Pelvic inflammatory disease medical therapy: Difference between revisions

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{{Pelvic inflammatory disease}}
{{Pelvic inflammatory disease}}
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{{CMG}}; {{AE}} {{MehdiP}}


==Overview==
==Overview==
Empiric antimicrobial therapy must be administered to all patients with a confirmed diagnosis of pelvic inflammatory disease. Hospitalization may be necessary for patients who are pregnant, immunodeficient, and those with severe disease. Combination (rather than monotherapy) is recommended to increase coverage, including gram-negative anaerobes. Antimicrobial therapies generally include [[doxycycline]] and a [[β-lactam]]. [[Metronidazole]] may be added to cover anaerobic bacteria.
In order to decrease the risk of complications, treatment should be initiated as soon as the presumptive diagnosis has been made. Hospitalization may be necessary for patients who are [[pregnant]], [[Immunodeficiency|immunodeficient]], and those with severe disease. Combination therapy is recommended to increase anti microbial coverage. Follow up is necessary in all treated patients and partner screening is recommended.


==Medical Therapy==
==Medical Therapy==
*Empiric antimicrobial therapy must be administered to all patients with a confirmed diagnosis of pelvic inflammatory disease.
*Treatment should be initiated as soon as the presumptive diagnosis has been made to decrease the risk of complications.<ref name="pmid12015517">{{cite journal |vauthors=Ness RB, Soper DE, Holley RL, Peipert J, Randall H, Sweet RL, Sondheimer SJ, Hendrix SL, Amortegui A, Trucco G, Songer T, Lave JR, Hillier SL, Bass DC, Kelsey SF |title=Effectiveness of inpatient and outpatient treatment strategies for women with pelvic inflammatory disease: results from the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) Randomized Trial |journal=Am. J. Obstet. Gynecol. |volume=186 |issue=5 |pages=929–37 |year=2002 |pmid=12015517 |doi= |url=}}</ref>
*Combination (rather than monotherapy) is recommended to increase coverage, including gram-negative anaerobes.
*The long term prognosis is highly dependent on immediate appropriate [[antibiotic therapy]].
*Patients are usually treated as outpatients. Indications to hospitalize patients include the following:
*Combination therapy is recommended to increase antibacterial coverage.
:*Severe symptoms (e.g. nausea, vomiting, high-grade fever)
*Patients are usually treated as [[outpatients]].  
:*Pregnancy
Indications for hospital admission include:<ref name="pmid26042815">{{cite journal |vauthors=Workowski KA, Bolan GA |title=Sexually transmitted diseases treatment guidelines, 2015 |journal=MMWR Recomm Rep |volume=64 |issue=RR-03 |pages=1–137 |year=2015 |pmid=26042815 |doi= |url=}}</ref><ref name="pmid25992748">{{cite journal |vauthors=Brunham RC, Gottlieb SL, Paavonen J |title=Pelvic inflammatory disease |journal=N. Engl. J. Med. |volume=372 |issue=21 |pages=2039–48 |year=2015 |pmid=25992748 |doi=10.1056/NEJMra1411426 |url=}}</ref>
:*Immunodeficiency
 
:*No response to PO antimicrobial therapy
*[[Surgical emergency|Surgical emergencies]] (e.g., [[appendicitis]]) cannot be excluded
:*Development of complications, such as tubo-ovarian abscess
*[[Tubo-ovarian abscess]]
:*Monitoring for unconfirmed diagnosis
*[[Pregnancy]]
*Severe illness, [[nausea]] and [[vomiting]], or [[high fever]]
*Unable to follow or tolerate an outpatient oral regimen
*No clinical response to [[Antimicrobial agent|oral antimicrobial therapy]].
 
 
===Antibiotic therapy===
====Parenteral treatment====
*[[Parenteral|Parenteral therapy]] has more benefits than oral/[[intramuscular]] therapy.<ref name="pmid26042815">{{cite journal |vauthors=Workowski KA, Bolan GA |title=Sexually transmitted diseases treatment guidelines, 2015 |journal=MMWR Recomm Rep |volume=64 |issue=RR-03 |pages=1–137 |year=2015 |pmid=26042815 |doi= |url=}}</ref><ref name="pmid27107781">{{cite journal |vauthors=Ford GW, Decker CF |title=Pelvic inflammatory disease |journal=Dis Mon |volume=62 |issue=8 |pages=301–5 |year=2016 |pmid=27107781 |doi=10.1016/j.disamonth.2016.03.015 |url=}}</ref><ref name="pmid25992748">{{cite journal |vauthors=Brunham RC, Gottlieb SL, Paavonen J |title=Pelvic inflammatory disease |journal=N. Engl. J. Med. |volume=372 |issue=21 |pages=2039–48 |year=2015 |pmid=25992748 |doi=10.1056/NEJMra1411426 |url=}}</ref>
*Clinical experience should guide decisions regarding the transition to oral therapy, which can usually be initiated within 24–48 hours of clinical improvement.
 
 
 
{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
|+
! style="background: #4479BA; width: 180px;" | {{fontcolor|#FFFFFF|Rout of administration}}
! style="background: #4479BA; width: 500px;" | {{fontcolor|#FFFFFF|Regimen}}
|-
| style="padding: 7px 7px; background: #DCDCDC;" |'''Parenteral'''
| style="padding: 7px 7px; background: #F5F5F5;" |
Preferred:
:::::[[Cefotetan]] 2 g IV every 12 hours         
:::::::::'''PLUS'''
:::::[[Doxycycline]] 100 mg orally or IV every 12 hours
----
:::::[[Cefoxitin]] 2 g IV every 6 hours
:::::::::'''PLUS'''
:::::[[Doxycycline]] 100 mg orally or IV every 12 hours
----
:::::[[Clindamycin]] 900 mg IV every 8 hours
:::::::::'''PLUS'''
:::::[[Gentamicin]] [[loading dose]] IV or IM (2 mg/kg),  
:::::followed by a [[maintenance dose]] (1.5 mg/kg) every 8 hours.
:::::Single daily dosing (3–5 mg/kg) can be substituted
----
 
Alternative:
:::::[[Ampicillin/Sulbactam]] 3 g IV every 6 hours
:::::::::'''PLUS'''
:::::[[Doxycycline]] 100 mg orally or IV every 12 hours
|-
|}
 
====Intramuscular/Oral Treatment====
*[[Intramuscular]]/oral therapy can be considered for women with mild-to-moderately severe acute PID, because the clinical outcomes among women treated with these regimens are similar to those treated with [[intravenous therapy]].<ref name="pmid26042815">{{cite journal |vauthors=Workowski KA, Bolan GA |title=Sexually transmitted diseases treatment guidelines, 2015 |journal=MMWR Recomm Rep |volume=64 |issue=RR-03 |pages=1–137 |year=2015 |pmid=26042815 |doi= |url=}}</ref>
*Women who do not respond to IM/oral therapy within 72 hours should be reevaluated to confirm the diagnosis and should be administered intravenous therapy.<ref name="pmid12015517">{{cite journal |vauthors=Ness RB, Soper DE, Holley RL, Peipert J, Randall H, Sweet RL, Sondheimer SJ, Hendrix SL, Amortegui A, Trucco G, Songer T, Lave JR, Hillier SL, Bass DC, Kelsey SF |title=Effectiveness of inpatient and outpatient treatment strategies for women with pelvic inflammatory disease: results from the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) Randomized Trial |journal=Am. J. Obstet. Gynecol. |volume=186 |issue=5 |pages=929–37 |year=2002 |pmid=12015517 |doi= |url=}}</ref>
 


==Antimicrobial Therapy==
{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
*Empiric therapy
|+
:*1. '''Parenteral Treatment''' <ref name="pmid21160459">{{cite journal| author=Workowski KA, Berman S, Centers for Disease Control and Prevention (CDC)| title=Sexually transmitted diseases treatment guidelines, 2010. | journal=MMWR Recomm Rep | year= 2010 | volume= 59 | issue= RR-12 | pages= 1-110 | pmid=21160459 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21160459  }} </ref>
! style="background: #4479BA; width: 180px;" | {{fontcolor|#FFFFFF|Rout of administration}}
::* Preferred regimen (1): ([[Cefotetan]] 2 g IV q12h for 14 days {{or}} [[Cefoxitin]] 2 g IV q6h) for 14 days {{and}} [[Doxycycline]] 100 mg PO or IV q12h starting on day 2-3 until day 14
! style="background: #4479BA; width: 500px;" | {{fontcolor|#FFFFFF|Regimen}}
::* Preferred regimen (2): [[Clindamycin]] 900 mg IV q8h for 14 days {{and}} [[Gentamicin]] loading dose IV or IM (2 mg/kg of body weight) followed by a maintenance dose (1.5 mg/kg) q8h for 14 days. Single daily dosing (3-5 mg/kg) can be substituted.
|-
::* Alternative regimen (1): [[Ampicillin]]/[[Sulbactam]] 3 g IV q6h for 14 days {{and}} [[Doxycycline]] 100 mg PO or IV q12h for 14 days
| style="padding: 7px 7px; background: #DCDCDC;" |'''Intramuscular/Oral'''
::* Alternative regimen (2): [[Azithromycin]] 500 mg IV q24 for 1-2 doses followed by 250 mg PO for 5-6 days
| style="padding: 7px 7px; background: #F5F5F5;" |
::* Alternative regimen (3): [[Azithromycin]] 500 mg IV q24 for 1-2 doses followed by 250 mg PO for 5-6 days {{and}} [[Metronidazole]] 500 mg PO bid for 12 days
Preferred:  
::* Note: Oral doxycycline is preferred since IV doxycycline may cause pain. The bioavailabilities of both oral and IV doxycycline are similar.
 
:*2. '''IM/Oral Treatment'''
:::::[[Ceftriaxone]] 250 mg IM in a single dose      
::* Preferred regimen (1): [[Ceftriaxone]] 250 mg IM in a single dose {{and}} [[Doxycycline]] 100 mg PO bid for 14 days {{withorwithout}} [[Metronidazole]] 500 mg PO bid for 14 days
:::::::::'''PLUS'''
::* Preferred regimen (2): [[Cefoxitin]] 2 g IM in a single dose {{and}} [[Probenecid]] 1 g PO administered concurrently in a single dose {{and}} [[Doxycycline]] 100 mg PO bid for 14 days {{withorwithout}} [[Metronidazole]] 500 mg PO bid for 14 days
:::::[[Doxycycline]] 100 mg orally twice a day for 14 days
::*Alternative regimen (1): [[Azithromycin]] 500 mg IV qd for 1-2 doses followed by 250 mg PO qd for 12-14 days {{withorwithout}} [[Metronidazole]] 500 mg PO bid for 14 days
:::::::::'''with/without'''
::* Alternative regimen (1): [[Ceftriaxone]] 250 mg IM single dose and [[Azithromycin]] 1 g PO once a week for 14 days
:::::[[Metronidazole]] 500 mg orally twice a day for 14 days
::* Alternative regimen (2): ([[Levofloxacin]] 500 mg PO qd for 14 days {{or}} [[Ofloxacin]] 400 mg bid for 14 days {{or}} [[Moxifloxacin]] 400 mg PO qd for 14 days}}) {{and}} [[Metronidazole]] 500 mg PO bid for 14 days.
----
*'''Specific considerations'''
:::::[[Cefoxitin]] 2 g IM in a single dose and [[Probenecid]] 1 g orally administered concurrently in a single dose
:*'''Tubo-ovarian abscess'''
:::::::::'''PLUS'''
::*Preferred regimen: [[Doxycycline]] 100 mg PO or IV q12h for 14 days {{and}} ([[Clindamycin]] 450 mg PO qid for 14 days {{or}} [[Metronidazole]] 500 mg PO bid for 14 days)
:::::[[Doxycycline]] 100 mg orally twice a day for 14 days
:::::::::'''with/without'''
:::::[[Metronidazole]] 500 mg orally twice a day for 14 days
----
:::::[[Clindamycin]] 900 mg IV every 8 hours
:::::::::'''PLUS'''
:::::[[Gentamicin]] [[loading dose]] IV or IM (2 mg/kg),
:::::followed by a [[maintenance dose]] (1.5 mg/kg) every 8 hours.
:::::Single daily dosing (3–5 mg/kg) can be substituted
----
----
Alternative:
:::::[[Azithromycin]] 1 g orally once a week for 2 weeks
:::::::::'''PLUS'''
:::::[[ceftriaxone]] 250 mg IM single dose
:::::::::'''with'''
:::::[[Metronidazole]] 500 mg orally twice a day for 14 days
|-
|}


==Follow-up==
==Follow-up==
*Patients should return for re-evaluation at the third day of antimicrobial therapy to evaluate for the success vs. failure of therapy.
*Patients should return for re-evaluation on the third day of [[Antimicrobials|antimicrobial therapy]] to evaluate the success of therapy.
*Patients who do not improve within 3 days of therapy may require hospitalization, additional diagnostic tests, and surgical intervention.
*Patients who do not improve within 3 days of therapy may require hospitalization, additional diagnostic tests, and/or surgical intervention.
*Women with documented chlamydial or gonococcal infections have a high rate of reinfection within 6 months of treatment.
*Women with documented [[chlamydial]] or [[Gonorrhea|gonococcal]] infections have a high rate of reinfection within 6 months of treatment.
*Repeat testing of all women who have been diagnosed with [[chlamydia]] or [[gonorrhea]] is recommended 3–6 months after treatment, regardless of whether their sex partners were treated. All women diagnosed with acute PID should be offered HIV testing.
*Repeat testing of all women who have been diagnosed with [[chlamydia]] or [[gonorrhea]] is recommended between 3 and 6 months after treatment, regardless of whether their sexual partners were treated.


==Treatment of Sexual Partners==
==Treatment of Sexual Partners==
*Male partners of women who have PID are often asymptomatic.
*Male partners of women who have PID are often asymptomatic.
*Both symptomatic and asymptomatic sexual partners of patients with pelvic inflammatory disease should be also be evaluated and treated.
*Both symptomatic and asymptomatic sexual partners of patients with pelvic inflammatory disease should be also be evaluated and, if necessary, treated.


==References==
==References==
{{reflist|2}}
{{reflist|2}}
{{WH}}
{{WS}}
[[Category:Disease]]
[[Category:Disease]]
[[Category:Infectious disease]]
[[Category:Gynecology]]
[[Category:Gynecology]]
[[Category:Abdominal pain]]
[[Category:Abdominal pain]]
[[Category:Sexually transmitted diseases]]
[[Category:Sexually transmitted diseases]]
[[Category:Infectious Disease Project]]
[[Category:Infectious Disease Project]]
{{WH}}
[[Category:Emergency mdicine]]
{{WS}}
[[Category:Up-To-Date]]
[[Category:Infectious disease]]

Latest revision as of 23:37, 29 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Seyedmahdi Pahlavani, M.D. [2]

Overview

In order to decrease the risk of complications, treatment should be initiated as soon as the presumptive diagnosis has been made. Hospitalization may be necessary for patients who are pregnant, immunodeficient, and those with severe disease. Combination therapy is recommended to increase anti microbial coverage. Follow up is necessary in all treated patients and partner screening is recommended.

Medical Therapy

  • Treatment should be initiated as soon as the presumptive diagnosis has been made to decrease the risk of complications.[1]
  • The long term prognosis is highly dependent on immediate appropriate antibiotic therapy.
  • Combination therapy is recommended to increase antibacterial coverage.
  • Patients are usually treated as outpatients.

Indications for hospital admission include:[2][3]


Antibiotic therapy

Parenteral treatment

  • Parenteral therapy has more benefits than oral/intramuscular therapy.[2][4][3]
  • Clinical experience should guide decisions regarding the transition to oral therapy, which can usually be initiated within 24–48 hours of clinical improvement.


Rout of administration Regimen
Parenteral

Preferred:

Cefotetan 2 g IV every 12 hours
PLUS
Doxycycline 100 mg orally or IV every 12 hours
Cefoxitin 2 g IV every 6 hours
PLUS
Doxycycline 100 mg orally or IV every 12 hours
Clindamycin 900 mg IV every 8 hours
PLUS
Gentamicin loading dose IV or IM (2 mg/kg),
followed by a maintenance dose (1.5 mg/kg) every 8 hours.
Single daily dosing (3–5 mg/kg) can be substituted

Alternative:

Ampicillin/Sulbactam 3 g IV every 6 hours
PLUS
Doxycycline 100 mg orally or IV every 12 hours

Intramuscular/Oral Treatment

  • Intramuscular/oral therapy can be considered for women with mild-to-moderately severe acute PID, because the clinical outcomes among women treated with these regimens are similar to those treated with intravenous therapy.[2]
  • Women who do not respond to IM/oral therapy within 72 hours should be reevaluated to confirm the diagnosis and should be administered intravenous therapy.[1]


Rout of administration Regimen
Intramuscular/Oral

Preferred:

Ceftriaxone 250 mg IM in a single dose
PLUS
Doxycycline 100 mg orally twice a day for 14 days
with/without
Metronidazole 500 mg orally twice a day for 14 days
Cefoxitin 2 g IM in a single dose and Probenecid 1 g orally administered concurrently in a single dose
PLUS
Doxycycline 100 mg orally twice a day for 14 days
with/without
Metronidazole 500 mg orally twice a day for 14 days
Clindamycin 900 mg IV every 8 hours
PLUS
Gentamicin loading dose IV or IM (2 mg/kg),
followed by a maintenance dose (1.5 mg/kg) every 8 hours.
Single daily dosing (3–5 mg/kg) can be substituted

Alternative:

Azithromycin 1 g orally once a week for 2 weeks
PLUS
ceftriaxone 250 mg IM single dose
with
Metronidazole 500 mg orally twice a day for 14 days

Follow-up

  • Patients should return for re-evaluation on the third day of antimicrobial therapy to evaluate the success of therapy.
  • Patients who do not improve within 3 days of therapy may require hospitalization, additional diagnostic tests, and/or surgical intervention.
  • Women with documented chlamydial or gonococcal infections have a high rate of reinfection within 6 months of treatment.
  • Repeat testing of all women who have been diagnosed with chlamydia or gonorrhea is recommended between 3 and 6 months after treatment, regardless of whether their sexual partners were treated.

Treatment of Sexual Partners

  • Male partners of women who have PID are often asymptomatic.
  • Both symptomatic and asymptomatic sexual partners of patients with pelvic inflammatory disease should be also be evaluated and, if necessary, treated.

References

  1. ↑ 1.0 1.1 Ness RB, Soper DE, Holley RL, Peipert J, Randall H, Sweet RL, Sondheimer SJ, Hendrix SL, Amortegui A, Trucco G, Songer T, Lave JR, Hillier SL, Bass DC, Kelsey SF (2002). "Effectiveness of inpatient and outpatient treatment strategies for women with pelvic inflammatory disease: results from the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) Randomized Trial". Am. J. Obstet. Gynecol. 186 (5): 929–37. PMID 12015517.
  2. ↑ 2.0 2.1 2.2 Workowski KA, Bolan GA (2015). "Sexually transmitted diseases treatment guidelines, 2015". MMWR Recomm Rep. 64 (RR-03): 1–137. PMID 26042815.
  3. ↑ 3.0 3.1 Brunham RC, Gottlieb SL, Paavonen J (2015). "Pelvic inflammatory disease". N. Engl. J. Med. 372 (21): 2039–48. doi:10.1056/NEJMra1411426. PMID 25992748.
  4. ↑ Ford GW, Decker CF (2016). "Pelvic inflammatory disease". Dis Mon. 62 (8): 301–5. doi:10.1016/j.disamonth.2016.03.015. PMID 27107781.

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