Pelvic inflammatory disease medical therapy: Difference between revisions

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Revision as of 16:39, 21 October 2016

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

References

↑ 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.

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[pmid12015517-1] 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.

[1]

@@ Line 59: / Line 59: @@
 |}
+====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.
 *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="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;" |'''Intramuscular/Oral'''
+| style="padding: 7px 7px; background: #F5F5DC;" |
+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
+|-
+|}
-*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>
-::* 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 {{withorwithout}} [[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 {{withorwithout}} [[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 {{withorwithout}} [[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==