GPs should be vigilant for pelvic inflammatory disease

Pelvic inflammatory disease (PID) typically results from ascending infection through the endocervix, from the lower to the upper genital tract. This leads to inflammation of the endometrium, uterus, fallopian tubes, adnexal structures or pelvic peritoneum. PID accounts for one in 60 GP consultations by women under 45. The long-term effects of PID include chronic pelvic pain, subfertility and ectopic pregnancy. The most common cause of PID is sexually transmitted infection. Patients with PID may be asymptomatic or may present with a spectrum of symptoms including: lower abdominal pain (typically bilateral, sometimes radiating to the legs, abnormal vaginal or cervical discharge (often purulent), dysuria, deep dyspareunia and abnormal vaginal bleeding (postcoital, intermenstrual and breakthrough). A general, abdominal and pelvic examination should be performed. Outpatient therapy is considered to be as effective as inpatient treatment for patients with clinically mild to moderate PID. Most clinical trial data support the use of IM cefoxitin, however, as this drug is not readily available in the U.K. ceftriaxone has been deemed a suitable alternative. Metronidazole is usually included in most outpatient regimens to cover for the presence of anaerobes. The duration of outpatient treatment is usually 14 days. Patients should be told to avoid any form of sexual intercourse until they, and their partner(s) have completed their full course of treatment.

Uterine cervical non-gonococcal and non-chlamydial bacterial flora and its antibiotic sensitivity in women with pelvic inflammatory disease: did it vary over 20 years?

BACKGROUND

Although the presence of bacteria in the cervix is not a sign of disease, the majority of pathogens involved in pelvic inflammatory disease originate from this "normal" flora.

OBJECTIVES

To assess the distribution of cervical nongonococcal and non-chlamydial bacteria in hospitalized women with PID and the bacteria's antibiotic sensitivity.

METHODS

We retrospectively evaluated the cultures obtained from the uterine cervix over a 1 year period (2008) at Wolfson Medical Center, Holon. The distribution of cervical nongonococcal and non-chlamydial bacteria in women with PID and the bacteria's antibiotic sensitivity was compared to that in our previous 1 year study that was performed at Kaplan Medical Center, Rehovot (1988-89).

RESULTS

In 2008, a total of 412 cultures were obtained of which 126 (30.5%) were sterile. The prevalence of negative cultures was similar in 2008 and in 1988, namely, 30.5% and 33.7%, respectively (P = 0.23). PID was finally diagnosed in 116 patients with positive cultures. The most prevalent bacteria in the 2008 study were Enterococcus species and Escherichia coli- 24.0% and 26.4% respectively compared to 18.0% and 38.1% in the 1988 study, with the decrease in E. coli isolates being significant (P = 0.0003). In 2008 the antimicrobial sensitivity for various antibiotics ranged from 44.3% to 100.0% (median 90.2%) while in 1988 it ranged from 2.9% to 80.1% (median 51.9%).

CONCLUSIONS

The cervical bacterial flora in hospitalized women with PID did not vary significantly between 1988 and 2008. However, antimicrobial sensitivity of the isolated bacteria increased dramatically, probably due to a decrease in resistance to antibiotics.

Comparison of anti-inflammatory and anti-nociceptive activities of Curcuma wenyujin Y.H. Chen et C. Ling and Scutellaria baicalensis Georgi

The study aimed to compare the anti-inflammatory and anti-nociceptive activities of Curcuma wenyujin Y.H. Chen et C. Ling (Curcuma wenyujin) and Scutellaria baicalensis Georgi (Scutellaria baicalensis). This study used three parts to compare the two herbs. Firstly, animals were randomly divided into a Scutellaria baicalensis group, a Curcuma wenyujin group, an indomethacin group, and a model-control group to perform an ear edema test, a carrageenin-induced paw edema test, a cotton pellet-induced granuloma formation test, and an acetic acid-induced writhing test. Secondly, model rats with pelvic inflammation were established, and the serum levels of TNF-α and IL-6 in each group was detected with the Enzyme-Linked Immunosorbent Assay (ELISA). Thirdly, pharmacokinetics analysis of Scutellaria baicalensis and Curcuma wenyujin was conducted on the model rats. The ear edema test, carrageenin-induced paw edema test, cotton pellet-induced granuloma formation test, and acetic acid-induced writhing test all showed that Curcuma wenyujin had stronger anti-inflammatory and anti-nociceptive effects than Scutellaria baicalensis. There is significant difference between the effects of Curcuma wenyujin and Scutellaria baicalensis on the levels of TNF-α and IL-6 for the model rats. Curcuma wenyujin decreased the levels of TNF-α and IL-6 more than Scutellaria baicalensis. The pharmacokinetics analysis showed that curcumol's Tmax, Cmax, and the area under the curve (AUC) were all higher than baicalin's. This study indicated that for pelvic inflammation, Curcuma wenyujin had better anti-inflammatory and anti-nociceptive effects than Scutellaria baicalensis.

Clinical eficacy of placentrex injection in pelvic inflammatory disease

Combination of placentrex injection with antimicrobial therapy is a better option for treating pelvic inflammatory disease (PID) than only antimicrobial therapy; which also gives more sustained effect and lesser recurrences. Improvements in symptoms continue despite stopping therapy. Addition of placentrex leads to marked improvement in dyspareunia, less fornix tenderness and better uterine mobility suggesting better effect on adnexal tissues and parametrium. As placentrex decreases adnexal inflammation to significant level in comparison to antimicrobials alone, it can be a good option- specially to reduce the risk of tubal damage, infertility and formation of adnexal mass. In a study of 100 cases of PID, 50 in group I and II each; 42 in group 1 and 32 in group II completed the study. Marked reduction in various symptoms was observed in study group I (27-59%) where as in group II where only antimicrobial was given, reduction was found in range of 12-48%. Thus overall, group I had better as well as sustained effect of therapy on relieving dyspareunia, fornix tenderness and uterine restricted mobility which was statistically significant. In other symptoms and signs, there was marginal efficacy except in cervical erosion where no improvement was observed.

Common gynecologic infections

Many women seek care for vulvar, vaginal, or pelvic complaints. Primary care providers should possess a solid understanding of the differential diagnosis and treatment of gynecologic infections. Many infections in the reproductive tract are sexually transmitted, whereas other common infections are attributable to an overgrowth of the normally present bacteria or yeast in the vagina. Presenting symptoms and signs are helpful in determining the source of infection, but often a battery of tests must be performed to make a definitive diagnosis.

Moxifloxacin: new indication. Do not use in gynaecological infections or other conditions

In pelvic inflammatory disease, fluoroquinolones are not first-line drugs and moxifloxacin is the worst of these drugs.

Septic Pelvic Thrombophlebitis and Preeclampsia Are Related Disorders

OBJECTIVE

To elicit factors associated with the postpartum development of septic pelvic thrombophlebitis in a single large referral tertiary patient population.

METHODS

A nine-year single institution retrospective case review of all patients with enigmatic fever and septic pelvic thrombophlebitis was analyzed.

RESULTS

A total of 55 patients with septic pelvic thrombophlebitis were provided care during the study interval. The average gestational age at delivery was 36.8 +/- 4.3 weeks. The most prevalent concurrent medical complication of pregnancy was preeclampsia (45%) while chorioamnionitis affected only 13%. The average length of ruptured membranes was 22.8 +/- 56.8 hours (median 10.5, 95% confidence interval [CI] 7.0-38.7 hours), with 22% of patients undergoing amnion rupture at the time of cesarean delivery. Prolonged (>24 hours) amnion rupture occurred in only 9% of patients. Most affected patients were delivered abdominally (91%) but a minority delivered vaginally (9%). Antibiotic therapy for presumed infection was initiated at 27.4 +/- 24.6 hours postpartum. Subsequently intravenous heparin therapy was initiated 128.9 +/- 54.2 hours thereafter enigmatic fever defervesed 37.2 +/- 36.8 hours later (median 34.0, 95% CI 27.2-47.3 hours). Patients received 6.3 +/- 1.8 days of heparin therapy.

CONCLUSION

In this series, septic pelvic thrombophlebitis was frequently preceded by cesarean delivery and commonly associated with preeclampsia. Unexpectedly, a small number of patients suffered prolonged rupture of membranes or chorioamnionitis. We speculate that the cesarean delivery of a population of at-risk patients with preeclampsia may predispose them to develop septic pelvic thrombophlebitis.

[Abdominal actinomycosis: four cases]

The abdominal actinomycosis (AA) is a rare and often unrecognised suppurative chronic illness. It is caused by an anaerobic Gram positive bacteria, Actinomyces israelii. Abdominal actinomycosis is responsible for pseudotumoral syndrome often leading, to a large and mutilating surgery whereas a prolonged treatment by antibiotics would have permitted to cure the disease. The diagnosis is obtained generally from anatomopathologic exam. We report four cases of abdominal actinomycosis being revealed by a pseudotumoral syndrome. The diagnosis was only made after surgery. In spite of an active treatment by antibiotics during several months, two of our patients had a relapse of the infectious process. These four observations confirm the diagnostic and therapeutic difficulties previously reported by other authors.

[Comparison of clinical efficacies for treatment of 93 patients with chronic pelvic inflammation by Chinese composite yanting decoction medicated via two different paths]

OBJECTIVE

To compare the clinical efficacies of Chinese composite Yanting Decoction medicated via two different paths (via oral and via retention enema) in treating chronic pelvic inflammation.

METHODS

Adopting the randomized multicentered parallel contrast principle, 93 patients were assigned to the retention enema (RE) group (47 cases) and the oral medicated (OM) group (46 cases) at random, Yanting Decoction was administered via respective paths for 10 days as one course. The changes of syndromes (qi-stagnance and blood stasis) and local signs were observed before and after treatment.

RESULTS

In the 47 patients of the RE group, 3 were cured, the treatment was markedly effective in 20, effective in 22 and ineffective in 2, the total effective rate being 95.7%; while in the 46 patients of the OM group, the corresponding number were 1, 8, 30, 7 and 84.8%, respectively, the difference of the total effective rate between groups was statistically significant (P <0.05). The total effective rate for TCM syndromes in the RE and the OM group was 95.7% (45/47) and 82.6% (38/46) respectively, and that for local signs, 97.9% (46/47) and 84.8% (39/46) respectively, the improvements in the RE group were better than those in the OM group (P <0.05).

CONCLUSION

Chinese preparation Yanting Decoction shows good clinical efficacy in treating chronic pelvic inflammation of qi-stagnant blood-stasis type, the effect could be enhanced by medicating via retention enema than that via oral.

A comparative study of injection placentrex and conventional therapy in treatment of pelvic inflammatory disease

To compare the effect of placentrex injection given along with conventional therapy, with conventional treatment alone on the symptoms and signs of pelvic inflammatory disease (PID) ie, abdominal pain, dysmenorrhoea and adnexal tenderness, 50 out of 100 women with PID were randomly assigned to receive intramuscular placentrex injection along with two-week conventional therapy and 50 received conventional treatment only. Abdominal pain, dysmenorrhoea and adnexal tenderness were evaluated at the end of 2 months. There was marked reduction in the sign of adnexal tenderness in the placentrex group as compared to conventional treatment group (p < 0.001). Subjective symptoms of lower abdominal pain and dysmenorrhoea were also relieved better in placentrex group (p < 0.01 and 0.05 respectively). This study showed significant and persistent improvement of signs and symptoms of PID in women who received injection placentrex.

Pelvic inflammatory disease

INTRODUCTION

Pelvic inflammatory disease is caused by infection of the upper female genital tract and is often asymptomatic. Pelvic inflammatory disease is the most common gynaecological reason for admission to hospital in the USA and is diagnosed in almost 2% of women aged 16-45 years consulting their GP in England and Wales.

METHODS AND OUTCOMES

We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of empirical treatment compared with treatment delayed until the results of microbiological investigations are known? How do different antimicrobial regimens compare? What are the effects of routine antibiotic prophylaxis to prevent pelvic inflammatory disease before intrauterine contraceptive device (IUD)8 insertion? We searched: Medline, Embase, The Cochrane Library and other important databases up to May 2007 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

RESULTS

We found 9 systematic reviews, RCTs or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

CONCLUSIONS

In this systematic review we present information relating to the effectiveness and safety of the following interventions: antibiotics (oral, parenteral, empirical treatment, treatment guided by test results, different durations, outpatient, inpatient), and routine antibiotic prophylaxis (before intrauterine device insertion in women at high risk or low risk).

[Fallopian tube primary invasive adenocarcinoma associated with acute inflammatory pelvic disease. Case report and literature review]

The primary fallopian tube invader adenocarcinoma is a preoperative diagnosis rarely reported in the literature, because is the most uncommon of all gynecological tumors, with prevalence from 0.3 to 1.8%. Since its clinical evolution is very unspecific, in general this tumor is diagnosed during a laparothomy for other purpose or by the pathologist in the final histopathological report. The most frequent signs and symptoms are abdominal pain or a pelvic mass in 80% of cases; transvaginal bleeding in 50%, intense transvaginal serohematic discharge (hidrops tubae profluens) in 11.1%, and peritonitis in pelvis in 3.7%. In 25 to 60% of the cases a report of adenocarcinoma in the pap smear with negative endometrial biopsy can be found. The treatment is predominantly surgical, as that of epithelial ovarian carcinoma, and consists of an intraperitoneal washing, total abdominal hysterectomy with bilateral salpingo-oophorectomy and a proper staging. It is required an omentectomy with pelvic and paraaortic lymphadenectomy in systematic way. In the more advanced stages III and IV that required a radical debulking, we have to be very emphatic in citoreduction. In some cases, as the persistence or recurrence of illness, it can be necessary adjuvant chemotherapy. In some patients in early stage I or II with low risk, the complete staging could not be necessary. There is controversy about administration criteria of adjuvant treatment, since there is not evidence of survival increase related to its use. The five years survival rate was 64% for stage I, 42% for stage II, 32% for stage III, and 17% for stage IV. Fallopian tube malignancies are rare and involve a poor prognosis.

Talcum powder, chronic pelvic inflammation and NSAIDs in relation to risk of epithelial ovarian cancer

Chronic inflammation has been proposed as the possible causal mechanism that explains the observed association between certain risk factors, such as the use of talcum powder (talc) in the pelvic region and epithelial ovarian cancer. To address this issue we evaluated the potential role of chronic local ovarian inflammation in the development of the major subtypes of epithelial ovarian cancer. Factors potentially linked to ovarian inflammation were examined in an Australia-wide case-control study comprising 1,576 women with invasive and low malignant potential (LMP) ovarian tumours and 1,509 population-based controls. We confirmed a statistically significant increase in ovarian cancer risk associated with use of talc in the pelvic region (adjusted odds ratio 1.17, 95% CI: 1.01-1.36) that was strongest for the serous and endometrioid subtypes although the latter was not statistically significant (adjusted odds ratios 1.21, 95% CI 1.03-1.44 and 1.18, 95% CI 0.81-1.70, respectively). Other factors potentially associated with ovarian inflammation (pelvic inflammatory disease, human papilloma virus infection and mumps) were not associated with risk but, like others, we found an increased risk of endometrioid and clear cell ovarian cancer only among women with a history of endometriosis. Regular use of aspirin and other nonsteroidal anti-inflammatory drugs was inversely associated with risk of LMP mucinous ovarian tumours only. We conclude that on balance chronic inflammation does not play a major role in the development of ovarian cancer.

Cost-effectiveness of alternative outpatient pelvic inflammatory disease treatment strategies

OBJECTIVE

Effectiveness differences between outpatient pelvic inflammatory disease (PID) treatment regimens are uncertain, but significant differences in cost exist.

GOAL

To examine the influence of antibiotic costs on PID therapy cost-effectiveness.

STUDY DESIGN

The authors used a Markov decision model to estimate the cost-effectiveness of recommended antibiotic regimens for PID and performed a value of information analysis to guide future research.

RESULTS

Antibiotic costs vary between USD 43 and USD188. Pairwise comparisons, assuming a hypothetical 1% relative risk reduction in PID complications with the more expensive regimen, showed economically reasonable cost-effectiveness ratios. Value of information and sample size considerations support further investigation to detect 10% PID complication rate differences between regimens with >or=USD 50 cost differences.

CONCLUSIONS

Within the cost range of recommended regimens, use of more expensive antibiotics would be economically reasonable if relatively small decreases in PID complication rates exist. Further investigation of effectiveness differences between regimens is needed.

[Ten cases of Fitz-Hugh-Curtis syndrome]

Fitz-Hugh-Curtis syndrome, a kind of perihepatitis, occurs approximately in 3 to 10 percent of patients with pelvic inflammatory disease. It is not easy to detect in clinical settings due to requirement of invasive methods for diagnosis, for example, like a laparoscopic examination. Now, it has become possible to recognize it easily with the aid of non-invasive methods including an abdominal dynamic CT scan and laboratory tests. Moreover, it can be improved after the oral administration of antibiotics. Therefore, noninvasive diagnosis is desirable. Herein, clinical characteristics of ten cases of Fitz-Hugh-Curtis syndrome are reported, with a review of the literature.

[Analysis on the significance of pelvic hemodynamics in efficacy evaluation of TCM treatment for chronic pelvic inflammation]

OBJECTIVE

To explore the significance of pelvic hemodynamics as an index in evaluating efficacy of TCM treatment for chronic pelvic inflammation (CPI).

METHODS

Sixty patients with CPI received treatment with Penyanping, a self-formulated TCM recipe, for 30 days, and the changes of pelvic hemodynamic indexes in them were measured before and after treatment within the 3 - 7 days after menstruation using color Doppler.

RESULTS

Improvement of pelvic hemodynamics indexes were shown after treatment in ovarian left arteriopalmus index, bilateral resistance index, maximal speed of left arterial blood flow and score of time-velocity, as compared with those before treatment, the difference was significant respectively (P < 0.05).

CONCLUSION

Pelvic hemodynamic indexes could be taken as one of the objective parameters for evaluating efficacy of TCM treatment of CPI according to principle of activating blood circulation to remove stasis, clearing heat and detoxifying.

[Effect of Penqiangyan Granule on the immune function of patients with chronic pelvic inflammatory disease of blood-stasis and Shen-deficiency syndrome type]

OBJECTIVE

To explore the effect of Penqiangyan Granule (PG) on the immunity of patients with chronic pelvic inflammatory disease (CPID) of blood stasis and Shen-deficiency syndrome (BSSDS) type.

METHODS

Sixty patients were randomly assigned to two groups: the treatment group treated with PG and the control group with Penyanjing Granule, 30 cases in each group. The treatment course was 4 weeks for both groups. The clinical efficacy, plasma levels of CD4 and CD8, and the serum levels of tumor necrosis factor-alpha (TNF-alpha) and interleukin-2 (IL-2) were measured before and after treatment.

RESULTS

After treatment, the total effective rate in the treatment group and the control group was 96.7% and 63.3% respectively with significant difference between groups (P < 0.05); in the treatment group the plasma CD4, CD4/CD8 and serum IL-2 increased obviously, while the plasma CD8 and serum TNF-alpha decreased markedly (P < 0.05), all were significantly different with those in the control group (P < 0.05).

CONCLUSION

PG can improve the immune function and alleviate inflammation in CPID patients of BSSDS type.

Antibiotic therapy for acute pelvic inflammatory disease: the 2006 Centers for Disease Control and Prevention sexually transmitted diseases treatment guidelines

Pelvic inflammatory disease (PID) is a substantial cause of reproductive morbidity in young women. A systematic review of the literature related to PID management was performed in preparation for the 2006 Centers for Disease Control and Prevention sexually transmitted diseases treatment guidelines. This search was conducted using PubMed and was limited to articles written in English and published between 1 January 2002 and 31 January 2005 that were related to PID treatment. Studies were evaluated for new data on PID with regard to site, route, and timing of antimicrobial administration; regimen adherence; experience in adolescents and women >35 years of age; coinfection with human immunodeficiency virus; and management of sex partners. Strong evidence suggests that neither site nor route of treatment administration affects the short- or long-term major outcome of women with mild or moderate clinical presentations. Data on these outcomes in women with more severe clinical presentations are inadequate to provide guidance as to the preferred agents or route of administration. Important contributions to the literature that impact the 2006 guidelines are described in this article.

Comparing Ceftriaxone Plus Azithromycin or Doxycycline for Pelvic Inflammatory Disease

OBJECTIVE

To evaluate the equivalence of ceftriaxone plus doxycycline or azithromycin for cases of mild pelvic inflammatory disease (PID).

METHODS

Patients with PID received an intramuscular injection of 250 mg of ceftriaxone, and were randomly assigned to receive 200 mg/d of doxycycline for 2 weeks, or 1 g of azithromycin per week, for 2 weeks. The degree of pain was assessed on days 2, 7, and 14 and clinical cure was assessed on day 14.

RESULTS

From 133 patients eligible for the study, 13 were excluded for having conditions other than PID, 11 were lost on follow-up, and three had oral intolerance to the antibiotics, yielding 106 for protocol analysis. No significant difference was observed regarding the degree of pain between the doxycycline and azithromycin groups. Clinical cure per protocol was 98.2% (56 of 57; 95% confidence interval [CI], 0.9-0.99) with azithromycin, and 85.7% (42 of 49; 95% CI, 0.72-0.93) with doxycycline (P=0.02). In a modified intention to treat analysis, clinical cure was 90.3% (56 of 62; 95% CI, 0.80-0.96) with azithromycin, and 72.4% (42 of 58; 95% CI, 0.58-0.82) with doxycycline (P=.01); a relative risk of 0.35, and a number needed to treat of six for benefit with azithromycin.

CONCLUSION

When combined with ceftriaxone, 1g of azithromycin weekly for 2 weeks is equivalent to ceftriaxone plus a 14-day course of doxycycline for treating mild PID.

[Surgical treatment of acute purulent inflammatory processes in the pelvic area]

The article gives the results of laparoscopic treatment of 126 patients with the acute inflammatory diseases of annexums of womb and pelvis-peritonitis using ozone solution of antibiotics in the process of operative period. The dynamic laparoscopy was done in 17 cases. Advantages of ozonotherapy were determined during the endosurgical treatment of abscess-inflammatory diseases of the organs of small pelvis in women.

Newest Approaches to Treatment of Pelvic Inflammatory Disease: A Review of Recent Randomized Clinical Trials

Treatment of pelvic inflammatory disease (PID) should provide high rates of clinical and microbiological cure for a range of pathogens and should ultimately prevent reproductive morbidity. Between 1992 and 2006, 5 randomized clinical trials of moxifloxacin (1 trial), ofloxacin (1 trial), clindamycin-ciprofloxacin (1 trial), and azithromycin (2 trials) treatment among women with mild to moderate PID were found to have clinical cure rates of 90%-97%. Trials of ofloxacin and clindamycin-ciprofloxacin reported rates of cure of Neisseria gonorrhoeae and Chlamydia trachomatis infection of 100%, although microbiological cure data for other pathogens were not presented. One azithromycin trial reported a 98% eradication of C. trachomatis, N. gonorrhoeae, Mycoplasma hominis, and anaerobes. Moxifloxacin exhibited high eradication rates for N. gonorrhoeae, C. trachomatis, M. hominis, Mycobacterium genitalium, and gram-negative anaerobes. Clinical cure rates from 2 doxycycline-metronidazole trials were low (35% and 55%). Although a handful of studies have shown that monotherapies for PID achieve high rates of clinical cure, the efficacy of these regimens in treating anaerobic PID and in preventing adverse reproductive sequelae is not fully elucidated.

[Summary of the practice guideline 'Pelvic inflammatory disease' (first revision) from the Dutch College of General Practitioners]

The 1995 guideline on pelvic inflammatory disease (PID) has been updated. The general practitioner should consider PID whenever a woman of childbearing age complains of lower abdominal pain; the diagnosis should then be based on 5 criteria: (a) non-acute lower abdominal pain; (b) pain on upward movement or adnexal tenderness during vaginal touch; (c) painful or swollen adnexae; (d) ESR > or = 15 mm in the 1st hour or a temperature > 38 degree C, and (e) no indications for other diseases, such as appendicitis or an extra-uterine pregnancy. In case of diagnostic doubt, a gynaecologist must be consulted. Rapid treatment with antibiotics diminishes symptoms, shortens the course of disease, and may prevent complications such as infertility or extra-uterine pregnancy. Treatment should be started with ofloxacin and metronidazole. Due to the increasing antibiotic resistance of Neisseria gonorrhoeae, when there are indications for this pathogen the medicinal treatment should immediately be directed at it by means of cefotaxim, doxycycline and metronidazole. In his or her information to the patient, the general practitioner should devote attention to the major role of sexually transmissible micro-organisms and give advice, if necessary, regarding high-risk behaviour.

Peri-implantation pelvic inflammatory disease with normal pregnancy outcome

OBJECTIVE

To report on the presentation, diagnostic assessment, treatment, and outcome of a case of peri-implantation pelvic inflammatory disease.

DESIGN

Case report.

SETTING

Emergency department and gynecology ward of a tertiary university hospital.

PATIENT(S)

A 25-year-old multiparous woman in her 1st month of pregnancy.

INTERVENTION(S)

Diagnostic laparoscopy, antibiotic therapy, and pregnancy surveillance.

MAIN OUTCOME MEASURE(S)

Surveillance and outcome of pregnancy.

RESULT(S)

The patient presented with abdominal pain and fever 26 days after her last menstrual period. Examination revealed peritoneal irritation and cervical tenderness, with free fluid in the pelvis. Diagnostic laparoscopy was performed, with no evidence of ectopic pregnancy. A significant quantity of yellow purulent fluid was drained from the pelvis, which cultured for Escherichia coli. Antibiotic therapy yielded excellent response. The pregnancy continued, with no complications, to healthy term delivery.

CONCLUSION(S)

This rare diagnosis of peri-implantation pelvic inflammatory disease should be considered in the differential diagnosis of abdominal pain in early pregnancy. Timely, rational treatment, including early pelvic drainage and appropriate antibiotic therapy, may save the pregnancy.

[Efficacy of intraosseous administration of antibiotics in the treatment of pelvic inflammatory diseases in women]

The results of complex therapy of 87 young women with severe acute pelvic inflammatory diseases by intraosseous administration of antibiotics were analysed. The efficacy of the intraosseous administration of antibiotics vs. the traditional treatment was estimated.

A review on infection with Chlamydia trachomatis

Infection with Chlamydia trachomatis accounts for the most common bacterial sexually transmitted infection in the UK. Men between 20 and 24 years and women between 16 and 19 years have the highest prevalence of chlamydial infection. Because the majority of women with chlamydial infection are asymptomatic, a proportion remains untreated and eventually develops pelvic inflammatory disease (PID). PID can result in ectopic pregnancy, infertility and chronic pelvic pain. Screening for chlamydial infection might reduce the incidence of complications of PID. The advent of nucleic acid amplification tests and single-dose therapy for chlamydial infection has made home testing and easy treatment possible.

[Clinical investigation on administration method of gatifloxacin based on PK/PD theory]

There have not been sufficient clinical studies based on pharmacokinetics/pharmacodynamics (PK/PD) theory, on which many clinical doctors have recently focused. To consider the optimized administration method based on PK/PD theory for gatifloxacin (GFLX), which was one of the oral fluoroquinolone antibacterial, we influenzae investigated clinical efficacies and adverse events for pelvic inflammatory disease (PID) in giving GFLX daily 400 mg divided twice a day or four times a day. The number of leukocyte and the value of CRP were significantly reduced by chemotherapy in twice a day group, compared with four times a day group. We were able to measure the blood level in 4 cases. The AUC/MIC values for presumption causative bacteria (causative bacteria in both cases: Escherichia coli) in cured patients were 142.28 and 280.16, however, in therapy-failed patients, the AUC/MIC value to presumption causative bacterium were 4.10 (causative bacteria: Prevotella bivia) and 4.35 (causative bacteria: Pseudomonas aeruginosa). These results suggested the importance of the therapeutic method based on PK/PD theory.

[Two adult patients with pneumococcal peritonitis]

Two women, aged 31 and 37 years, had abdominal pain and fever several months after giving birth and a few weeks after receiving an intrauterine device. Both patients were admitted and treated under the working diagnosis of pelvic inflammatory disease (PID). They appeared to have pneumococcal adnexitis and pneumococcal peritonitis. Both patients recovered after initiating directed antibiotic treatment. Peritonitis in previously healthy adults is seldom caused by pneumococci. Standard antibiotics that are effective when given empirically for PID may be a suboptimal treatment for pneumococcal peritonitis.

Epidemiology, pathogenesis and treatment of pelvic inflammatory disease

Pelvic inflammatory disease, the infection and inflammation of the female upper genital tract, is a common cause of infertility, chronic pain and ectopic pregnancy. Diagnosis and management are challenging, due largely to a polymicrobial etiology which is not fully delineated. Signs and symptoms of this syndrome vary widely, further complicating diagnosis and treatment. Due to the potential for serious sequelae, a low threshold for diagnosis and treatment is recommended. Since pelvic inflammatory disease has a multimicrobial etiology including Neisseria gonorrhoeae, Chlamydia trachomatis and anaerobic and mycoplasmal bacteria, treatment of pelvic inflammatory disease should be broad spectrum. Recent treatment trials have focused on shorter duration regimens such as azithromycin and monotherapies including ofloxacin, although data are sparse. Research comparing sequelae development by differing antimicrobial regimens is extremely limited, but will ultimately shape future treatment guidelines. Several promising short-duration and monotherapy antibiotic regimens should be evaluated in pelvic inflammatory disease treatment trials for compliance, microbiological and clinical cure, and reduction of subsequent adverse reproductive and gynecological morbidity.

Use of an institutional intervention to improve quality of care for adolescents treated in pediatric ambulatory settings for pelvic inflammatory disease

PURPOSE

To evaluate the impact of a quality improvement intervention for outpatient management of pelvic inflammatory disease (PID) on provider compliance with published guidelines and to explore issues affecting patient adherence to outpatient care regimens.

METHODS

This study utilized an interrupted time series design. The intervention included an algorithm and clinical practice guideline based on the 2002 Centers for Disease Control STD Guidelines, a complete course of medications to be given at discharge after initial doses given in the site, standardized discharge instructions, close follow-up at 24-48 hours and after two weeks of treatment by a member of the PID team, and a referral for follow-up.

RESULTS

At baseline, 38% of patients did not receive an appropriate medication regimen and only 10% of clinic outpatients returned for follow-up evaluations within 72 hours. In the postintervention group, 91% of patients received an appropriate outpatient regimen and 43% of emergency department and clinic patients returned for care. Based on the results of logistic regression models, adolescents in the postintervention group were 8.4 times more likely (adjusted odds ratio [AOR]: 8.4, confidence interval [CI]: 2.6-26.8, p <. 001) to receive an appropriate outpatient medication regimen than girls in the baseline group. Follow-up interview revealed that 61% of postintervention patients completed all doses of the medication, 67% practiced temporary abstinence, 86% notified their partner for treatment, and 96% were satisfied with their care.

CONCLUSIONS

Interventions utilizing a multi-level approach to the management of outpatient PID improve provider compliance with published guidelines and quality of care delivered to adolescents in academic settings. Many adolescents, however, continue to have difficulty with adherence. Additional research is warranted to address adherence to outpatient regimens for the treatment of PID in adolescent girls.

[Experimental treatment of chronic pelvic inflammatory disease in rats with acupoint injection of Astragalus parenteral solution]

OBJECTIVE

To observe the effect of acupoint injection with astragalus parenteral solution in rat chronic pelvic inflammatory disease (CPID).

METHODS

Fifty female Wistar rats were randomly divided into 6 groups: CPID model was induced in 4 groups, in addition to control group and false surgery group. The rats were given acupoint (Guanyuan and Zusanli) injection with astragalus parenteral solution and saline. The drug group was fed with Qianjinpian solutions. The histopathologic changes of uterus were observed and serum IL-2 and TNF-alpha levels detected.

RESULT

The rats in the model group showed chronic inflammatory changes, the animals in astragalus parenteral injection group and Qianjinpian group showed little histopathological changes. The serum TNF-alpha levels in the model group were significantly higher than those in the normal group and the astragalus parenteral injection group; while the IL-2 levels in model group were significantly lower than those of other 5 groups. The TNF-alpha and IL-2 levels in astragalus parenteral injection group were similar to those of normal group.

CONCLUSION

The treatment of chronic pelvic inflammatory disease with acupoint injection of astragalus parenteral solution might be effective.

Moxifloxacin versus ofloxacin plus metronidazole in uncomplicated pelvic inflammatory disease: results of a multicentre, double blind, randomised trial

OBJECTIVE

This multinational, multicentre, prospective, randomised, double blind, parallel group, non-inferiority study compared the efficacy and safety of moxifloxacin monotherapy with ofloxacin plus metronidazole in women with uncomplicated pelvic inflammatory disease.

METHODS

Women from hospitals throughout 13 countries received a 14 day course of either oral moxifloxacin, 400 mg once daily (n = 384), or oral ofloxacin, 400 mg twice daily plus oral metronidazole, 500 mg twice daily (n = 365).

RESULTS

Of the 741 patients in the intent to treat (ITT) population, 564 (74.2%) were valid for the per protocol (PP) analyses; 112 (19.9%) of these were included in the microbiologically valid population (MBV). Clinical resolution rates in the PP population at the test of cure visit (TOC, 5-24 days post-therapy, primary efficacy end point) were 90.2% (248/275) for moxifloxacin and 90.7% (262/289) for ofloxacin plus metronidazole (95% CI: -5.7% to 4.0%). At follow up (28-42 days post-therapy), resolution rates in the PP population were 85.8% (236/275) and 87.9% (254/289) for moxifloxacin and comparator, respectively (95% CI: -8.0% to 3.1%). Bacteriological success rates in the MBV population at TOC were 87.5% (49/56) for moxifloxacin and 82.1% (46/56) for comparator (95% CI: -8.3% to 18.8%). Against Chlamydia trachomatis and Neisseria gonorrhoeae, bacteriological success rates with moxifloxacin were 88.5% (23/26) and 100% (13/13) and for comparator 85.7% (18/21) and 81.8% (18/22), respectively. Drug related adverse events occurred less frequently with moxifloxacin (22.5% (85/378)) versus the comparator (30.9% (112/363)) (p = 0.01).

CONCLUSION

In uncomplicated PID, once daily moxifloxacin monotherapy was clinically and bacteriologically as efficacious as twice daily ofloxacin plus metronidazole therapy and was associated with fewer drug related adverse events.

Diagnosis and treatment of Neisseria gonorrhoeae infections

The most common site of Neisseria gonorrhoeae infection is the urogenital tract. Men with this infection may experience dysuria with penile discharge, and women may have mild vaginal mucopurulent discharge, severe pelvic pain, or no symptoms. Other N. gonorrhoeae infections include anorectal, conjunctival, pharyngeal, and ovarian/uterine. Infections that occur in the neonatal period may cause ophthalmia neonatorum. If left untreated, N. gonorrhoeae infections can disseminate to other areas of the body, which commonly causes synovium and skin infections. Disseminated gonococcal infection presents as a few skin lesions that are limited to the extremities. These legions start as papules and progress into bullae, petechiae, and necrotic lesions. The most commonly infected joints include wrists, ankles, and the joints of the hands and feet. Urogenital N. gonorrhoeae infections can be diagnosed using culture or nonculture (e.g., the nucleic acid amplification test) techniques. When multiple sites are potentially infected, culture is the only approved diagnostic test. Treatments for uncomplicated urogenital, anorectal, or pharyngeal gonococcal infections include cephalosporins and fluoroquinolones. Fluoroquinolones should not be used in patients who live in or may have contracted gonorrhea in Asia, the Pacific islands, or California, or in men who have sex with men. Gonorrhea infection should prompt physicians to test for other sexually transmitted diseases, including human immunodeficiency virus.

A clinical study on the treatment of chronic pelvic inflammation of Qi-stagnation with blood stasis syndrome by Penyanqing capsule

OBJECTIVE

To observe the clinical efficacy of Penyanqing Capsule (PYQC) in treating pelvic inflammation of Qi-stagnation with blood stasis syndrome.

METHODS

The randomized, single blinded, parallel positive drug controlled method was adopted, with 82 patients assigned into two groups by envelop method. The 42 patients in the treated group received PYQC 3 times a day, 4 capsules each time taken orally; the 40 patients in the control group were given orally Fuyankang tablets (FYKT) 3 times a day, 6 tablets each time. The therapeutic course for both groups was 2 months, and 2 courses of treatment were given successively to observe the comprehensive effect, changes of symptoms and signs before and after treatment. The effects of PYQC on hemorrheological character in part of the patients and on the pathogenetic chlamydia and mycoplasma were also observed.

RESULTS

The total effective rate in the treated group was 83.3%, which was insignificantly different from that in the control group (77.5%, P > 0.05). However, PYQC could significantly lower the hemorrheologic indexes in patients and showed definite influence on the pathogenetic chlamydia and mycoplasma.

CONCLUSION

PYQC has good therapeutic effect in treating chronic pelvic inflammation of Qi-stagnation with blood stasis syndrome, and showed definite effect on chlamydia and mycoplasma.

Diagnosis and treatment of Chlamydia trachomatis infection

Chlamydia trachomatis infection most commonly affects the urogenital tract. In men, the infection usually is symptomatic, with dysuria and a discharge from the penis. Untreated chlamydial infection in men can spread to the epididymis. Most women with chlamydial infection have minimal or no symptoms, but some develop pelvic inflammatory disease. Chlamydial infection in newborns can cause ophthalmia neonatorum. Chlamydial pneumonia can occur at one to three months of age, manifesting as a protracted onset of staccato cough, usually without wheezing or fever. Treatment options for uncomplicated urogenital infections include a single 1-g dose of azithromycin orally, or doxycycline at a dosage of 100 mg orally twice per day for seven days. The recommended treatment during pregnancy is erythromycin base or amoxicillin. The Centers for Disease Control and Prevention and the U.S. Preventive Services Task Force recommend screening for chlamydial infection in women at increased risk of infection and in all women younger than 25 years.

Effect of Human Immunodeficiency Virus-1 Infection on Treatment Outcome of Acute Salpingitis

OBJECTIVE

To examine the effect of human immunodeficiency virus (HIV)-1 infection on treatment outcome of laparoscopically verified acute salpingitis.

METHODS

Women aged 18-40 years with laparoscopically verified acute salpingitis received antibiotic therapy that included cefotetan 2 g intravenously and doxycycline 100 mg orally every 12 hours and laparoscopically guided drainage of tuboovarian abscesses of 4 cm or more. Clinical investigators blinded to HIV-1 serostatus used predetermined clinical criteria, including calculation of a clinical severity score and a standard treatment protocol to assess response to therapy.

RESULTS

Of the 140 women with laparoscopically confirmed acute salpingitis, 61 (44%) women had mild, 38 (27%) had moderate, and 41 (29%) had severe disease (ie, pyosalpinx, tuboovarian abscesses, or both). Fifty-three (38%) were HIV-1-infected. Severe disease was more common in HIV-1-infected in comparison with HIV-1-uninfected women (20 [38%] compared with 21 [24%], P = .02). Defined as time of hospital discharge or 75% or more reduction in baseline clinical severity score, HIV-1-infected women with severe (6 days [4-16] compared with 5 days [3-9], P = .09) but not those with either mild (4 days [2-6] compared with 4 days [2-6] P = .4) or moderate salpingitis (4 days [3-7] compared with 4 days [3-6] P = .32) tended to take longer to meet criteria for clinical improvement. The need for intravenous clindamycin or additional surgery was not different in HIV-1-infected and uninfected cases (15 [28%] compared with 18 [21%], P = .3).

CONCLUSION

Although HIV-1 infection may prolong hospitalization in women with severe salpingitis, all women hospitalized with acute salpingitis responded promptly to antibiotic therapy and surgical drainage regardless of HIV-1 infection status.

LEVEL OF EVIDENCE

II-2.

Atypical presentation of serious pelvic inflammatory disease following mifepristone-induced medical abortion

Mifepristone-induced abortion is increasingly common. Recent alerts have highlighted the occurrence of infrequent but serious complications. We report a case of serious bacterial infection after medical termination that occurred in the absence of the usual signs of infection.

The challenge of pelvic inflammatory disease

Pelvic inflammatory disease (PID) is an infection of the upper genital tract in women that can include endometritis, parametritis, salpingitis, oophoritis, tubo-ovarian abscess, and peritonitis. The spectrum of disease ranges from subclinical, asymptomatic infection to severe, life-threatening illness; sequelae include chronic pelvic pain, ectopic pregnancy, and infertility. PID is diagnosed clinically, with laboratory and imaging studies reserved for patients who have an uncertain diagnosis, are severely ill, or do not respond to initial therapy. The Centers for Disease Control and Prevention diagnostic criteria include uterine, adnexal, or cervical motion tenderness with no other obvious cause in women at risk of PID. Empiric treatment should be initiated promptly and must cover Chlamydia trachomatis and Neisseria gonorrhoeae; the possibility of fluoroquinolone-resistant N. gonorrhoeae also should be considered. Hospitalization for initial parenteral therapy is necessary for patients with tubo-ovarian abscess and for those who are pregnant, severely ill, unable to follow a prescribed treatment plan, or unable to tolerate oral antibiotics. Patients also should be hospitalized if a surgical emergency cannot be excluded or if no clinical improvement occurs after three days. Routine screening for asymptomatic chlamydial infection can help prevent PID and its sequelae.

Intrauterine contraceptive device-associated pelvic actinomycosis caused by Actinomyces urogenitalis

We report a case of intrauterine contraceptive device (IUD) associated pelvic actinomycosis due to Actinomyces urogenitalis in a previously healthy young adult woman. Diagnosis was confirmed by 16S ribosomal RNA gene sequencing of bacterial colonies growing from the extracted device. This is the first documented report of human infection caused by this micro-organism.