A 20-year-old G2P0020 with an LMP 5 days ago presents to the emergency department with a chief complaint of a 24-hour history of increasing pelvic pain. This morning she experienced chills and fever, although she did not take her temperature. She reports no changes in her bladder or bowel habits. She has had nausea or vomiting, and has not been able to tolerate liquids. She reports no medical problems, and her only surgery was a laparoscopy performed last year for an ectopic pregnancy. She reports regular menses without dysmenorrhea. She is currently sexually active with a new sexual partner, and had intercourse with him just prior to her last menstrual period. She reports no history of abnormal Pap smears or sexually transmitted diseases. Urine pregnancy test is negative. Urinalysis is normal. WBC is 18,000. Temperature is 38.8°C (102°F). On physical examination, her abdomen is diffusely tender in the lower quadrants with rebound and voluntary guarding. Bowel sounds are present but diminished.
Which of the following is the most appropriate initial antibiotic treatment regimen for this patient?
A. Doxycycline 100 mg PO twice daily for 14 daysThe patient is most likely to have PID. Ovarian torsion, appendicitis, and acute salpingitis are all commonly associated with fever, abdominal pain, and elevated white blood cell count. Ruptured ovarian cysts present with acute abdominal pain without fever. Ovarian torsion usually presents as waxing and waning pain that is associated with an adnexal mass. Pain from ruptured ovarian cysts may occur at any time throughout the menstrual cycle but often present around the time of ovulation. Although appendicitis is in the differential diagnosis in any woman presenting with abdominal pain and fever, this patients specific pain history, examination, and associated symptoms are less consistent with appendicitis. In cases of kidney stone, urinalysis usually indicates the presence of blood and there is often flank pain. PID should be managed as an inpatient with intravenous antibiotics in cases where the patient cannot tolerate oral therapy, has not been compliant with oral therapy, has failed oral therapy, or has severe illness with high fever and pain. Outpatient oral therapy may be appropriate for patients with PID who have more mild to moderate symptoms. The decision for inpatient versus outpatient treatment of a patient with PID depends on several factors such as patient compliance, tolerance of oral medications, and certainty of diagnosis. Given this patient’s symptoms, the best treatment for this patient is inpatient intravenous antibiotics. A TOA may form in a patient with untreated PID. A patient with a TOA should also be initially hospitalized and treated with intravenous antibiotics. Patients with TOAs, who do not improve on broadspectrum antibiotics, may require drainage of the abscesses by laparotomy, laparoscopy, or percutaneously under CT guidance.
The recommendation of Centers for Disease Control for inpatient management of PID includes the following:
1. Cefoxitin 2 g IV every 6 hours OR cefotetan 2 g IV every 12 hours PLUS doxycycline 100 mg PO or IV twice daily
OR
2. Clindamycin 900 mg IV every 8 hours PLUS gentamicin loading dose IV or IM (2 mg/kg) followed by maintenance dose (1.5 mg/kg) every 8 hours. Single daily dosing (3-5mg/kg) may be substituted.
The recommendation of Centers for Disease Control for the outpatient management of PID includes the following:
1. Cefoxitin 2 g IM plus probenecid 1 g PO in a single dose concurrently OR ceftriaxone 250 mg IM PLUS doxycycline 100 mg PO twice daily for 14 days WITH OR WITHOUT metronidazole 500 mg PO twice daily for 14 days.