Rosen & Barkin's 5-Minute Emergency Medicine Consult (519 page)

• No specific pre-hospital considerations
  
• Appropriate pain management
  

• Resuscitation rarely indicated
  
• Pain control
  

• Ceftriaxone or cefoxitin/probenecid + doxycycline; with metronidazole when anaerobes are a particular concern
  
• Alternatives include ceftriaxone + azithromycin.
  
• Must evaluate and treat sex partner as appropriate
  

• Doxycycline + cefoxitin or cefotetan
  
• Alternatives include gentamicin + clindamycin; or ampicillin/sulbactam + doxycycline
  
• Continue parenteral antibiotic administration for 24 hr after clinical improvement, then switch to oral antibiotics to finish 14 day course
  
• Laparoscopy can be used to lyse adhesions in the acute and chronic stages of Fitz-Hugh–Curtis syndrome
  
• Add metronidazole when anaerobes are a particular concern
  

• Ampicillin/sulbactam: 3 g IV q6h
  
• Azithromycin: 1 g PO once per week for 2 wk
  
• Cefotetan: 2 g IV q12h
  
• Cefoxitin: 2 g IM single dose (outpatient); 2 g IV q6h (inpatient)
  
• Ceftriaxone: 250 mg IM single dose
  
• Clindamycin: 450 mg PO QID for 14 days (outpatient); 900 mg IV q8h (inpatient)
  
• Doxycycline: 100 mg PO BID for 14 days (outpatient); 100 mg IV or PO q12h (inpatient)
  
  • Oral doxycycline is preferred due to pain of IV infusion
    
  • IV and oral doxycycline have similar bioavailability
    
• Gentamicin: 2 mg/kg loading dose followed by 1.5 mg/kg IV q8h. Single daily IV dosing of gentamicin may also be used.
  
• Metronidazole: 500 mg PO BID for 14 days (outpatient); 500 mg IV q8h (inpatient)
  
• Probenecid: 1 g PO single dose
  

• For outpatient:
  
  • Ceftriaxone or cefoxitin/probenecid + doxycycline
    
    • With metronidazole when anaerobes are a particular concern, in suspected
      Trichomonas vaginalis
      infection
      
    • Or in women with recent history of pelvic instrumentation
      
• Of note, oral cephalosporins are no longer a recommended treatment for gonococcal infections (CDC recommends combination therapy with single IM dose of ceftriaxone + oral azithromycin or doxycycline)
  
• For inpatient:
  
  • Doxycycline + cefoxitin or cefotetan
    

• For outpatient:
  
  • Ceftriaxone + azithromycin with or without metronidazole
    
• For inpatient:
  
  • Gentamicin + clindamycin; or ampicillin/sulbactam + doxycycline
    

FOLLOW-UP

• Uncertain diagnosis and toxic appearance
  
• Suspected pelvic abscess, including TOA
  
• Pregnancy
  
• Immunodeficiency
  
• Severe illness (e.g., vomiting or severe pain)
  
• Failure of outpatient therapy
  
• Probable noncompliance with outpatient therapy (e.g., adolescents)
  
• Consider admission if appropriate clinical follow-up cannot be arranged
  

• Patients who do not meet admission criteria may be treated as outpatients
  
• Recent studies have shown that in women with mild to moderate PID, there was no difference in reproductive outcomes between women randomized to inpatient vs. outpatient treatment
  

TOAs may require drainage or surgical intervention in addition to antibiotics

• If outpatient therapy is selected, it is important to have follow-up in 48–72 hr to assess for clinical improvement
  
• If the patient has not defervesced by 72 hr, inpatient treatment and further evaluation should be considered
  

• PID represents a spectrum of disease from simple endometritis to fatal intra-abdominal sepsis
  
• Quinolones and oral cephalosporins are no longer recommended in US for the treatment of gonorrhea or associated conditions such as PID, due to increasing rates of resistance
  
• Patients with PID should have extensive counseling and testing for other STDs, including HIV
  
• Male sex partners of women with PID should be treated if they had sexual contact with the patient during the previous 60 days prior to the patient’s onset of symptoms
  

• Centers for Disease Control and Prevention (CDC). Update to CDC’s sexually transmitted diseases treatment guidelines, 2006: Fluoroquinolones no longer recommended for treatment of gonococcal infections.
  MMWR Morb Mortal Wkly Rep
  . 2007;56:332–336.
  
• Centers for Disease Control and Prevention. 2010 STD Treatment Guidelines. Available at
  http://www.cdc.gov/std/treatment/2010/default.htm
  
• Judlin P, Liao Q, Liu Z, et al. Efficacy and safety of moxifloxacin in uncomplicated pelvic inflammatory disease: The MONALISA study.
  BJOG.
  2010;117:1475–1484.
  
• Ness RB, Trautmann G, Richter HE, et al. Effectiveness of treatment strategies of some women with pelvic inflammatory disease: A randomized trial.
  Obstet Gynecol
  . 2005;106:573–580.
  
• Owusu-Edusei K Jr, Bohm MK, Chesson HW, et al. Chlamydia screening and pelvic inflammatory disease: Insights from exploratory time-series analyses.
  AM J Prev Med.
  2010;38:652–657.
  
• Savaris RF, Teixeira LM, Torres TG, et al. Comparing ceftriaxone plus azithromycin or doxycycline for pelvic inflammatory disease: A randomized controlled trial.
  Obstet Gynecol
  . 2007;110:53–60.
  
• Short VL, Totten PA, Ness RB, et al. Clinical presentation of Mycoplasma genitalium Infection versus Neisseria gonorrhoeae infection among women with pelvic inflammatory disease.
  Clin Infect Dis.
  2009;48:41–47.
  
• Soper DE. Pelvic inflammatory disease.
  Obstet Gynecol.
  2010;116:419–428.
  
• Wiesenfeld HC, Hillier SL, Meyn LA, et al. Subclinical pelvic inflammatory disease and infertility.
  Obstet Gynecol.
  2012;120:37–43.
  
• Workowski KA, Berman S, Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines, 2010.
  MMWR Recomm Rep.
  2010;59:1--110.
  

CODES

• 079.88 Other specified chlamydial infection
  
• 098.19 Other gonococcal infection (acute) of upper genitourinary tract
  
• 614.9 Unspecified inflammatory disease of female pelvic organs and tissues
  

BASICS

• Autoantibody (IgG)-mediated blistering disease of the skin and mucous membrane:
  
  • Characterized by loss of cell-to-cell adhesion called acantholysis
    
• Median age 71 yr
  
  • Reports of disease occurring in neonates through elderly
    
• Rare; worldwide incidence 0.7/100,000
  
• Females > males, 66 vs. 34%
  
• Pemphix
  is Greek for bubble or blister
  
• Pemphigus, specific term for autoantibody disease against some portion of epidermis
  
• Pemphigoid: A term describing the group of syndromes that cause a separation of the epidermis from the dermis, typically more benign course
  
• Mortality is highest in those with mucocutaneous involvement
  
  • If untreated, mortality rates average 60–90%, with treatment this nears 5%
    
• 3 major subtypes exist:
  
  • Vulgaris; typically more serious with deeper mucocutaneous involvement:
    
    • Accounts for 70–80% of all pemphigus
      
    • Up to 70% with vulgaris present with oral lesions, which is often the presenting complaint
      
    • Autoantibodies to Dsg 1 and 3
      
    • Affects most races in middle age and elderly Ashkenazi Jews
      
  • Foliaceus; milder and more superficial cutaneous lesions:
    
    • Oral lesions and better prognosis
      
    • Autoantibodies to Dsg 1 only
      
  • Paraneoplastic pemphigus; often with severe mucocutaneous involvement
    
    • Most commonly seen in lymphoreticular malignancies
      

• Pemphigus is rare in neonates and children but may occur in adolescents
  
• Early diagnosis and treatment significantly impact growth, psychological, social, and cultural development
  
• Histopathology is identical to adult disease
  
• Neonates may develop the disease secondary to transplacental transfer of IgG
  
• Neonatal pemphigus spontaneously resolves in several weeks as the maternal antibodies are catabolized
  

Effective treatment of maternal disease prior to conception lowers the risk of neonatal transmission and gestational complications

• IgG autoantibodies are directed against desmosomal cadherins desmoglein 1 and desmoglein 3 found in all keratinocytes
  
• Autoantibodies cause histopathologic acantholysis, cytoskeletal derangements, and apoptosis
  
• Bullae formation is caused by the loss of cell–cell adhesion and separation of the keratinocytes
  
• Immunogenetic predisposition secondary to higher frequencies of specific human leukocyte antigen HLA haplotypes including DR4 and DRw6
  
• Drugs such as penicillamine, captopril, rifampin, piroxicam, and phenobarbital can trigger pemphigoid reactions
  
• Endemic pemphigus foliaceus (fogo selvagem), most common in South America, may be triggered or transmitted by bites from flying insects
  
• Pemphigoid reactions may occur in association with a neoplasm, usually lymphoma (paraneoplastic pemphigus)