Pelvic inflammatory disease medical therapy

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

Overview

Antimicrobial therapy is indicated in the treatment for Pelvic Inflammatory Disease (PID). Prompt empiric therapy is administered to prevent complications. Hospitalization may be necessary for patients who are pregnant, immunodeficient, and those with severe disease. Treating partners for sexually transmitted diseases is a very important part of PID treatment and prevention. Anyone with PID and partners of patients who have been diagnosed with PID in the past six months should be treated to prevent reinfection.

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 tubes.

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.

Hospitalization to treat PID may be recommended if the woman

(1) Is severely ill (e.g., nausea, vomiting, and high fever)

(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

(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).

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.

If symptoms continue or if an abscess does not go away, surgery may be needed.

Empiric Treatment

Treatment is usually started 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.

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:

• Cervical motion tenderness

or

• Uterine tenderness

or

• 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).

PID TREATMENT Preferred Regimen Outpatient ▸ Ceftriaxone 250 mg IM or IV x 1 dose PLUS ▸ Metronidazole 500 mg po bid x 14 days PLUS ▸ Doxycycline 100 mg po bid x 14 days OR ▸ Cefoxitin 2 gm IM with Probenecid 1 gm po both as single dose PLUS ▸ Doxycycline 100 mg po bid x 14 days PLUS ▸ Metronidazole 500 mg bid x 14 days Inpatient ▸ Cefoxitin 2 gm IV q6h PLUS ▸ Doxycycline 100 mg IV/po q12h Alternative Regimen Outpatient ▸ Ceftriaxone 250 mg IM or IV x 1 dose PLUS ▸ Azithromycin 1 gm po weekly x 2 weeks Inpatient ▸ Clindamycin 900 mg IV q8h PLUS ▸ Gentamicin 2 mg/kg loading dose, then 1.5 mg/kg q8h or 4.5 mg/kg once/day then Doxycycline 100 mg po bid x 14 days OR ▸ Amp-Sulb 3 gm IV q6h PLUS ▸ Doxycycline 100 mg IV/po q12h

Follow-Up

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.

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.

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 concomitantM. 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

IUDs are popular contraceptive choices for women. Both levonorgestrel and copper-containing devices are marketed in the United States. The risk for PID associated with IUDuse is primarily confined to the first 3 weeks after insertion and is uncommon thereafter. Given the popularity of IUDs, practitioners might encounter PID in IUD users. Evidence is insufficient to recommend that the removal of IUDs 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).

Antimicrobial regimen

• Empiric therapy

• 1. Parenteral Treatment

• 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
• 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
• Alternative regimen (2): Azithromycin 500 mg IV q24 for 1-2 doses followed by 250 mg PO for 5-6 days
• 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
• 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

• Preferred regimen (1): Ceftriaxone 250 mg IM in a single dose AND Doxycycline 100 mg PO bid for 14 days ± Metronidazole 500 mg PO bid for 14 days
• 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 ± Metronidazole 500 mg PO bid 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 ± Metronidazole 500 mg PO bid for 14 days
• Alternative regimen (1): Ceftriaxone 250 mg IM single dose and Azithromycin 1 g PO once a week 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

• Tubo-ovarian abscess

• Preferred regimen: Doxycyline 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)