What are the recommended antibiotics for Pelvic Inflammatory Disease (PID)?

From the Guidelines

The recommended antibiotic regimen for pelvic inflammatory disease (PID) includes ceftriaxone 500mg IM once plus doxycycline 100mg orally twice daily for 14 days, with optional metronidazole 500mg orally twice daily for 14 days. For outpatient treatment, alternatives include cefoxitin 2g IM with probenecid 1g orally, or other parenteral third-generation cephalosporins like ceftizoxime or cefotaxime, followed by doxycycline 1. For inpatient treatment, either cefotetan 2g IV every 12 hours or cefoxitin 2g IV every 6 hours plus doxycycline 100mg orally/IV every 12 hours is recommended.

Key Considerations

• Treatment should continue for 24-48 hours after clinical improvement, followed by oral therapy to complete 14 days.
• These regimens target the polymicrobial nature of PID, covering Neisseria gonorrhoeae, Chlamydia trachomatis, anaerobes, gram-negative facultative bacteria, and streptococci.
• Partners should be treated to prevent reinfection, and patients should abstain from sexual intercourse until treatment completion.
• Follow-up within 72 hours is essential to ensure clinical improvement, with hospitalization recommended for severe illness, pregnancy, inability to follow outpatient regimens, or failure to respond to oral antibiotics 1.

Additional Options

• Amoxicillin/clavulanic acid plus doxycycline was effective in obtaining short-term clinical response in a single clinical trial; however, gastrointestinal symptoms might limit compliance with this regimen 1.
• Azithromycin has been evaluated in the treatment of upper reproductive tract infections, but the data are insufficient to recommend this agent as a component of any of the oral treatment regimens for PID 1.

From the FDA Drug Label

Pelvic Inflammatory Disease caused by Neisseria gonorrhoeae Ceftriaxone sodium, like other cephalosporins, has no activity against Chlamydia trachomatis. Gynecological infections, including endometritis, pelvic cellulitis, and pelvic inflammatory disease caused by Escherichia coli, Neisseria gonorrhoeae (including penicillinase-producing strains), Bacteroides species including B. fragilis, Clostridium species, Peptococcus niger, Peptostreptococcus species, and Streptococcus agalactiae Cefoxitin for Injection, USP, like cephalosporins, has no activity against Chlamydia trachomatis.

PID Antibiotics:

• Ceftriaxone (2) is indicated for the treatment of Pelvic Inflammatory Disease (PID) caused by Neisseria gonorrhoeae.
• Cefoxitin (3) is indicated for the treatment of gynecological infections, including endometritis, pelvic cellulitis, and pelvic inflammatory disease caused by Escherichia coli, Neisseria gonorrhoeae, Bacteroides species, Clostridium species, Peptococcus niger, Peptostreptococcus species, and Streptococcus agalactiae.
• However, both Ceftriaxone and Cefoxitin have no activity against Chlamydia trachomatis, so additional anti-chlamydial coverage should be added when treating PID.

From the Research

PID Antibiotics

• The treatment of Pelvic Inflammatory Disease (PID) typically involves the use of antibiotics to target the underlying bacterial infection 4, 5, 6, 7, 8.
• Commonly prescribed regimens for PID include a combination of ceftriaxone, doxycycline, and metronidazole, which have been shown to be effective and well-tolerated 4, 7.
• The addition of metronidazole to ceftriaxone and doxycycline has been found to be beneficial in reducing endometrial anaerobes, decreasing M. genitalium, and reducing pelvic tenderness 4.
• Alternative regimens, such as gentamicin-clindamycin and cefoxitin-doxycycline, have also been shown to be effective in treating PID, although they may have different efficacy and safety profiles compared to the ceftriaxone, doxycycline, and metronidazole regimen 5, 8.
• The choice of antibiotic regimen may depend on various factors, including the severity of the infection, the presence of specific bacterial pathogens, and the patient's medical history and tolerance to different antibiotics 6, 7.

Antibiotic Efficacy and Safety

• Ceftriaxone has been shown to be effective against Neisseria gonorrhoeae, with all isolates having an MIC of 0.03 μg/mL 6.
• Moxifloxacin has been found to have a broader spectrum of activity against facultative and anaerobic pathogens compared to doxycycline, and may be a useful alternative in certain cases 6.
• The combination of ceftriaxone, metronidazole, and doxycycline has been found to be effective in eradicating endometrial pathogens, although head-to-head clinical studies are needed to evaluate its clinical efficacy compared to other regimens 6.
• Antibiotics used to manage PID have high efficacy and safety profiles, with most adverse effects being mild and manageable, such as gastrointestinal disturbances or hypersensitivity reactions 7.