Pelvic inflammatory disease medical therapy: Difference between revisions

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Latest revision as of 23:37, 29 July 2020

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]

Surgical emergencies (e.g., appendicitis) cannot be excluded
Tubo-ovarian abscess
Pregnancy
Severe illness, nausea and vomiting, or high fever
Unable to follow or tolerate an outpatient oral regimen
No clinical response to oral antimicrobial therapy.

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

↑ ^1.0 ^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.
↑ ^2.0 ^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.
↑ ^3.0 ^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.
↑ Ford GW, Decker CF (2016). "Pelvic inflammatory disease". Dis Mon. 62 (8): 301–5. doi:10.1016/j.disamonth.2016.03.015. PMID 27107781.

Template:WH Template:WS

[pmid12015517-1] 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.

[pmid26042815-2] 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.

[pmid25992748-3] 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.

[pmid27107781-4] 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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[2]

[3]

[4]

@@ Line 1: / Line 1: @@
 __NOTOC__
 {{Pelvic inflammatory disease}}
-{{CMG}}
+{{CMG}}; {{AE}} {{MehdiP}}
 ==Overview==
-Treatment depends on the cause and generally involves use of [[antibiotic]] therapy.  If the patient has not improved within two to three days after beginning treatment with the antibiotics, they should return to the hospital for further treatment.  Drugs should also be given orally and/or intravaneously to the patient while in the hospital to begin treatment immediately to increase the effectiveness of antibiotic treatment.   Hospitalization may be necessary if tubo-ovarian abscess, very ill, immunodeficient, pregnancy, incompetence, or because this or something else life threatening can not be ruled out.  Treating partners for STD's is a very important part of treatment and prevention. Anyone with PID and partners of patients with PID since six months prior to diagnosis should be treated to prevent reinfection.  Psychotherapy is highly recommended to women diagnosed with PID as the fear of redeveloping the disease after being cured may exist. It is important for a patient to communicate any issues and/or uncertainties they may have to a doctor, especially a specialist such as a gynecologist, and in doing so, to seek follow-up care.
+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==
-PID can be cured with several types of antibiotics. A health care provider will determine and prescribe the best therapy. However, antibiotic treatment does not reverse any damage that has already occurred to the reproductive organs. If a woman has pelvic pain and other symptoms of PID, it is critical that she seek care immediately. Prompt antibiotic treatment can prevent severe damage to reproductive organs. The longer a woman delays treatment for PID, the more likely she is to become infertile or to have a future ectopic pregnancy because of damage to the [[fallopian tube]]s.
+*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>
+*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:<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>
-Because of the difficulty in identifying organisms infecting the internal reproductive organs and because more than one organism may be responsible for an episode of PID, PID is usually treated with at least two antibiotics that are effective against a wide range of infectious agents. These antibiotics can be given by mouth or by injection. The symptoms may go away before the infection is cured. Even if symptoms go away, the woman should finish taking all of the prescribed medicine. This will help prevent the infection from returning. Women being treated for PID should be re-evaluated by their health care provider three days after starting treatment to be sure the [[antibiotics]] are working to cure the infection. In addition, a woman’s sex partner(s) should be treated to decrease the risk of re-infection, even if the partner(s) has no symptoms. Although sex partners may have no symptoms, they may still be infected with the organisms that can cause PID.
+*[[Surgical emergency|Surgical emergencies]] (e.g., [[appendicitis]]) cannot be excluded
+*[[Tubo-ovarian abscess]]
+*[[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]].
-[[Hospitalization]] to treat PID may be recommended if the woman
-(1) Is severely ill (e.g., [[nausea]], [[vomiting]], and high [[fever]])
+===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.
-(2) Is pregnant
-(3) Does not respond to or cannot take oral medication and needs intravenous antibiotics
-(4) Has an abscess in the [[fallopian tube]] or [[ovary]] (tubo-ovarian abscess) or
+{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
+|+
-(5) Needs to be monitored to be sure that her symptoms are not due to another condition that would require emergency surgery (e.g., [[appendicitis]]).
+! style="background: #4479BA; width: 180px;" | {{fontcolor|#FFFFFF|Rout of administration}}
+! style="background: #4479BA; width: 500px;" | {{fontcolor|#FFFFFF|Regimen}}
-No evidence is available to suggest that adolescents benefit from hospitalization for treatment of PID. The decision to hospitalize adolescents with acute PID should be based on the same criteria used for older women. Younger women with mild-to-moderate acute PID have similar outcomes with either outpatient or inpatient therapy, and clinical response to outpatient  treatment is similar among younger and older women.
+|-
+| style="padding: 7px 7px; background: #DCDCDC;" |'''Parenteral'''
-If symptoms continue or if an abscess does not go away, surgery may be needed.
+| style="padding: 7px 7px; background: #F5F5F5;" |
+Preferred:
-===Empiric Treatment===
+:::::[[Cefotetan]] 2 g IV every 12 hours
-Treatment is usually started [[empirical|empirically]] because of the terrible complications. The optimal treatment regimen and long-term outcome of early treatment of women with asymptomatic or subclinical PID are unknown. Diagnosis and management of other common causes of lower abdominal pain (e.g., [[ectopic pregnancy]], acute [[appendicitis]], and functional pain) are unlikely to be impaired by initiating empiric antimicrobial therapy for PID.
+:::::::::'''PLUS'''
+:::::[[Doxycycline]] 100 mg orally or IV every 12 hours
-Empiric treatment for PID should be initiated in sexually active young women and other women at risk for STDs if they are experiencing pelvic or lower abdominal pain, if no cause for the illness other than PID can be identified, and if one or more of the following minimum criteria are present on pelvic examination:
+----
+:::::[[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
+----
-* [[Cervix|Cervical]] motion tenderness
+Alternative:
-or
+:::::[[Ampicillin/Sulbactam]] 3 g IV every 6 hours
-* [[Uterus|Uterine]] tenderness
+:::::::::'''PLUS'''
-or
+:::::[[Doxycycline]] 100 mg orally or IV every 12 hours
-* Adnexal tenderness.
-;Shown below is a table summarizing the preferred and alternative empiric treatment for Pelvic inflammatory disease (includes [[salpingitis]], tubo-ovarian abscess and [[pelvic peritonitis]]).
-{| style="background: #FFFFFF;"
-| valign=top |
-{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
-! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|PID TREATMENT}}
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
-|-
-| style="padding: 0 5px; font-size: 90%; background: #4479BA;" align=center | '''''Outpatient'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ceftriaxone]] 250 mg IM or IV x 1 dose'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Metronidazole]] 500 mg po bid x 14 days'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Doxycycline]] 100 mg po bid x 14 days'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | OR
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefoxitin]] 2 gm IM with [[Probenecid]] 1 gm po both as single dose'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Doxycycline]] 100 mg po bid x 14 days'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Metronidazole]] 500 mg bid x 14 days'''''
 |-
+|}
+====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>
-| style="padding: 0 5px; font-size: 90%; background: #4479BA;" align=center | '''''Inpatient'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Cefoxitin]] 2 gm IV q6h'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Doxycycline]] 100 mg IV/po q12h'''''
-|-
-| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
-|-
-| style="padding: 0 5px; font-size: 90%; background: #4479BA;" align=center | '''''Outpatient'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ceftriaxone]] 250 mg IM or IV x 1 dose'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Azithromycin]] 1 gm po weekly x 2 weeks'''''
-|-
-| style="padding: 0 5px; font-size: 90%; background: #4479BA;" align=center | '''''Inpatient'''''
+{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
-|-
+|+
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Clindamycin]] 900 mg IV q8h'''''
+! style="background: #4479BA; width: 180px;" | {{fontcolor|#FFFFFF|Rout of administration}}
-|-
+! style="background: #4479BA; width: 500px;" | {{fontcolor|#FFFFFF|Regimen}}
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Gentamicin]] 2 mg/kg loading dose, then 1.5 mg/kg q8h or 4.5 mg/kg once/day'''''<br>then<br>'''''[[Doxycycline]] 100 mg po bid x 14 days'''''
 |-
+| style="padding: 7px 7px; background: #DCDCDC;" |'''Intramuscular/Oral'''
+| style="padding: 7px 7px; background: #F5F5F5;" |
+Preferred:
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | OR
+:::::[[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
 |-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Amp-Sulb]] 3 gm IV q6h'''''
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
-|-
-| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Doxycycline]] 100 mg IV/po q12h'''''
-|-
-|}
 |}
-====Follow-Up====
+==Follow-up==
+*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/or surgical intervention.
+*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 between 3 and 6 months after treatment, regardless of whether their sexual partners were treated.
-Patients should demonstrate substantial clinical improvement (e.g., defervescence; reduction in direct or rebound abdominal tenderness; and reduction in uterine, adnexal, and cervical motion tenderness) within 3 days after initiation of therapy. Patients who do not improve within this period usually require hospitalization, additional diagnostic tests, and surgical intervention.
+==Treatment of Sexual Partners==
+*Male partners of women who have PID are often asymptomatic.
-If no clinical improvement has occurred within 72 hours after outpatient oral or parenteral therapy, further assessment should be performed. Subsequent hospitalization and an assessment of the antimicrobial regimen and diagnostics (including the consideration of diagnostic laparoscopy for alternative diagnoses) are recommended in women without clinical improvement. 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 3–6 months after treatment, regardless of whether their sex partners were treated. All women diagnosed with acute PID should be offered HIV testing.
+*Both symptomatic and asymptomatic sexual partners of patients with pelvic inflammatory disease should be also be evaluated and, if necessary, treated.
-===  Management of Sex Partners ===
-Male partners of women who have PID often are asymptomatic.
-Male sex partners of women with PID should be examined and treated if they had sexual contact with the patient during the 60 days preceding the patient’s onset of symptoms. If a patient’s last sexual intercourse was >60 days before onset of symptoms or diagnosis, the patient’s most recent sex partner should be treated. Patients should be instructed to abstain from sexual intercourse until therapy is completed and until they and their sex partners no longer have symptoms. Evaluation and treatment are imperative because of the risk for reinfection of the patient and the strong likelihood of urethral gonococcal or chlamydial infection in the sex partner. Male partners of women who have PID caused by ''C. trachomatis'' and/or ''N. gonorrhoeae'' frequently are asymptomatic.
-Sex partners should be treated empirically with regimens effective against both of these infections, regardless of the etiology of PID or pathogens isolated from the infected woman. Even in clinical settings in which only women are treated, arrangements should be made to provide care or appropriate referral for male sex partners of women who have PID. Expedited partner treatment and enhanced patient referral are alternative approaches to treating male partners of women who have chlamydia or gonococcal infections.
-===  Special Considerations ===
-====  Pregnancy ====
-Because of the high risk for maternal [[morbidity]] and preterm delivery, pregnant women who have suspected PID should be hospitalized and treated with parenteral [[antibiotics]].
-====  HIV Infection ====
-Differences in the clinical manifestations of PID between HIV-infected women and HIV-negative women have not been well delineated. In previous observational studies, HIV-infected women with PID were more likely to require surgical intervention; more comprehensive observational and controlled studies now have demonstrated that HIV-infected women with PID have similar symptoms when compared with uninfected controls, except they were more likely to have a tubo-ovarian abscess; both groups of women responded equally well to standard parenteral and oral antibiotic regimens. The microbiologic findings for HIV-positive and HIV-negative women were similar, except HIV-infected women had higher rates of concomitant''M. hominis'', candida, streptococcal, and HPV infections and HPV-related cytologic abnormalities. Regardlesss of these data, whether the management of immunodeficient HIV-infected women with PID requires more aggressive interventions (e.g., hospitalization or parenteral antimicrobial regimens) has not been determined.
-====  Intrauterine Contraceptive Devices ====
-[[IUD]]s are popular contraceptive choices for women. Both [[levonorgestrel]] and copper-containing devices are marketed in the United States. The risk for PID associated with [[IUD]]use is primarily confined to the first 3 weeks after insertion and is uncommon thereafter. Given the popularity of [[IUD]]s, practitioners might encounter PID in [[IUD]] users. Evidence is insufficient to recommend that the removal of [[IUD]]s in women diagnosed with acute PID. However, caution should be exercised if the [[IUD]] remains in place, and close clinical follow-up is mandatory. The rate of treatment failure and recurrent PID in women continuing to use an [[IUD]] is unknown, and no data have been collected regarding treatment outcomes by type of [[IUD]] (e.g., copper or levonorgestrel).
 ==References==
 {{reflist|2}}
+{{WH}}
+{{WS}}
 [[Category:Disease]]
-[[Category:Infectious disease]]
 [[Category:Gynecology]]
 [[Category:Abdominal pain]]
 [[Category:Sexually transmitted diseases]]
-{{WH}}
+[[Category:Infectious Disease Project]]
-{{WS}}
+[[Category:Emergency mdicine]]
+[[Category:Up-To-Date]]
+[[Category:Infectious disease]]