Question

1. A 20 year-old female college student presents with complaints of crampy abdominal pain for days and vaginal bleeding. She denied symptoms of urinary tract infection and abnormal vaginal discharge, and had not noted any chills or fever. She had no nausea or vomiting. The pain increased in the 24 hours prior to presentation, and at the time of examination she also noted pain in the upper right quadrant. She was sexually active with one partner in the last 3 months and with 3 other partners in the last year. Clinically, this patient was believed to have pelvic inflammatory diseases (PID) and was admitted to the hospital for antibiotic treatment. What would be a likely bacterial cause of this disease (#1 bacterial STD)? How would you diagnose? Why did she not have any previous symptoms of infection? (10 pts)

She was treated with a beta-lactam antibiotic and tetracycline. How effective are beta-lactams in treating infections caused by this organism? What is the rationale for including a beta-lactam? (5 pts).

Answer 1

Pelvic inflammatory disease (PID) is an infectious and inflammatory disorder of the upper female genital tract, including the uterus, fallopian tubes, and adjacent pelvic structures. Infection and inflammation may spread to the abdomen, including perihepatic structures.

What would be a likely bacterial cause of this disease?

Chlamydia trachomatis, Neisseria gonorrhea and Gardnerella vaginalis

Chlamydia trachomatis is the predominant sexually transmitted organism associated with PID.

How would you diagnose?

The diagnosis of acute pelvic inflammatory disease is primarily based on historical and clinical findings. The diagnostic process is imprecise, with no single piece of historical, physical, or laboratory information found to be highly specific or sensitive for the disease. Patients with endocervical infections and PID may be asymptomatic. Uncomplicated endocervical infections with C trachomatis and N gonorrhoeae are underdiagnosed and tend to be undertreated.

Due to the relatively poor specificity and sensitivity of clinical findings, the Centers for Disease Control and Prevention (CDC) has established minimal criteria for the diagnosis of PID. According to these criteria, empiric treatment of PID is indicated when a patient who is at risk for sexually transmitted disease (STD) has pelvic or lower abdominal pain, no identifiable cause for her illness other than PID, and, on pelvic examination, 1 or more of the following minimal criteria,

• Cervical motion tenderness

• Uterine tenderness

• Adnexal tenderness

Why did she not have any previous symptoms of infection?

Most cases of PID are presumed to occur in 2 stages. The first stage is acquisition of a vaginal or cervical infection. This infection is often sexually transmitted and may be asymptomatic. Therefore the patient not felt any previous symptoms.

The second stage is direct ascent of microorganisms from the vulva or cervix to the upper genital tract, with infection and inflammation of these structures. The mechanism by which microorganisms ascend from the lower genital tract is unclear.Intercourse may contribute to the ascent of infection through rhythmic uterine contractions occurring during orgasm. Bacteria may also be carried along with sperm into the uterus and fallopian tubes. Also cervical mucus provides a functional barrier against upward spread, the efficacy of this barrier may be decreased by vaginal inflammation and by hormonal changes that occur during ovulation and menstruation.

How effective are beta-lactams in treating infections caused by this organism? What is the rationale for including a beta-lactam?

Treatment should be initiated fastly and should include empirical broad-spectrum antibiotics to cover the full complement of common organisms. All regimens must be effective against C trachomatis and N gonorrhoeae, as well as against gram-negative facultative organisms, anaerobes, and streptococci.

Usually beta lactams and tetracyclins are treatment of chioce for PID. Third generation cephalosporins among beta lactams are used in PID. The treatment regimen is,

• Ceftriaxone 250 mg intramuscularly (IM) once as a single dose plus

• Doxycycline 100 mg orally twice daily for 14 days

• Metronidazole 500 mg orally twice daily for 14 days can be added if there is evidence or suspicion of vaginitis.