Treatment of Pelvic Inflammatory Disease Secondary to Bacterial Vaginosis
For PID secondary to bacterial vaginosis, the recommended treatment is a regimen that includes metronidazole 500 mg orally twice daily for 14 days along with standard PID therapy to ensure adequate anaerobic coverage. 1, 2
Outpatient Treatment Options
First-Line Regimen
- Ceftriaxone 250 mg IM in a single dose
- PLUS Doxycycline 100 mg orally twice daily for 14 days
- PLUS Metronidazole 500 mg orally twice daily for 14 days 1, 2
This combination provides optimal coverage against:
- Neisseria gonorrhoeae (ceftriaxone)
- Chlamydia trachomatis (doxycycline)
- Anaerobic bacteria associated with bacterial vaginosis (metronidazole) 3, 4
Alternative Outpatient Regimen
- Cefoxitin 2 g IM in a single dose PLUS Probenecid 1 g orally administered concurrently
- PLUS Doxycycline 100 mg orally twice daily for 14 days
- PLUS Metronidazole 500 mg orally twice daily for 14 days 3
Inpatient Treatment (if needed)
Criteria for Hospitalization
Consider inpatient treatment if:
- Severe illness or high fever
- Nausea/vomiting preventing oral medication
- Tubo-ovarian abscess is suspected
- Pregnancy
- Failed outpatient therapy
- Inability to follow outpatient regimen 3
Inpatient Regimens
Regimen A:
- Cefotetan 2 g IV every 12 hours OR Cefoxitin 2 g IV every 6 hours
- PLUS Doxycycline 100 mg IV or orally every 12 hours
- Continue for at least 24 hours after clinical improvement, then complete 14 days of doxycycline 3
Regimen B:
- Clindamycin 900 mg IV every 8 hours
- PLUS Gentamicin loading dose IV or IM (2 mg/kg) followed by maintenance dose (1.5 mg/kg) every 8 hours
- Continue for at least 24 hours after clinical improvement, then complete 14 days with either doxycycline or clindamycin 3
Clinical Pearls and Follow-up
Evidence for Metronidazole Addition
A randomized controlled trial demonstrated that adding metronidazole to ceftriaxone and doxycycline:
- Reduced endometrial anaerobes (8% vs 21%)
- Decreased pelvic tenderness (9% vs 20%)
- Was well-tolerated with similar adherence to placebo 2
Follow-up
- Patients should demonstrate substantial clinical improvement within 72 hours (reduced fever, abdominal tenderness, and cervical motion tenderness)
- If no improvement within 72 hours, reevaluate diagnosis and consider hospitalization for parenteral therapy 3, 1
Partner Treatment
- Sex partners should be examined and treated if they had sexual contact with the patient during the 60 days preceding onset of symptoms
- This is crucial to prevent reinfection 3, 1
Common Pitfalls
Failing to add metronidazole when BV is present - Standard PID regimens without metronidazole provide inadequate anaerobic coverage for BV-associated PID 2, 5
Inadequate follow-up - Failure to reassess within 72 hours can miss treatment failures requiring hospitalization 3
Overlooking partner treatment - Untreated partners lead to high reinfection rates 1
Stopping antibiotics too early - Complete the full 14-day course even if symptoms resolve quickly 3, 1