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: :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.

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.