A 31-year-old woman is brought to the emergency department due to fever, chills, abdominal pain, and urinary frequency for the past 5 days. She vomited twice today, and her symptoms have become progressively worse. The patient reports increased malodorous vaginal discharge but no abnormal vaginal bleeding. She has no associated dysuria, hematuria, diarrhea, constipation, or sick contacts. The patient has no chronic medical conditions or previous surgeries. Her last menstrual period was a week ago. She is sexually active and uses oral contraceptives. The patient has no known drug allergies. Temperature is 38.9 C (102 F), blood pressure is 100/60 mm Hg, pulse is 110/min, and respirations are 18/min. Physical examination shows a pale and diaphoretic woman. The abdomen is soft, diffusely tender, and nondistended; no rebound tenderness or rigidity is present. Bowel sounds are increased. There is no splenomegaly, costovertebral angle tenderness, or tenderness to palpation of the lower back. On pelvic examination, there is light yellow discharge at the external cervical os and tenderness on lateral movement of the cervix. Laboratory results are as follows:
| Hemoglobin | 12.6 g/dL |
| Mean corpuscular volume | 90 µm3 |
| Leukocytes | 15,000/mm3 |
| Segmented neutrophils | 80% |
| Bands | 7% |
| Eosinophils | 0% |
| Lymphocytes | 12% |
| Monocytes | 1% |
Urinalysis results are unremarkable. Urine pregnancy test is negative. Pelvic ultrasonography shows a small uterus with no adnexal masses. Which of the following is the most appropriate next step in management of this patient?
Pelvic inflammatory disease | |
Symptoms |
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Risk |
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Physical |
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Treatment |
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Complications |
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This patient's fever, abdominal pain, cervical motion tenderness, and mucopurulent cervical discharge are consistent with acute pelvic inflammatory disease (PID). Risk factors include multiple sexual partners, prior PID, inconsistent barrier contraception use, and age 15-25. Complications include tuboovarian abscess, infertility, ectopic pregnancy, and perihepatitis, all of which are reduced with prompt antibiotic treatment (Choice D).
The decision for inpatient versus outpatient management depends on disease severity, ability to tolerate oral antibiotics, and patient compliance. This patient's fever, chills, vomiting, and leukocytosis indicate severe infection and require inpatient treatment with intravenous antibiotics.
PID is a polymicrobial infection, and antibiotic treatment should cover Chlamydia trachomatis, Neisseria gonorrhoeae, and vaginal flora (eg, Escherichia coli, Mycoplasma) that can contaminate the upper genital tract. A cephalosporin, typically cefoxitin, provides coverage of gram-negative bacilli (eg, E coli). The addition of doxycycline treats gram-positive (eg, Streptococcus), gram-negative (eg, N gonorrhoeae), and atypical organisms (eg, C trachomatis, Mycoplasma).
(Choice B) The most common organisms responsible for PID are N gonorrhoeae and C trachomatis, and treatment must cover both. Metronidazole covers anaerobic bacteria, and ceftriaxone is active against N gonorrhoeae; however, neither covers C trachomatis.
(Choice C) Fluoroquinolones such as ciprofloxacin are not recommended for the treatment of PID due to increasing N gonorrhoeae resistance. Metronidazole may be added for additional anaerobic coverage in patients with a tuboovarian abscess. This patient's ultrasound reveals no adnexal masses.
(Choice E) Piperacillin plus tazobactam provides coverage for gram-positive and gram-negative organisms but not against atypical organisms such as C trachomatis.
Educational objective:
Pelvic inflammatory disease (PID) presents with fever, abdominal pain, mucopurulent cervical discharge, and cervical motion tenderness. PID is a polymicrobial infection caused by Chlamydia trachomatis, Neisseria gonorrhoeae, and vaginal flora. Treatment is with broad-spectrum antibiotics (eg, cefoxitin plus doxycycline).