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PID – THE PRICE TO PAY

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  1. PID – THE PRICE TO PAY

  2. Definitions - STIs and RTIs • Sexually transmitted infections (STIs) • Infections that are primarily passed from person to person by sexual contact • STIs are part of a broader group of infections known as reproductive tract infections (RTIs) • RTIs include all infections of the reproductive tract, including those not caused by sexual contact

  3. Magnitude of RTIs in India • No precise statistics available, but evidence from community studies indicate that many Indian women suffer from RTIs • 55 - 70% of women have at least one symptom • Clinical examination – • cervicitis : 8 - 40% • vaginitis : 10 - 15% • PID : 1 - 17%

  4. Magnitude of RTIs in India • Laboratory assessment shows specific infections • bacterial vaginosis : 18.2% • candidiasis : 5.2% • trichomoniasis : 7.5% • chlamydia : 0.5% • gonorrhoea : 0.8% -Integrating RTI Services with Primary Health Care Number 95 March 1998 Population Council

  5. Impact of RTI and STI • Most important sequelae of STD’s is Pelvic Inflammatory Disease (PID). • Affecting young, sexually active women (aged 15 to 25 years). • Accounts for 94% of the morbidity associated with STDs. • Tuberculosis is an RTI which is also responsible for much morbidity in India and should be kept in mind in evaluation of cases of pelvic infections

  6. Seriousness of Complications • STIsaffect both women and men • Women are more susceptible to infection and less likely to seek treatment • Potential complications of untreated RTIs are more serious in women

  7. Seriousness of Complications Complicationsinclude • Infertility • Chronic pelvic pain • Spontaneous abortion • Ectopic pregnancy • Premature labor and delivery • Cardiovascular or neurological problems • Pneumonia, respiratory and eye infections may occur in infants

  8. Sequelae Of PID Tubal Factor Infertility- • 8% women after a single episode • 19.5% after 2 episodes • 40% after 3 or more episodes • The PEACH study reveals that mild to moderate endometritis is not associated with infertility

  9. Sequelae Of PID Ectopic Pregnancy • 7 - 10 fold increase in the rate in women with history of PID. • 6% risk for one episode • 22% risk with 3 or more episodes of salpingitis. Pelvic Adhesions leading to Chronic Pelvic Pain (CPP) • 20% women suffer from CPP. • It is perhaps due to adhesions that result from the inflammatory process.

  10. Accepted Young age Multiple Sexual Partners Prior History of PID Sexually Transmitted Infection Non-use of barrier contraceptives Proposed Low socio-economic status Unmarried Urban Living High frequency of Coitus Use of IUCD Cigarette Smoking Substance Abuse Douching RISK FACTORS FOR PID

  11. Microorganisms Causing PID • Chlamydia trachomatis • Gardnerella vaginalis • Neisseria gonorrhoea • Peptostreptococcus species • Bacteroides species • Ureaplasma species

  12. Diagnostic Criteria • CDC - only 65% - 90% positive predictive value for the clinical diagnosis of PID in their latest guidelines. Minimum criteria • Uterine / adnexal tenderness • Cervical motion tenderness • No other cause of the above signs noted

  13. Diagnostic Criteria Additional criteria that support diagnosis • Oral temperature of greater than 1010 F (>38.30C) • Abnormal cervical or vaginal mucopurulent discharge • Presence of white blood cells on saline microscopy of vaginal secretions • Elevated erythrocyte sedimentation rate • Elevated C-reactive protein • Laboratory documentation of cervical infection with N gonorrhoea or C trachomatis

  14. Treatment • Relief of acute symptoms • Prevention of long-term sequelae of PID • Fertility is enhanced when patients are treated earlier in the disease process ( within 48 hours of onset of symptoms )

  15. Criteria For Hospitalization In Women With PID ( CDC) • Pregnancy • Inability to exclude surgical emergency ( i.e. appendicitis ) • Failure to respond to outpatient oral therapy • Inability to tolerate oral therapy ( eg. severe nausea / vomiting ) • Severe illness ( eg. high fever, peritonitis ) • Presence of Tubo Ovarian abscess

  16. Recommended Treatment Regimens - CDC Parenteral Recommendation: • Cefotetan : 2 gm IV 12h OR • Cefoxitin : 2 gm IV 6h + Doxycycline : 100 mg oral / IV 12h OR • Clindamycin : 900 mg IV 8h + Gentamicin : IV / IM (2mg / kg load, then 1.5 mg / kg 8h)

  17. Recommended Treatment Regimens - CDC Parenteral Recommendation: Alternative • Ofloxacin : 400 mg IV 12h OR • Levofloxacin : 500 mg IV with or without Metronidazole : 500 mg IV 8h OR • Ampicillin / Sulbactam : 3 g IV 6h + Doxycycline : 100 mg po / IV 12

  18. Recommended Treatment Regimens - CDC ORAL • Olfoxacin : 400 mg bd x 14 days OR • Levofloxacin : 500 mg x 14 days with or without Metronidazole : 400 mg po bd x 14 days

  19. Recommended Treatment Regimens - CDC ORAL • Ceftriaxone250 mg : IM x 1 dose OR • Cefoxitin2 mg : IM x 1 dose and Probenicid1g : oral x 1 dose The overall cure rates are • Clinical - 75% to 94% • Microbiological - 71% to 100%

  20. Prevention Primary prevention • Health education and awareness in young women and at-risk teenagers by • brochures • posters • videos • patient education programs in health clinics.

  21. Prevention Secondary prevention • Screening asymptomatic women for evidence of • Lower genital tract infection • Chlamydia by DNA amplification studies in cervical & urine samples of at risk populations.

  22. Prevention • All sexually active women younger than 25 years of age should be screened annually. • Sexual partners should be screened and treated if they had sexual contact with the patient within 60 days of onset of symptoms. • Screening and treatment should be empiric because men often are asymptomatic for Neisseria gonorrhea and Chlamydia trachomatis. • Patient having STDs should be screened for . . . • HIV • Hepatitis B • Syphilis

  23. Asymptomatic infections • Some STIs . . . • Chlamydia • Gonorrhea • Human Papilloma Virus - HPV • Hepatitis B • Genital herpes . . .often cause infections that are asymptomatic • Asymptomatic infections can be transmitted to others and can cause serious complications, particularly for women

  24. Vaginal discharge Vaginitis Cervicitis Candidiasis Chlamydia Trichomonas Neisseria gonorrhoeae Bacterial Vaginosis STIs RTIs

  25. Candidiasis • Gram -positive fungus Candida albicans that flourishes in acidic vagina • Common in diabetics, immuno – compromised women, or those on prolonged antibiotic therapy, OCs or other steroids • Curdy, thick white discharge that adheres to vagina as plaques, which when removed, leaves behind multiple petechial hemorrhagic areas • Intense pruritus, excoriation of vulva and superficial dyspareunia • Wet saline mount with 10% KOH is diagnostic

  26. Treatment Guidelines Candidiasis • Clotrimazole 500 mg per vagina single dose or • Miconazole 400 mg per vagina each night for 3 days

  27. Trichomoniasis • The most common vaginal infection in women • Sexually transmitted • Caused by Trichmonas vaginalis, an actively motile flagellate anaerobic protozoan • 50% are asymptomatic • Secondary infection occasionally seen with E coli or pathogenic cocci

  28. Trichomoniasis • Symptoms – • dysuria • dyspareunia • lower abdominal pain • backache • Malodorous vaginal discharge which is profuse, thin, creamy or slightly green in color and frothy • Pruritus and inflammation of the vulva, and multiple small punctate strawberry spots on the vagina • Wet film is diagnostic

  29. Treatment Guidelines Trichomoniasis • Metronidazole : 2 gm orally single dose • Metronidazole : 500 mg orally twice a day for 7 days For symptomatic relief • Clotrimazole :100mgVaginal Suppository for 7 days

  30. Bacterial Vaginosis (BV) • BV produces a disturbance of the normal vaginal flora • Normally present lactobacilli are reduced and replaced by organisms such as Gardnerella, Ureaplasma, Bacteroids and other anaerobes • Classically BV presents with white or grey fishy smelling vaginal discharge • BV can lead to serious complications in pregnant women like • premature rupture of membranes • preterm labor and delivery • chorioamnionitis • LBW babies

  31. Treatment GuidelinesBacterial Vaginosis Metronidazole: • 400 mg orally twice a day for 7 days or Metronidazole • 2 gm orally single dose First trimester of pregnancy : Clindamycin • 300 mg orally twice a day for 7 days

  32. Chlamydia trachomatis • The most common of all bacterial STIs, • Symptoms include abnormal vaginal discharge and burning during urination • If untreated, chlamydial infection may lead to • pelvic inflammatory disease • ectopic pregnancy • infertility

  33. Treatment Guidelines Chlamydia Non - gonococcal urethritis or cervicitis: • Azithromycin 1 gm : orally single dose orDoxycyline 100 mg : orally twice a day for 7 days or Tetracycline 500 mg : orally four times a day for 7 days If pregnant • Erythromycin 500 mg : orally four times a day for 7 days

  34. Gonorrhoea • N gonorrhoeae is a major STI in both men and women • Green or yellow vaginal discharge • Abnormal vaginal bleeding • Pelvic pain • Burning micturition • Genital lesions may be present

  35. Treatment Guidelines Gonorrhea Gonococcal urethritis / cervicitis: • Cefixine 400 mg : single oral dose or • Ceftriaxone 250 mg : IM single doseplus Treatment for non-gonococcal urethritis or cervicitis

  36. Take Home Message PID – a preventable problem Strategies include : • Target high risk groups eg. the youth • Educate and increase awareness • Implement screening methods especially for high risk groups • Diagnose and treat PID adequately • Treat sexual partners • Promote use of condoms

  37. Concept – Dr. Duru Shah • Contributors Dr. Vanita Raut • Dr. Anahita Chauhan • Dr. Asha R Dalal • Dr. Ameya C Purandare • Editors Dr. Sangeeta Agrawal Dr. Reena Wani

  38. We acknowledge the efforts of our : Coordinators : • Dr. Sangeeta Agrawal - Central • Dr. Narendra Malhotra - North • Dr. Hema Divakar - South • Dr. P. C. Mahapatra - East • Dr. Uday Thanawala - West In bringing the FOGSI YOUTH EXPRESS to your city.

  39. This Youth Express has been possible through an educational grant from : • Charak Pharma Pvt. Ltd • CIPLA Ltd. • Emcure Pharmaceuticals Ltd • GlaxoSmithKline Pharmaceuticals Limited • Glenmark Pharmaceuticals Ltd. • Metropolis Health Services (India) Pvt.Ltd. • Organon India Ltd • Roche Pharmaceuticals Ltd. • Sandoz Private Limited • USV Limited • Wyeth Limited