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

From the Guidelines

Treatment for pelvic inflammatory disease (PID) should involve a combination of antibiotics to address the polymicrobial infection, with the recommended regimen including ceftriaxone 500 mg intramuscularly as a single dose, plus doxycycline 100 mg orally twice daily for 14 days, with optional metronidazole 500 mg orally twice daily for 14 days to provide better coverage against anaerobic bacteria. The choice of treatment regimen should be based on the severity of the disease, patient compliance, and antimicrobial susceptibility 1. For more severe cases requiring hospitalization, intravenous antibiotics such as cefotetan 2 g IV every 12 hours or cefoxitin 2 g IV every 6 hours plus doxycycline 100 mg orally or IV every 12 hours may be used until clinical improvement, followed by oral doxycycline to complete the 14-day course 1.

Some key points to consider in the treatment of PID include:

• The need for broad-spectrum coverage of likely pathogens, including N. gonorrhoeae, C. trachomatis, anaerobes, Gram-negative facultative bacteria, and streptococci 1
• The importance of treating sexual partners from the past 60 days to prevent reinfection 1
• The need for patients to abstain from sexual intercourse until treatment is completed and symptoms have resolved 1
• The recommendation for follow-up evaluation 2-3 days after starting treatment to ensure improvement 1

It is also important to note that PID treatment is crucial to prevent complications like chronic pelvic pain, infertility, and ectopic pregnancy, as the infection can cause scarring of the fallopian tubes and other reproductive organs if left untreated 1.

In terms of hospitalization, the decision should be based on the discretion of the healthcare provider, taking into account factors such as the severity of the disease, patient compliance, and the presence of complications such as tubo-ovarian abscess 1.

Overall, the treatment of PID requires a comprehensive approach that takes into account the severity of the disease, patient compliance, and antimicrobial susceptibility, with the goal of preventing long-term complications and promoting optimal outcomes.

From the FDA Drug Label

Cefoxitin for Injection, USP is indicated for the treatment of serious infections caused by susceptible strains of the designated microorganisms in the diseases listed below. ... (4) 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 Ceftriaxone for Injection, USP is indicated for the treatment of the following infections when caused by susceptible organisms: ... PELVIC INFLAMMATORY DISEASE caused by Neisseria gonorrhoeae CEFOTAN (Cefotetan for Injection, USP) is indicated for the therapeutic treatment of the following infections when caused by susceptible strains of the designated organisms: ... 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).

The treatment for Pelvic Inflammatory Disease (PID) includes:

• Cefoxitin 2
• Ceftriaxone 3
• Cefotetan 4 It is essential to note that these antibiotics may not be effective against Chlamydia trachomatis, so additional anti-chlamydial coverage may be necessary.

From the Research

Treatment Options for Pelvic Inflammatory Disease (PID)

• The treatment of PID is directed at containment of infection, resolution of clinical symptoms and signs, eradication of pathogens from the genital tract, and prevention of sequelae including infertility, ectopic pregnancy, and chronic pelvic pain 5.
• The choice of an antibiotic regimen used to treat PID relies upon the appreciation of the polymicrobial etiology of this ascending infection, including Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium, and other lower genital tract endogenous anaerobic and facultative bacteria 5.
• Currently available evidence and the CDC treatment recommendations support the use of broad-spectrum antibiotic regimens that adequately cover the above-named microorganisms 5.

Antibiotic Regimens

• The outpatient treatment of mild-to-moderate PID should include tolerated antibiotic regimens consisting of an extended-spectrum cephalosporin in conjunction with either azithromycin or doxycycline 5.
• Clinically severe PID should prompt hospitalization and imaging to rule out a tubo-ovarian abscess, and parenteral broad-spectrum antibiotic therapy with activity against a polymicrobial flora, particularly Gram-negative aerobes and anaerobes, should be implemented 5.
• Azithromycin versus doxycycline: there was no clear evidence of a difference between the two drugs in rates of cure for mild-moderate PID, severe PID, or adverse effects leading to discontinuation of treatment 6.
• Quinolone versus cephalosporin: there was no clear evidence of a difference between the two drugs in rates of cure for mild-moderate PID, severe PID, or adverse effects leading to discontinuation of treatment 6.

Hospitalization and Parenteral Antibiotics

• Hospitalization for parenteral antibiotics is recommended in patients who are pregnant or severely ill, in whom outpatient treatment has failed, those with tubo-ovarian abscess, or if surgical emergencies cannot be excluded 7.
• Cefotetan plus doxycycline and cefoxitin plus doxycycline demonstrated high rates of initial clinical response in the treatment of acute pelvic inflammatory disease 8.

Prevention and Screening

• Prevention of PID includes screening for C. trachomatis and N. gonorrhoeae in all women younger than 25 years and those who are at risk or pregnant, plus intensive behavioral counseling for all adolescents and adults at increased risk of sexually transmitted infections 7.
• Sex partner treatment is recommended; expedited partner treatment is recommended where legal 7.