Analgesics For PID

• Paracetamol is safe and effective antipyretic and analgesic.
• Ibuprofen is effective in pain management.
• Codeine is used with or without paracetamol, if paracetamol is not sufficient to produce the effect and if Codeine is used separately has wider range of dosing in pain management.

Use Of Metronidazole In PID

Metronidazole is added to provide coverage to anaerobes, as initial infection with Chlamydia or Neisseria gonorrhea can cause epithelial damage and allowing other organisms to invade the cervix and cause ascending infection.

Adverse Effects Of Antibiotics Used In PID

• Broad spectrum antibiotics cause gastrointestinal side effects such as nausea, vomiting or diarrhea.
• Ceftriaxone is a cephalosporin antibiotic, patients having allergy to penicillins show cross sensitivity to cephalosporins in about 8% of the people, in that case cephalosporins to be avoided.
• Metronidazole causes gastrointestinal side effects such as nausea, vomiting and metallic taste. Metronidazole causes disulfiram-like reactions (such as increased heart rate, increased pulse rate, flushing) if used with alcohol. So the patient must be informed about the possible interactions of metronidazole with alcohol.
• Ofloxacin which is a quinolone antibiotic, it causes tendon damage and seizures. If patient suffers pain or inflammation in tendons with the use of this antibiotic, it must be promptly stopped. Seizures are not generally observed in healthy individuals unless or otherwise previous history of epilepsy.
• Doxycycline causes gastrointestinal irritation and photosensitivity.

Antibiotics To Treat PID

• Ceftriaxone 250 mg intramuscularly as a single dose followed by doxycycline 100 mg twice daily orally and metronidazole 400 mg twice daily orally both for 14 days.
• The alternative regimen is cofloxacin 400 mg twice daily orally and metronidazole 400 mg twice daily orally both for 14 days. This regimen is not recommended in gonococcal PID due to increased resistance to gonorrhea infection in the UK.  

Complications of PID

• Tubal infertility occurs in 10% of the women affected with PID,
• Ectopic pregnancy occurs in 1-5% of the women affected with PID and tries to conceive,
• Tubo-ovarian abscess occurs in patients with anaerobic infection,
• Chronic pelvic pain occurs in 30% of the women who have had PID.

Referral Of Patient to Hospital

• If the patient is pregnant,
• If the diagnosis is uncertain (such as appendicitis or ectopic pregnancy could not be excluded),
• If the patient is immunosuppressed (that is HIV positive),
• The patient cannot tolerate oral medicines.

Ideal Place To Manage a case of PID

Ideally all women known with PID should be managed in a GUM (Genito Urinary Medicine) clinic, and treatment should not delay once they are known of PID.

Symptoms of PID

PID is usually asymptomatic and the incidence of PID is unknown. Symptoms include:

• Lower abdominal pain (use to identify PID),
• Dyspareunia,
• Abnormal vaginal bleeding,
• Abnormal vaginal discharge,
• Dysuria,
• Nausea and vomiting (rare in acute infections).

Pelvic Inflammatory Disease

PID is a general term for the infection of the upper genital tract including uterus, fallopian tubes and ovaries; this can be due to the infection in the lower genital tract.

Sexually transmitted infections are common cause; the organisms responsible are Chlamydia trachomatis and Neisseria gonorrhea.

No specific symptom, sign or laboratory finding is both sensitive for the diagnosis of pelvic inflammatory disease.

Nutritional Advice In Pregnancy

A healthy diet in pregnancy prevents low birth weight infant, the diet should include pulses, fish, and cereals, lean meat, bread, rice, potatoes, fruits and vegetables and low fat milk and diary. Listeriosis is a serious disease in pregnancy which is rare and is caused by undercooked meat, eggs, poultry, Camembert, Brie, blue veined cheeses. Fruits, vegetables and salads must be washed thoroughly.

Counseling the patient on the use of Antibiotic for UTI

You have been prescribed cephalexin, which must be taken every eight hourly for seven days; the patient has to complete the course as prescribed.

Are you allergic to any antibiotics? (Approximately 10 %of the patients who are allergic to penicillins are also allergic to cephalosporins).

Antibiotics contraindicated in Pregnancy

Quinolones are contraindicated in all stages of pregnancy due to associated risk of arthropathy.

Antibiotics to be used with caution in Pregnancy

Trimethoprim can be used in women if she has no folate deficiency or if she is not using folate antagonists. Trimethoprim can be given with folic acid to avoid neural tube defects in fetus during the first trimester of pregnancy. Trimethoprim cannot be used repeatedly (within three months) due to recurrent infections resistant to this drug.

Co-amoxiclav which is a combination of amoxicillin and clavulanic acid can be tolerated well in pregnancy. Nitrofurantoin can be used in women if she is not glucose 6 phosphate dehydrogenase deficient, if G6PD deficient then infant has chance of hemolysis if used near term, so it is not recommended to use during third trimester of pregnancy. The tablet formulation of nitrofurantoin can be better tolerated. Other formulation that is microcrystalline powder filled capsules as twice daily modified release can be used as an alternative if there is nausea.

Second generation cephalosporins are not well absorbed orally and are more expensive than first generation cephalosporins and have more gastrointestinal side effects, so are used only when specifically indicated.

Third generation cephalosporins are only used parenterally and are reserved for use in hospital settings.

Pivmecillinam is not known to be teratogenic but is not recommended to be used in pregnancy because of insufficient safety data available.

Safe Antibiotics In Pregnancy

Amoxicillin is used only if the organisms are sensitive to penicillins. Penicillins are not associated with the risk to the fetus.

Cephalexin can also be used, it is a first generation cephalosporin, it is also not associated with increased risk to the fetus and is effective in most urinary pathogens.