Cefotan

The Centers for Disease Control recently released a report on the diagnosis and treatment of pelvic inflammatory disease PID).(1). The following information is derived f rom that report. Diagnosis

Clinical diagnosis of PID is difficult because of the wide variation in symptoms and signs. Many women with PID exhibit subtle, vague or mild symptoms not readily recognized as indicative of PID.

Laparoscopy can be used to obtain a more accurate diagnosis of salpingitis and a more complete bacteriologic diagnosis. However, this diagnostic tool is often neither readily available for acute cases nor easily justified when symptoms and signs are mild and/ or vague. Moreover, endometritis cannot be detected with laparoscopy, nor may subtle inflammation of the fallopian tubes be detected. Consequently, diagnosis of PID is often based on clinical findings supplemented with results of cultures or other tests of samples obtained from the endocervix.

The recommendations for diagnosing PID outlined in the accompanying table are intended to help clinicians both recognize when PID should be suspected and gain additional information to increase diagnostic certainty. These recommendations reflect a growing concern that PID is often not diagnosed, especially among women with mild or atypical clinical signs. Because of the potential for damage to the reproductive health of women by even apparently mild cases of PID, a "low threshold for diagnosis" of PID is recommended. Three qualifications regarding this sensitive diagnostic approach must be noted.

First, the use of highly sensitive PID diagnostic criteria means that many women who do not have PID will be misdiagnosed and treated for PID. Patients and their sexual partners often have strong emotional reactions when faced with the implications of a diagnosis of a sexually transmitted disease. The health care provider must, therefore, carefully inform the patient about a diagnosis of PID. Both the uncertainty of the diagnosis and the value of empiric treatment must be clearly explained.

Second, careful follow-up is necessary. If no clinical improvement has occurred at 48 to 72 hours, other diagnoses (e.g., appendicitis, endometriosis, ruptured ovarian cyst or adnexal torsion) should be reconsidered. Use of alternate or additional antimicrobial therapy should also be considered.

Third, use of even the minimum clinical criteria may exclude some cases of PID. Clinicians should not withhold therapy from a patient in whom they suspect PID but who does not exhibit these criteria.

Treatment

Although several antimicrobial regimens have proved highly effective in achieving clinical cure, no single therapeutic regimen of choice exists for PID. It is a complex syndrome that encompasses a broad spectrum of inflammatory disease (e.g., endometritis, salpingitis and tubo-ovarian abscess) and may be caused by a variety of organisms.

Guidelines for treatment of patients with PID have been designed to provide flexibility in therapeutic choices. Suggested treatment regimens provide a broad spectrum of coverage against likely pathogens. In addition to considering microbial etiology, selection criteria for a treatment regimen should also include institutional availability, cost-control efforts, patient acceptance and regional differences in antimicrobial susceptibility.

The treatment regimens outlined in the accompanying tables represent recommendations, and the specific antibiotics named are examples. Antimicrobial treatment of PID will continue to provide broad-spectrum coverage until more definitive studies are performed. Any regimen used, however, should cover Chlamydia trachomatis, Neisseria gonorrhoeae, anaerobes, gram-negative rods and streptococci.

Continuation of medication after hospital discharge is important, particularly for the treatment of persons who may have C. trachomatis infection. Clindamycin has more complete anaerobic coverage than doxycycline. Although preliminary data suggest that clindamycin is effective against C. trachomatis infection, doxycydine remains the treatment of choice for patients with chlamydial disease. Thus, when C. trachomatis is strongly suspected as an etiologic agent, doxycycline is the preferred alternative. In such instances, doxycycline therapy maybe started while the patient is hospitalized if initiating therapy before hospital discharge will likely improve patient outcome.

Clinicians have extensive experience with combination therapy with cefoxitin (Mefoxin) and doxycycline or clindamycin and an aminoglycoside, as outlined in the table on inpatient treatment. Each of these regimens provides broad coverage against polymicrobial infection and has been shown in numerous studies to be highly effective in achieving clinical cures. However, data are lacking on the efficacy of these regimens, as well as other regimens, in preventing late sequelae.

Cefotetan (Cefotan) has properties similar to those of cefoxitin and requires less frequent dosing. Clinical data are limited on the use of other third-generation cephalosporins, such as ceftizoxime (Cefizox), cefotaxime (Claforan) and ceftriaxone (Rocephin), in place of cefoxitin or cefotetan, although many authorities believe they are effective. The bioavailability of doxycycline administered orally is similar to that of the intravenous formulation, and oral doxycycline may be given if gastrointestinal function is normal.

Experimental studies suggest that aminoglycosides may not be optimal when gram-negative organisms are present within abscesses, but clinical studies suggest that aminoglycosides are highly effective for abscesses when an aminoglycoside is administered in combination with clindamycin.

The empiric regimens outlined in the table on outpatient treatment provide broad-spectrum coverage against the common etiologic agents in PID. These regimens were particularly designed to treat persons with chlamydial and gonococcal infections; few data are available on the efficacy of these regimens for treating persons with PID, particularly nonchlamydial and nongonococcal PID. Parenteral beta-lactam antibiotics are recommended in all cases. The cephalosporins are effective against gram-negative organisms, including enteric rods, anaerobic organisms and gonococci. Although decreased susceptibility of gonococci to cefoxitin has recently been noted, clinically evident treatment failure has not been a problem.

Patients who do not respond to therapy within 72 hours should be hospitalized for parenteral therapy. Doxycycline provides definitive therapy for chlamydial infections. Patients treated on an outpatient basis need to be monitored closely and reevaluated in 72 hours.

REFERENCES

1. Pelvic inflammatory disease: guidelines

for prevention and management.

MMWR Recommendations and Reports

1991;40(RR-5):1-25.

COPYRIGHT 1991 American Academy of Family Physicians
COPYRIGHT 2004 Gale Group