Upper genital tract infections (UGTI)

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    Upper genital tract infections are bacterial infections of the uterus (endometritis) and/or the fallopian tubes (salpingitis), which may be complicated by peritonitis, pelvic abscess or septicaemia.
    UGTI may be sexually transmitted or arise after childbirth or abortion. Antibiotic choices are directed by the most common pathogens in each scenario.
    If peritonitis or pelvic abscess is suspected, request a surgical opinion while initiating antibiotic therapy.

    Clinical features

    Sexually transmitted infections

    Diagnosis may be difficult, as clinical presentation is variable.

    • Suggestive symptoms are: abdominal pain, abnormal vaginal discharge, fever, dyspareunia, menometrorrhagia, dysuria.
    • Infection is probable when one or more of the above symptoms are associated with one or more of the following signs: cervical motion tenderness, adnexal tenderness, tender abdominal mass.

    Infections after childbirth or abortion

    • Most cases present with a typical clinical picture, developing within 2 to 10 days after delivery (caesarean section or vaginal delivery) or abortion (spontaneous or induced):
      • Fever, generally high
      • Abdominal or pelvic pain
      • Malodorous or purulent lochia
      • Enlarged, soft and/or tender uterus
    • Check for retained placenta.
    • In the early stages, fever may be absent or moderate and abdominal pain may be mild.

    Treatment

    • Criteria for hospitalisation include:
      • Clinical suspicion of severe or complicated infection (e.g. peritonitis, abscess, septicaemia)
      • Diagnostic uncertainty (e.g. suspicion of extra-uterine pregnancy, appendicitis)
      • Significant obstacles to ambulatory oral treatment
      • No improvement after 48 hours, or deterioration within 48 hours, of outpatient treatment
    • All other patients may be treated on an ambulatory basis. They should be reassessed routinely on the third day of treatment to evaluate clinical improvement (decrease in pain, absence of fever). If it is difficult to organise routine follow-up, advise patients to return to clinic if there is no improvement after 48 hours of treatment, or sooner if their condition is worsening.

    Sexually transmitted infections

    • Antibiotic therapy combines 3 antibiotics to cover the most frequent causative organisms: gonococci, chlamydiae, and anaerobes.
      • Ambulatory treatment:
        cefixime PO: 400 mg single dose or ceftriaxone IM: 250 mg single dose
        doxycycline PO: 100 mg 2 times daily for 14 days a Citation a. In pregnant/breastfeeding women: erythromycin PO: 1 g 2 times daily or 500 mg 4 times daily for 14 days
        Single dose azithromycin is not effective against chlamydia in the treatment of sexually transmitted UGTI.

        metronidazole PO: 500 mg 2 times daily for 14 days
      • Treatment in hospital:
        ceftriaxone IM: 250 mg once daily
        doxycycline PO: 100 mg 2 times daily for 14 days a Citation a. In pregnant/breastfeeding women: erythromycin PO: 1 g 2 times daily or 500 mg 4 times daily for 14 days
        Single dose azithromycin is not effective against chlamydia in the treatment of sexually transmitted UGTI.

        metronidazole PO or IV infusion: 500 mg 2 times daily for 14 days
        Continue triple therapy for 24 to 48 hours after signs and symptoms have improved (resolution of fever, decrease in pain), then continue doxycycline (or erythromycin) + metronidazole to complete 14 days of treatment.
    • If an IUD is in place, it should be removed (offer another method of contraception).
    • Analgesic treatment according to pain intensity.
    • Treatment of the partner: single dose treatment for both gonorrhoea AND chlamydia (as for Urethral discharge), whether or not symptoms are present.

    Infections after childbirth or abortion

    • Antibiotic therapy: treatment must cover the most frequent causative organisms: anaerobes, Gram negatives and streptococci.
      • Ambulatory treatment (early stages only):
        amoxicillin/clavulanic acid (co-amoxiclav) PO for 7 days
        Use formulations in a ratio of 8:1 or 7:1 exclusively. The dose is expressed in amoxicillin:
        Ratio 8:1: 3000 mg daily (2 tablets of 500/62.5 mg 3 times daily)
        Ratio 7:1: 2625 mg daily (1 tablet of 875/125 mg 3 times daily)
        or
        amoxicillin PO: 1 g 3 times daily + metronidazole PO: 500 mg 3 times daily doses for 7 days
      • Treatment in hospital:
        amoxicillin/clavulanic acid (co-amoxiclav) IV (dose expressed in amoxicillin): 1 g every 8 hours
        gentamicin IM: 5 mg/kg once daily
        or
        ampicillin IV: 2 g every 8 hours
        metronidazole IV infusion: 500 mg every 8 hours
        gentamicin IM: as above
        Stop antibiotic therapy 48 hours after resolution of fever and clinical signs and symptoms.
        In penicillin-allergic patients, use clindamycin IV (900 mg every 8 hours) + gentamicin (as above).
    • In case of placental retention: perform digital curettage or manual vacuum extraction (refer to the guide Essential obstetric and newborn care, MSF) 24 hours after initiation of antibiotic therapy.
    • Analgesic treatment according to pain intensity.
    • If the patient’s condition deteriorates or if fever persists after 48-72 hours of treatment, consider the possibility of complication requiring additional treatment (e.g. pelvic abscess drainage), otherwise change the antibiotic to ceftriaxone + doxycycline + metronidazole as in hospital-based treatment of sexually transmitted UGTI.

     

    Footnotes
    • (a) In pregnant/breastfeeding women: erythromycin PO: 1 g 2 times daily or 500 mg 4 times daily for 14 days
      Single dose azithromycin is not effective against chlamydia in the treatment of sexually transmitted UGTI.