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

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.

Medical Therapy

• Treatment should be initiated as soon as the presumptive diagnosis has been made to decrease the risk of complications.
• The long term prognosis is highly dependent on immediate appropriate antibiotic therapy.
• Combination (rather than monotherapy) is recommended to increase coverage, including gram-negative anaerobes.
• Patients are usually treated as outpatients.

Indications for hospital admission:

• 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 benefit than oral/intramuscular therapy
• Clinical experience should guide decisions regarding transition to oral therapy, which usually can 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 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.
• 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.

• 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 (2): Ceftriaxone 250 mg IM single dose and Azithromycin 1 g PO once a week for 14 days
• Alternative regimen (3): (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: 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)

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 who do not improve within 3 days of therapy may require hospitalization, additional diagnostic tests, and 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 3–6 months after treatment, regardless of whether their sex partners were treated. All women diagnosed with acute PID should be offered HIV testing.

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 treated.