What is the diagnosis and treatment for Pelvic Inflammatory Disease (PID)?

From the Guidelines

Pelvic inflammatory disease (PID) is a serious infection that requires prompt antibiotic treatment, and for mild to moderate cases, outpatient treatment with ceftriaxone and doxycycline is recommended, as stated in the guidelines 1. The diagnosis of PID should be considered in patients with pelvic tenderness and signs of lower genital tract inflammation, and treatment may be indicated based on a patient's risk profile 1.

Key Considerations

• The most recent guidelines from 2017 recommend that patients with tubo-ovarian abscess that does not respond to antibiotics should undergo surgical drainage 1.
• PID is typically caused by sexually transmitted bacteria like gonorrhea and chlamydia ascending from the vagina and cervix to the upper reproductive tract.
• Without treatment, PID can lead to serious complications including chronic pelvic pain, ectopic pregnancy, and infertility due to scarring of the fallopian tubes.

Treatment Options

• For mild to moderate PID, outpatient treatment with ceftriaxone 500mg IM once plus doxycycline 100mg orally twice daily for 14 days, with optional metronidazole 500mg orally twice daily for 14 days, is recommended.
• Severe cases require hospitalization with IV antibiotics such as cefotetan 2g IV every 12 hours or cefoxitin 2g IV every 6 hours plus doxycycline 100mg orally or IV every 12 hours.

Prevention and Follow-up

• Sexual partners should be evaluated and treated to prevent reinfection.
• Patients should abstain from sexual intercourse until treatment is complete and symptoms have resolved.
• Follow-up evaluation within 72 hours is important to ensure improvement, and a pregnancy test should be performed before starting treatment as some antibiotics are contraindicated in pregnancy 1.

From the FDA Drug Label

• Gynecologic Infections caused by Staphylococcus aureus (methicillin susceptible), Staphylococcus epidermidis (methicillin susceptible, Streptococcus species, Streptococcus agalactiae, E coli, Proteus mirabilis, Neisseria gonorrhoeae, Bacteroides fragilis, Prevotella melaninogenicaBacteroides vulgatus, Fusobacterium species*, and gram-positive anaerobic cocci (including Peptococcus niger and Peptostreptococcus species). Cefotetan, like other cephalosporins, has no activity against Chlamydia trachomatis Therefore, when cephalosporins are used in the treatment of pelvic inflammatory disease, and C. trachomatis is one of the suspected pathogens, appropriate antichlamydial coverage should be added.

Cefotetan can be used to treat pelvic inflammatory disease caused by certain bacteria, but it has no activity against Chlamydia trachomatis. When using cefotetan to treat pelvic inflammatory disease, appropriate antichlamydial coverage should be added if Chlamydia trachomatis is suspected as one of the pathogens 2.

From the Research

Causes of Pelvic Inflammatory Disease

• Pelvic inflammatory disease (PID) is caused by a polymicrobial infection, including Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium, and other lower genital tract endogenous anaerobic and facultative bacteria 3
• The most common microorganisms isolated from the genital tract of patients with PID are Neisseria gonorrhoeae (53%) and Chlamydia trachomatis (31%) 4

Treatment of Pelvic Inflammatory Disease

• The treatment of PID involves the use of broad-spectrum antibiotics that cover the suspected microorganisms, including Neisseria gonorrhoeae, Chlamydia trachomatis, and anaerobic bacteria 3
• The Centers for Disease Control and Prevention (CDC) recommends the use of broad-spectrum antibiotic regimens, such as ceftriaxone and doxycycline, with or without metronidazole, for the treatment of PID 5, 6
• Outpatient treatment of mild-to-moderate PID can include tolerated antibiotic regimens consisting of an extended-spectrum cephalosporin in conjunction with either azithromycin or doxycycline 3
• Clinically severe PID should prompt hospitalization and imaging to rule out a tubo-ovarian abscess, and parenteral broad-spectrum antibiotic therapy should be implemented 3

Effectiveness of Antibiotic Regimens

• A study comparing the use of cefoxitin and doxycycline with clindamycin and tobramycin found no significant differences between the two groups in terms of clinical response or toxicity 4
• A review of 37 randomized controlled trials found no conclusive evidence that one regimen of antibiotics was safer or more effective than any other for the cure of PID 5
• A study comparing the use of azithromycin with doxycycline found that azithromycin may be more effective than doxycycline for curing mild-moderate PID 5
• A study comparing the use of ceftriaxone and doxycycline with or without metronidazole found that the addition of metronidazole resulted in reduced endometrial anaerobes, decreased M. genitalium, and reduced pelvic tenderness 6