What is the appropriate treatment for a patient with pelvic inflammatory disease (PID) and urinary tract infection (UTI) with Escherichia coli (E. coli) growth?

From the Guidelines

For a patient with pelvic inflammatory disease (PID) and a urinary tract infection (UTI) with E. coli growth, I recommend a dual antibiotic approach, prioritizing the most recent and highest quality study available 1.

Treatment Approach

• For PID, use ceftriaxone 250mg IM once plus doxycycline 100mg orally twice daily for 14 days, as this regimen targets the polymicrobial nature of PID, including potential gonorrhea and chlamydia.
• For the E. coli UTI, add nitrofurantoin 100mg orally twice daily for 5 days, as recommended by the American College of Physicians for uncomplicated cystitis 1.

Rationale

• The treatment of PID is complex due to its polymicrobial nature, and no single therapeutic regimen exists 1.
• However, the use of ceftriaxone and doxycycline is a commonly recommended approach for PID.
• For the UTI, the choice of antibiotic should target E. coli, which is the most common cause of uncomplicated cystitis 1.
• Nitrofurantoin is a recommended option for uncomplicated cystitis, with a treatment duration of 5 days 1.

Additional Considerations

• Ensure the patient completes the full course of antibiotics even if symptoms improve quickly.
• Sexual partners should be evaluated and treated if the PID has an STI component.
• The patient should follow up within 48-72 hours to assess treatment response.
• Pain management with NSAIDs may be appropriate, and the patient should abstain from sexual activity until treatment is complete and symptoms have resolved.

From the FDA Drug Label

Pelvic Inflammatory Disease caused by Neisseria gonorrhoeae Ceftriaxone sodium, like other cephalosporins, has no activity against Chlamydia trachomatis. Therefore, when cephalosporins are used in the treatment of patients with pelvic inflammatory disease and Chlamydia trachomatis is one of the suspected pathogens, appropriate antichlamydial coverage should be added Urinary Tract Infections (complicated and uncomplicated) caused by Escherichia coli

The patient has pelvic inflammatory disease and a UTI with E. Coli growth. Ceftriaxone can be used to treat the UTI caused by E. Coli. However, for the pelvic inflammatory disease, additional antichlamydial coverage should be considered if Chlamydia trachomatis is suspected as a pathogen.

• Ceftriaxone is effective against E. Coli.
• Piperacillin-tazobactam is also effective against E. Coli and can be used to treat pelvic inflammatory disease caused by beta-lactamase producing isolates of Escherichia coli 2. It is essential to note that the treatment of pelvic inflammatory disease should consider the possibility of Chlamydia trachomatis infection and provide appropriate antichlamydial coverage if necessary 3.

From the Research

Treatment Options for Pelvic Inflammatory Disease (PID) and UTI with E. Coli Growth

• The treatment of PID typically involves broad-spectrum antibiotics, and the choice of antibiotic regimen may depend on the severity of the disease and the presence of other infections, such as UTI with E. Coli growth 4, 5, 6, 7, 8.
• A study published in 2021 found that the addition of metronidazole to ceftriaxone and doxycycline was well tolerated and resulted in reduced endometrial anaerobes, decreased M. genitalium, and reduced pelvic tenderness compared to ceftriaxone and doxycycline alone 4.
• Another study published in 2020 found that azithromycin was probably more effective than doxycycline in treating mild-moderate PID, but the evidence was uncertain for severe PID 6.
• A study published in 2019 found that moxifloxacin was superior to doxycycline and metronidazole in covering BV-associated bacteria, and that the combination of ceftriaxone plus moxifloxacin provided similar coverage of facultative and anaerobic pathogens compared to the combination of ceftriaxone, metronidazole, and doxycycline 7.
• A randomized controlled trial published in 2007 found that ceftriaxone plus azithromycin was equivalent to ceftriaxone plus doxycycline in treating mild PID, with a higher clinical cure rate in the azithromycin group 8.

Considerations for Choosing Antibiotic Regimens

• The choice of antibiotic regimen should consider the likely etiologies and anticipated resistance patterns of the infection 5.
• The use of broad-spectrum antibiotics may be necessary for the treatment of patients with serious infections, but may also encourage the emergence of resistant bacteria 5.
• The addition of metronidazole to ceftriaxone and doxycycline may be beneficial in treating PID, especially in cases where anaerobic organisms are suspected 4.
• Azithromycin may be a suitable alternative to doxycycline in treating mild-moderate PID, but more research is needed to confirm its effectiveness in severe PID 6.