Whatever happened to PID?

 

Guidelines for treating PID continue to evolve, with questions about anaerobic infection and potential options for weekly dosing in select patients. Are you up to date, or are you lagging behind?

During the 1970s, the topic of PID was front and center. The family planning researchers were studying whether IUDs caused it, and whether hormonal contraception protected against it. Those in the infectious disease circles wondered what organisms caused it. Both groups evaluated the best ways to treat it, concerned that symptomatic PID led to tubal factor infertility.

By the 1980s, an all out war on PID was declared. Clinicians performed laparoscopies on all women with lower abdominal pain to determine whether acute PID was present ⁽¹⁾. This usually required hospitalization, a costly and inconvenient experience. Meanwhile, the infectious disease specialists learned that only a minority of PID could be traced to traditional bacterial organisms—gonorrhea and chlamydia. Retrospective studies showed that women with documented tubal factor infertility frequently had chlamydia antibodies but no prior history of lower abdominal pain or PID. Something strange was going on.

Fast-forward 30 years. STD treatment guidelines flirted with recommending broader antibiotic coverage for symptomatic PID, including metronidazole. In parallel, recognition of the role of subclinical PID in producing tubal factor infertility led to recommending that clinicians adopt a low threshold for initiating antibiotics in women with lower abdominal pain ⁽²⁾. Screening for and treatment of lower genital tract infections—especially chlamydia—became a focus for infertility prevention. Finally, the well-designed PEACH cohort study discovered that outpatient therapy was as effective but less costly and more convenient than inpatient treatment ⁽³⁾. Not surprisingly the number of hospitalized PID cases declined. By 2013, PID management in family planning settings settled down to a relatively routine process.

A recent update to what we currently know about PID has just been published ⁽⁴⁾. It includes the potential role for anaerobes and bacterial vaginosis in PID and the development of chronic reproductive tract disease. Because multiple studies have found that BV-associated bacteria have been isolated from the fallopian tubes of women with symptomatic salpingitis, the CDC recommends that coverage of anaerobes in PID can be “considered.” As of now, this is a clinical judgment call. The experts agreed that the minimum requirement for any PID antibiotic treatment regimen is effectiveness against both gonorrhea and chlamydia. Thus, ceftriaxone 250 mg intramuscularly and oral doxycycline 100 mg twice daily for two weeks remains the standard. One study suggested that oral azithromycin 1 g per week for two weeks could be as effective as daily doxycycline., but this has not yet been confirmed. Prospective trials will be necessary to more definitively understand whether addition of metronidazole to this regimen can affect both subclinical endometritis, as well as its long-term sequelae of tubal infertility.

For women with mild or moderate clinical severity, hospitalization is not necessary.  We know now that our move to outpatient-based therapy has saved costs and enabled proactive treatment for women with mild and moderate PID. Future research on the next steps for managing PID and reducing its long-term consequences will require additional diagnostic tools such as endometrial biopsy, diagnostic imaging methods, and bacterial genomic studies may help further clarify this is elusive syndrome. Stay tuned.

References

1. Westrom L, Joesoef R, Reynolds G, et al. Pelvic inflammatory disease and fertility. A cohort study of 1844 women with laparoscopically verified disease and 657 control women with normal laparoscopic results. Sex Transm Dis 1992; 19:185–192.
2. Wiesenfeld HC, Hillier SL, Meyn LA, et al. Subclinical pelvic inflammatory disease and infertility. Obstet Gynecol 2012
3. Ness RB, Soper DE, Holley RL, et al. Effectiveness of inpatient and outpatient treatment strategies for women with pelvic inflammatory disease: results from the pelvic inflammatory disease evaluation and clinical health peach randomized trial. Am J Obstet Gynecol 2002; 186:929–937.
4. Darville T, The pelvic inflammatory disease workshop proceedings committee. Pelvic inflammatory disease: identifying research gaps – proceedings of a workshop sponsored by Department of Health and Human Services/National Institutes of Health/National Institute of Allergy and Infectious Diseases, November 3–4, 2011. Sex Trans Dis  2013;40:761–767.

Willard Cates, Jr., MD, MPH, Distinguished scientist and Emeritus President, FHI 360b.