What is the treatment for pelvic inflammatory disease (PID)?

From the Guidelines

The treatment for pelvic inflammatory disease (PID) requires prompt antibiotic therapy to prevent complications, and the recommended regimen includes a combination of antibiotics to cover the common causative organisms, such as ceftriaxone 250mg as a single intramuscular injection, plus doxycycline 100mg orally twice daily for 14 days, with optional metronidazole 500mg orally twice daily for 14 days to improve coverage against anaerobic bacteria 1.

Key Considerations

• The decision to hospitalize a patient with PID should be based on the discretion of the healthcare provider, taking into account factors such as surgical emergencies, pregnancy, and severity of symptoms 1.
• Parenteral therapy can be discontinued 24 hours after a patient improves clinically, and continuing oral therapy should consist of doxycycline 100 mg orally twice a day or clindamycin 450 mg orally four times a day to complete a total of 14 days of therapy 1.
• When tubo-ovarian abscess is present, many healthcare providers use clindamycin for continued therapy rather than doxycycline, because clindamycin provides more effective anaerobic coverage 1.

Treatment Regimens

• Outpatient treatment: ceftriaxone 250mg as a single intramuscular injection, plus doxycycline 100mg orally twice daily for 14 days, with optional metronidazole 500mg orally twice daily for 14 days 1.
• Inpatient treatment: intravenous antibiotics, such as cefotetan 2g IV every 12 hours plus doxycycline 100mg IV or orally every 12 hours, or clindamycin 900mg IV every 8 hours plus gentamicin loading dose IV or IM (2mg/kg) followed by maintenance dose (1.5mg/kg) every 8 hours 1.

Follow-up and Prevention

• Follow-up evaluation is recommended 2-3 days after starting treatment to ensure improvement 1.
• Sexual partners from the past 60 days should be evaluated and treated for sexually transmitted infections 1.
• Patients should abstain from sexual intercourse until treatment is completed and symptoms have resolved 1.

From the FDA Drug Label

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 PELVIC INFLAMMATORY DISEASE caused by Neisseria gonorrhoeae

The treatment for pelvic inflammatory disease (PID) may include Cefoxitin or Ceftriaxone.

• Cefoxitin is indicated for the treatment of gynecological infections, including PID, caused by susceptible organisms such as Escherichia coli, Neisseria gonorrhoeae, and Bacteroides species.
• Ceftriaxone is indicated for the treatment of PID caused by Neisseria gonorrhoeae. It is essential to note that both Cefoxitin and Ceftriaxone have no activity against Chlamydia trachomatis, so appropriate anti-chlamydial coverage should be added when C. trachomatis is one of the suspected pathogens 2 3.

From the Research

Treatment for Pelvic Inflammatory Disease

The treatment for pelvic inflammatory disease (PID) typically involves the use of broad-spectrum antibiotics that cover a range of microorganisms, including Chlamydia trachomatis, Neisseria gonorrhoeae, and anaerobic bacteria 4, 5, 6, 7. The goals of therapy include the resolution of clinical symptoms and signs, the eradication of pathogens from the genital tract, and the prevention of sequelae such as infertility, ectopic pregnancy, and chronic pelvic pain 5.

Antibiotic Regimens

• For mild to moderate PID, outpatient treatment with a single intramuscular injection of a recommended cephalosporin followed by oral doxycycline for 14 days is recommended 6.
• Metronidazole is also recommended for 14 days in the setting of bacterial vaginosis, trichomoniasis, or recent uterine instrumentation 6.
• For severe PID, hospitalization for parenteral antibiotics is recommended, with coverage against a polymicrobial flora, particularly Gram-negative aerobes and anaerobes 5, 7.
• Azithromycin may be more effective than doxycycline for curing mild-moderate PID, based on moderate-quality evidence from a single study at low risk of bias 4.

Additional Considerations

• Sex partner treatment is recommended, with expedited partner treatment recommended where legal 6.
• 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 6.
• Percutaneous drain placement may be necessary to promote efficient source control in cases of large tubo-ovarian abscesses 7.