were reported to be ovarian neoplasia. The most frequent finding was dilatation of the fallopian tube (72.2%). String sign within the dilated tube that would reflect increased interface within the endosalpinx was found in 50.0%, fluid collection in the Douglas' pouch in 47.2%, which was confirmed by the culdocentesis and aspiration in 16 cases, and/or tumor formation at the adnexal region in 38.9%. These findings were characteristic but not specific in PID. Careful sonographic scrutinization should improve the diagnostic accuracy of PID in patients with low abdominal pain, high temperature and low back pain.     

Diagnostic evaluation of pelvic inflammatory disease

Pelvic inflammatory disease (PID) is a serious public health and reproductive health problem in the United States. An early and accurate diagnosis of PID is extremely important for the effective management of the acute illness and for the prevention of long-term sequelae. The diagnosis of PID is difficult, with considerable numbers of false-positive and false-negative diagnoses. An abnormal vaginal discharge or evidence of lower genital tract infection is an important and predictive finding that is often underemphasized and overlooked. This paper reviews the clinical diagnosis and supportive laboratory tests for the diagnosis of PID and outlines an appropriate diagnostic plan for the clinician and the researcher.     

The treatment of pelvic inflammatory disease

The treatment of pelvic inflammatory disease depends upon the etiology of the condition. Pelvic infection (PI) after parturition and abortion, gynecologic surgery, and a variety of invasive procedures is commonly associated with the isolation of anaerobic and aerobic flora of the vagina. The factors which influence the choice of antimicrobial treatment and the role of Bacteroides fragilis and Escherichia coli are discussed. Sexually transmissible agents of importance are Neisseria gonorrhoeae and Chlamydia trachomatis. Pelvic infections associated with these pathogens require antibiotics which exert an optimum effect against them. Examination and treatment of the sexual partner(s) are important. The possible role of the anaerobic and aerobic vaginal flora as opportunistic secondary pathogens is discussed. Developments in the surgical treatment of the sequelae of PID are reviewed. The results of treatment of uncomplicated gonorrhea in 262 women are reported. C. trachomatis was isolated from 53% of women before treatment. After treatment, PI developed in 11 women who had been given penicillin and in one woman who had been given tetracycline (P = 0.0071). It is suggested that recognition and treatment of postgonococcal cervicitis in women treated for uncomplicated gonorrhea with penicillin might provide one form of preventive treatment for nongonococcal PI.     

Hormonal contraception and pelvic inflammatory disease

Estrogen-progestogen contraception (OC) is significantly associated with a high prevalence of Chlamydia trachomatis in the lower genital tracts of young women. In contrast, pelvic inflammatory disease is less frequent and is associated with milder pelvic lesions in OC users than in non-users. A recent study suggests that OC use can be associated with silent endometritis and salpingitis. The usual clinical, biological and laparoscopic signs of acute and chronic pelvic inflammatory disease are described. As shown by several cost—benefit analyses, C. trachomatis detection in family planning centers is cost-effective and the eradication of bacteria is obtained in 90% of cases by a new treatment: azithromycin (1 g for 1 day).

Although the data clearly show that C. trachomatis screening is cost-effective, selection of the diagnostic laboratory tests used in such screening programs should be carefully evaluated relative to cost, feasibility, specificity and sensitivity, and should be adapted to the presumed prevalence in screened populations. A systematic screening is indicated in populations susceptible to a prevalence of 5% or more.     

Actinomycotic pelvic inflammatory disease simulating malignancy

The protean and indolent nature of pelvic actinomycosis combined with the rarity of the disease poses a diagnostic dilemma. Woody induration and pelvic fibrosis may be present to such a degree that a diagnosis of pelvic malignancy is entertained. Early diagnosis and aggressive antibiotic therapy prior to definitive surgical management, even in the face of extensive anatomic changes, may enable the surgeon to perform relatively conservative surgery, obviating the need for procedures usually reserved for malignant disease.     

Infertility following pelvic inflammatory disease.

OBJECTIVE: To assess the frequency of infertility after pelvic inflammatory disease (PID) and factors important in postinfectious tubal damage in an urban population at high risk for sexually transmitted diseases. METHODS: From a cohort of 213 women with PID documented by laparoscopy and/or endometrial biopsy, 58 women (27% of the initial cohort) were interviewed by phone 2 to 9 years after an index episode of PID. Data regarding the initial history, physical examination, microbiology, laparoscopic, and serologic findings, and data concerning interval contraception, subsequent pregnancy, subsequent infection, and chronic pelvic pain were compared among those with and without infertility at follow up. RESULTS: Nineteen (40%) of the 48 women not using contraception were involuntarily infertile after the index episode of PID. Compared with those who had an interval pregnancy, infertile women were older (P = 0.02), more likely to have a history of infertility prior to the index episode of PID (P = 0.001), and were more likely to have occluded or partially occluded fallopian tubes (P = 0.03), peritubal adhesions (P = 0.007), or perihepatic adhesions (P = 0.02) seen by laparoscopy performed during the index episode. Surprisingly, recovery of Chlamydia trachomatis was negatively related to infertility (P = 0.001), although a similar proportion of both groups had chlamydia immunoglobulin M antibody (40% vs. 31%). Chlamydia heat shock protein was weakly related to infertility (P = 0.08). The isolation of Neisseria gonorrhoeae was not significantly different between groups (53% vs. 57%). CONCLUSIONS: The high rate of postinfection infertility found was probably related to a combination of tubal damage before and during the index episode of PID. Prevention of recurrent PID and better understanding of the pathophysiology of postinfection tubal damage (which may differ between chlamydia and gonorrhea) is needed to develop more effective strategies to reduce permanent tubal damage.     

Bacterial synergy in pelvic inflammatory disease

Summary Polymicrobial aerobic and anaerobic flora are responsible for pelvic inflammatory disease (PID). The most frequent pathogens appear to beNeisseria gonorrhoea and anaerobic bacteria (most commonly anaerobic cocci andBacteroides sp.). Recent studies have demonstrated the recovery ofChlamydia trachomatis in up to a third of these infections. AlthoughN. gonorrhoea is frequently recovered from cervical cultures, it is less commonly recovered from intra-abdominal sites. Recent studies have demonstrated the in-vivo synergistic relationship betweenN. gonorrhoeae andBacteroides fragilis. The growth of each component of the mixed infection was enhanced when these were present together in an abscess. Furthermore, the emergence of encapsulated strains was enhanced in these infections. This synergy enables the organisms to cause more severe local and systemic damage to the host. Therapeutic intervention should include the use of antimicrobial agents effective against both the aerobic and anaerobic components of the mixed infection. Unless such therapy is given, the infection may persist. It is also recommended to use antimicrobials that possess synergy between them against the bacterial pathogens. Agents effective against the anaerobic pathogens are metronidazole, clindamycin and cefoxitin. Antimicrobials effective against the Gram-positive aerobic pathogens andN. gonorrhoeae are spiramycin and penicillins. Aminoglycosides or third generation cephalosporins are effective against Gram-negative enterics. The combination of metronidazole and spiramycin has shown to be synergistic against mixed infections ofBacteroides sp. andN. gonorrhoeae.     

盆腔炎性疾病的抗生素治疗

盆腔炎性疾病指女性上生殖道及其周围组织的一组感染性疾病,是妇科常见疾病,主要采用抗生素药物治疗。一经诊断,应及时、合理、广谱及个体化使用抗生素,彻底清除病原微生物,减少不孕、异位妊娠等后遗症的发生,提高妇女的生存质量。