MEDICAL TREATMENT :
From a public health point of view, the goal is to eradicate individual infection and treat potentially infected partners to prevent further spread of STDs. For the individual, the goal of management of salpingitis is to efficiently cure acute infection, thereby preserving fertility and preventing ectopic pregnancy, as well as decreasing the risk of long-term inflammatory sequelae. Early diagnosis and treatment appear to be crucial in the preservation of future fertility. If antibiotic treatment is to prevent complications of disease, it must be initiated early in the disease process. Treatment regimens must include empiric broad-spectrum coverage of all major pathogens, including N gonorrhoeae, C trachomatis, beta-lactamaseโproducing anaerobes, and facultative organisms, especially group B streptococcus and E coli.
A study from the University of Washington demonstrated that after appropriate antimicrobial therapy, significant decreases occurred in abnormal bleeding (60-29%), mucopurulent cervicitis (20-6%), uterine tenderness (20-6%), and histologic endometritis (38-4%) (all p <0.001).
Because of the difficulty of diagnosis and the devastating sequelae, even from mild or atypical disease, the CDC has emphasized that physicians should maintain a low threshold for diagnosis and aggressively treat the infection in women if any suspicion of disease exists. Overtreatment is preferable to missed diagnosis.
CDC recommendations are based in part on the fact that the diagnosis and management of other common causes of lower abdominal pain (eg, ectopic pregnancy, appendicitis, functional pain) are unlikely to be impaired by initiating empiric antimicrobial treatment for salpingitis. Antibiotics should be begun as soon as the diagnosis is suspected. Paying attention to emerging resistance patterns is important. Since the last CDC recommendations were published in 2002, clinically significant resistance to the quinolones has developed in Hawaii and the West Coast of the United States, as well as in Asia.
Unfortunately, at least one small study in an urban teaching hospital suggests poor compliance with all portions of the CDC guidelines.
The CDC recommends several parenteral and oral regimens in the 1998 Guidelines for Treatment of Sexually Transmitted Diseases. The CDC also has noted that little data exist on long-term outcomes with outpatient treatment. For this reason, the CDC has recommended criteria for hospital admission and intravenous antibiotic treatment. These are based on both observational data and theoretical concerns and include the following:
Inability to exclude surgical emergencies, such as appendicitis
Pregnant patients
Patients who do not respond clinically to an adequate oral antibiotic regimen
Patients who are unable to follow or tolerate an outpatient oral regimen
Patients who have severe illness, including nausea, vomiting, or high fever
Patients with TOA
Patients who are immunodeficient (eg, HIV with a decreased CD4 count, taking immunosuppressant drugs, poorly controlled diabetes)
Infections that follow placement of an IUD or after operative or diagnostic procedures are best treated in the hospital with IV antibiotics. Obtain large-bore IV access until ectopic pregnancy can be ruled out. Administer IV fluids if the patient is vomiting or dehydrated. Studies have indicated that patients with pelvic infection are not treated for pain adequately on a routine basis, and only a minority of patients receives narcotics. Treat patients with this condition promptly with analgesics. Patients also may require narcotics. Because tubal damage seems to be a result of inflammation, nonsteroidal anti-inflammatory drugs (NSAIDs) or corticosteroids are theorized to help reduce such damage. At present, studies have revealed no apparent benefit from the addition of these agents.
Surgical Care: Laparoscopy is an important diagnostic and therapeutic tool, particularly when the clinical picture is not completely clear. Laparoscopy may not only aid in the diagnosis of salpingitis, but it also is useful in order to exclude other entities such as appendicitis, ovarian torsion, and endometriosis. Findings consistent with salpingitis include inflammation, free pus or purulent fluid in the cul-de-sac or pelvis, and fresh adhesions in the pelvis. In addition, laparoscopy may be therapeutic. Cultures obtained directly from the pelvis can be used to tailor antibiotic therapy. Furthermore, laparoscopic pelvic lavage, drainage of abscesses, and lysis of adhesions may aid in the treatment of this condition.
Laparotomy generally is reserved for surgical emergencies, such as ruptured abscesses, or failed medical management of tuboovarian abscesses. Laparotomy also may be used for diagnostic purposes in cases where the patient is not a candidate for laparoscopy.
Surgical therapy often is required for cases of salpingitis complicated by TOAs that do not respond to medical management. Persistent or recurrent TOAs require drainage. Percutaneous drainage may be accomplished either via the vagina (posterior colpotomy) or transabdominally using CT or US guidance, depending on the location of the abscess. Patients who are not good candidates for, or fail, percutaneous drainage will require surgical drainage. While reports of successful laparoscopic drainage have been described, the most common method of surgical treatment is laparotomy.
Intraoperative findings and the patient's desire for future fertility dictate treatment. If the abscess only involves one tube and ovary, a unilateral salpingo-oophorectomy is performed and the contralateral adnexa and uterus may be conserved. However, often both adnexa and uterus are involved, requiring hysterectomy and bilateral oophorectomy.
Chronic inflammation associated with TOAs often results in dense pelvic adhesions, making surgery particularly challenging. Ideally, surgery for recurrent disease should be performed when the acute infection has resolved, ie, the patient is afebrile with a normal white count and a relatively nontender pelvis. Intraabdominal rupture of a TOA is the most life-threatening complication of salpingitis, and treatment requires aggressive resuscitation, IV antibiotics, and emergent laparotomy with removal of free pus, abscesses, and, usually, a total abdominal hysterectomy and bilateral salpingo-oophorectomy.
DRUG TREATMENT :
PARENTRAL ANTIBIOTICS : -- Parenteral regimen A includes cefotetan (Cefotan) or cefoxitin (Mefoxin) plus doxycycline (Doryx, Vibra-Tabs, Vibramycin). Parenteral regimen B includes clindamycin (Cleocin) plus gentamicin (Garamycin). Alternative parenteral regimens include ofloxacin (Floxin) plus metronidazole (Flagyl). Another alternative regimen includes ampicillin/sulbactam plus doxycycline (Doryx, Vibra-Tabs, Vibramycin). Ciprofloxacin (Cipro) plus doxycycline (Doryx, Vibra-Tabs, Vibramycin) plus metronidazole (Flagyl) may also be used.
- CEPHALOSPORIN + DOXYCYCLINE
- CLINDAMYCIN + GENTAMYCIN
- OFLOXACIN + METRONIDAZOLE
- AMPICILLIN/SULBACTUM + DOXYCYCLINE
- CIPROFLOXACIN + METRONIDAZOLE + DOXYCYCLINE
2. ORAL ANTIBIOTICS :
- OFLOXACIN + METRONIDAZOLE
- CEFTRIAXONE + PROBENECID + DOXYCYCLINE
Further Inpatient Care:
All patients should demonstrate substantial clinical improvement, with decreased fever and abdominal tenderness within 48-72 hours of initiation of therapy. When a patient's condition is unchanged or has deteriorated after 3 days, either adjunctive treatment with another antibiotic regimen or laparoscopic evaluation may be warranted.
Laparoscopy can confirm the diagnosis and exclude other entities that may require different treatment. Cultures obtained directly from the pelvis can be used to tailor antibiotic therapy. Laparoscopic pelvic lavage and drainage of abscesses have been reported to be therapeutic as well.
In the case of a TOA, 60-80% of patients respond to antibiotics alone. The remaining 20-40% will require either percutaneous or surgical drainage (see Surgical Care).
Further Outpatient Care:
All women who are treated as outpatients with a PO regimen must be reevaluated in 48-72 hours to assess their response to PO therapy. Admit patients who are not significantly improved to the hospital for IV antibiotics.
Continue IV antibiotics until the patient has been improved for 24 hours. Then the patient can be switched to PO antibiotics.
Continue PO antibiotics for a full 2-week course.
Women should remain abstinent from sexual activity until they are cured of symptoms and they have completed their full regimen of antibiotics.
Sexual partners of women with salpingitis have rates of infection with N gonorrhoeae and/or C trachomatis of approximately 50%, and a majority of these individuals are asymptomatic and do not seek treatment.
To prevent reinfection of the patient, ensure that all sex partners of women with this disease are treated before resuming unprotected intercourse.
Treat all sex partners that the patient has had within the 60 days prior to symptom onset.
Transfer:
Patient transfer is reserved for patients who are stable and only if the hospital is unable to manage a patient with acute gynecologic conditions.
Deterrence/Prevention:
Because the sequelae of salpingitis, both overt and silent, are related to the number of infections women experience, further prevention cannot be overemphasized. Three types of prevention must be employed.
Primary prevention involves avoiding either exposure to STDs or acquisition of infection following exposure. Counsel patients regarding safe sex practices in a manner appropriate to both the patient's understanding of sexual issues and stage of development.
When used consistently and correctly throughout sexual activity, a condom appears to be highly effective in preventing acquisition and transmission of the organisms that cause salpingitis. Barrier methods, such as the diaphragm, appear to decrease the risk of upper tract infection. The CDC now recommends against using any form of nonoxynol-9 for STD prevention. Condoms lubricated with nonoxynol-9 have been found to offer no protection against gonorrhea or chlamydial infection. A study of sex workers in Africa demonstrated that spermicide may actually increase infection. Condoms lubricated with nonoxynol have a short shelf life.
Advise patients to avoid high-risk sex partners and limit their number of sex partners. Patients who present for STD evaluation should be given hepatitis B vaccination or referred for vaccination. Hepatitis A vaccine should be administered, or the patient referred for vaccination, to men who have sex with men or patients who use illegal drugs.
Prompt urination and washing of the genitals and postcoital douching have been suggested as methods of preventing STD transmission, but none has proven effective.
Young age also is associated with both biological and behavioral factors that may increase the risk of cervical infection and salpingitis. Teenagers also apparently delay seeking treatment longer than older women. Advise these patients to delay the onset of sexual activity until at least age 16 years, and increase teenagers' awareness of symptoms of cervical infection and salpingitis.
In addition, the use of hormonal contraception may be encouraged to help protect women from ascending infections, but it should not be substituted for barrier methods.
In order to prevent salpingitis following gynecologic procedures, prophylactic antibiotics may be warranted in high-risk patients.
Secondary prevention involves preventing lower genital tract infection from ascending to the upper tract or from being further transmitted in the community.
Because many infected women have no symptoms and their partners often are asymptomatic, routine screening for Chlamydia and Gonorrhea infection is indicated.
Early detection of lower tract infection is crucial to salpingitis prevention strategies. Treat patients with lower tract infection or presumptive lower tract infection in accordance with the CDC guidelines for cervicitis.
Tertiary prevention involves preventing upper tract infection sequelae and educating the patient to seek early treatment for signs and symptoms of salpingitis.
Complications:
Complications of salpingitis include tubal damage and infertility; the rate of infertility increases with the degree of tubal inflammation produced and with increasing numbers of episodes of infection.
Ectopic pregnancy is a major complication of salpingitis and is approximately 7-10 times more common in women who have had 1 episode of salpingitis.
Other complications of the disease include chronic pelvic pain, dyspareunia, and adhesions.