Clinical Manual for Management of the HIV-Infected ... - myCME.com

6–86 | Clinical Manual for Management of the HIV-Infected Adult/2006
P: Plan
Diagnostic Evaluation
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Gram stain of endocervical discharge
Microscopic examination of saline preparation of
vaginal secretions
Endocervical and rectal cultures, urine for N
gonorrhoeae
Endocervical and rectal culture, or nucleic acid
amplification test, for endocervical swab or first void
urine
Pregnancy test (if menses is late or pregnancy is
possible)
Treatment
Because clinical diagnostic criteria for PID are not
always conclusive, presumptive diagnosis and early
treatment is common. The positive predictive value of
a clinical diagnosis is 65-90%. The absence of infection
from the lower genital tract, where samples are usually
taken, does not exclude PID and should not influence
the decision to treat.
Empiric treatment for PID should be initiated in
sexually active women at risk for sexually transmitted
infection if the following minimum criteria are met:
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Uterine or adnexal tenderness
Cervical motion tenderness
Additional criteria that support the diagnosis of PID
include:
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Oral temperature >101° F
Abnormal cervical or vaginal mucopurulent
discharge
Presence of white blood cells in vaginal secretions
Elevated erythrocyte sedimentation rate
Elevated C-reactive protein
Laboratory documentation of infection with N
gonorrhoeae or C trachomatis
Definitive criteria:
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Endometrial biopsy with histopathologic
evidence of endometritis
Transvaginal sonogram showing thickened, fluidfilled
tubes with or without free pelvic fluid or
tubo-ovarian complex
Laparoscopic abnormalities consistent with PID
Treatment considerations
Antimicrobial regimens must provide broad-spectrum
coverage of likely pathogens (Table 1). HIV-infected
women respond equally well to standard antibiotic
regimens as HIV-negative women. Whether the
management HIV-infected women with advanced
immunocompromise requires more aggressive
interventions (eg, hospitalization or parenteral
antimicrobial regimens) has not been determined.
Decisions about whether to use oral or parenteral
therapy must be individualized.
In moderate to severe cases of PID, intrauterine devices
(IUDs) should be removed, if present.
The goals of treatment are to:
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Alleviate the pain and systemic malaise associated
with infection
Achieve microbiological cure
Prevent development of permanent tubal damage
with associated problems, such as chronic pelvic
pain, ectopic pregnancy, and infertility
Prevent the transmission of infection to others
Indications for hospitalization of patients with PID
include:
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Unsure diagnosis; surgical emergency cannot be
excluded
Tubo-ovarian abscess
Severe illness with nausea and vomiting or high
fever
Pregnancy
Inability to follow outpatient regimen
Immunosuppression (low CD4 count or significant
comorbidity)
Pregnancy
If the patient is pregnant, aggressive treatment is
essential to prevent preterm delivery, fetal loss, and
maternal morbidity. Certain medications should
be avoided to reduce the risk of fetal toxicity; these
include doxycycline, fluoroquinolones, and gentamicin.
Hospitalization for parenteral antibiotic therapy is
recommended.