Pelvic Inflammatory Treatment

A 24-year-old woman presents to your practice with a diagnosis of pelvic inflammatory disease, suitable for outpatient treatment. Which of the following is recommended? Chose two that apply.

A. A single dose of IM ceftriaxone

B. A two-week course of oral doxycycline and oral metronidazole

C. A five-day course of oral azithromycin with a one-week course of oral ciprofloxacin

D. A single dose of IM penicillin
---
YouTube: https://www.youtube.com/watch?v=yZg1jA7SkAc&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=84

Visit fhea.com to learn more!

Transcript

Voiceover: Welcome to NP Certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. 

So, if you're ready, let's jump right in. 

Margaret Fitzgerald: A 24-year-old woman presents to your practice with a diagnosis of pelvic inflammatory disease, suitable for outpatient treatment. Which of the following is recommended? Chose two that apply.  

A: A single dose of IM ceftriaxone.  

B: A 2-week course of oral doxycycline and oral metronidazole. 

C: A 5-day course of oral azithromycin with a 1-week course of oral ciprofloxacin. 

D: A single dose of IM penicillin. 

The correct answers are A: A single dose of IM ceftriaxone and B: A 2-week course of oral doxycycline and oral metronidazole. 

Where should we start with this question? First, figure out what kind of a question it is. It's really clear here we're being asked to treat a previously made diagnosis, therefore this is a plan question. As we always do, let’s take a look at some background information. PID is an upper reproductive tract infection found in females, and consists of endometritis, salpingitis, and oophoritis. 

In other words, this infection involves the lining of the uterus, that's the endometritis; the fallopian tubes, the salpingitis; and the ovaries and surrounding structures, that's the oophoritis. About 60% of the time the problematic pathogen in this infection is sexually acquired and it is most often seen in females aged 25 years or younger who are sexually active with more than one person or have a partner who is sexually active with more than one person. 

Most common pathogens contributing to PID will include the STI organisms like Chlamydia trachomatis and Neisseria gonorrheae. At the same time, upwards to 40% of these infections are polymicrobial and the additional organisms could include Haemophilus influenzae, assorted streptococcus species, select anaerobes, and select ureaplasma and mycoplasma species. As you'll notice, many of these organisms often also cause lower reproductive tract infections, such as urethritis, cervicitis, and vaginitis.  

PID treatment options differ according to patient presentation. Most often with PID, the patient will be able to keep down oral medications and attend to hydration. In that case, treatment is as an outpatient with oral and parenteral antibiotics. Indeed, we're not being given much information about this patient. But remember, on the NP boards, you are given enough information to answer the question correctly. 

We're told that this is a person with PID who can be treated as an outpatient, and that's how we need to plan. So, no bringing in the 'yeah buts’, that we're often famous for. ‘Yeah, but I want to know more.’ This is what you know, you've got enough to answer the question. So, as was mentioned, PID can be polymicrobial in origin and hence treated with a variety of antibiotics. 

And we know that ceftriaxone and doxycycline will take care of two of the more common causative organisms: Chlamydia trachomatis and Neisseria gonorrheae. The metronidazole is added in the treatment of PID to provide coverage against anaerobes that might be in the pathogen mix. And this was demonstrated in a large clinical trial maybe 10-plus years ago, where it was noted among people treated with PID with ceftriaxone and doxy alone fared much poorer than people treated with IM ceftriaxone, doxy, and metronidazole.  

And this is also consistent with the CDC recommendations. In the presence of tubo-ovarian abscess, pregnancy, and/or severe GI upset that would preclude keeping down oral antibiotics, PID is usually treated in the inpatient setting to help manage hydration status and provide an IV antimicrobial. So, with that in mind, let's take a look at the question again and review the treatment options. 

A 24-year-old woman presents to your practice with a diagnosis of PID suitable for outpatient treatment. Which of the following is recommended? Choose two that apply. 

A: A single dose of IM ceftriaxone. This is of course one of the two correct options with ceftriaxone providing coverage against the gonococcal organism, as well as select streptococcus species. 

Keep in mind, we all need to be well-informed about antimicrobial stewardship. In other words, knowing when to prescribe antimicrobials and when not to prescribe. And then when we have to prescribe, prescribing the right option that's quite focused on the likely causative organisms. Unfortunately, ceftriaxone is considered to be the only drug left on earth that can be given IM, therefore fairly easily that provides activity against about 95% of all Neisseria gonorrheae organisms, and we have to be good stewards of these antibiotics.  

Use them when they're needed, don't use them when they're not. B: A 2-week course of oral doxycycline and oral metronidazole. Of course, as I mentioned, this is the right answer that the doxycycline will provide activity against Chlamydia trachomatis, Ureaplasma urelyticum, Mycoplasma genitalium, and the metronidazole will provide activity against the upper reproductive tract anaerobes. 

So, that coupled with the IM ceftriaxone, you've got pretty much all the causative bugs covered. Option C: A 5-day course of oral azithromycin with a 1-week course of ciprofloxacin. I know this question has a really odd format, but that's potentially found on one of the board exams where they'll ask you to choose two out of the four correct items. 

When looking at this one, you might think, ‘Wait azithromycin has been used in select STIs,’ but that was prior to the CDC's latest update. Because of extensive overuse, azithromycin's activity against Chlamydia trachomatis is waning. In addition, ciprofloxacin's activity is largely against gram-negative organisms that are usually not included in the most common PID pathogens. Option D, another incorrect answer, a single dose of IM penicillin. 

Honestly, we would need to roll the clock back about 40 years before we could find that IM penicillin is helpful in treating STIs, such as Neisseria gonorrheae. And this is due to rising antimicrobial resistance. As a matter of fact, when I first got out of NP school I remember learning that penicillin could be used to treat gonorrhea, but that was in the past. Key takeaway: even in PID, when you know you will have testing for pathogens pending, empiric antimicrobial therapy is the rule which is the choice of an antimicrobial based on the most likely pathogen or pathogens. 

This forms the backbone for clinical guidelines and guides safe and effective clinical practice.  

Voiceover: Thank you for listening to NP Certification Q&A presented by Fitzgerald Health Education Associates. Please rate, review, and subscribe to this podcast and for more NP resources, visit FHEA.com.