What are the treatments for Pelvic Inflammatory Disease (PID) causing pelvic infection?

From the Guidelines

Pelvic inflammatory disease (PID) treatment requires prompt antibiotic therapy to prevent complications like infertility and chronic pelvic pain, and the recommended outpatient regimen includes ceftriaxone 500mg IM once plus doxycycline 100mg orally twice daily for 14 days, with optional metronidazole 500mg orally twice daily for 14 days to improve anaerobic coverage. The treatment should be initiated as soon as the presumptive diagnosis has been made, because prevention of long-term sequelae has been linked directly with immediate administration of appropriate antibiotics 1.

Key Considerations

• The need to eradicate anaerobes from women who have PID has not been determined definitively, but anaerobic bacteria have been isolated from the upper reproductive tract of women who have PID, and data from in vitro studies have revealed that certain anaerobes can cause tubal and epithelial destruction 1.
• When selecting a treatment regimen, health-care providers should consider availability, cost, patient acceptance, and antimicrobial susceptibility 1.
• For inpatient treatment, options include IV cefotetan 2g every 12 hours or cefoxitin 2g every 6 hours plus doxycycline 100mg orally or IV every 12 hours, or IV clindamycin 900mg every 8 hours plus gentamicin loading dose of 2mg/kg followed by 1.5mg/kg every 8 hours 1.

Treatment Options

• Outpatient regimen: ceftriaxone 500mg IM once plus doxycycline 100mg orally twice daily for 14 days, with optional metronidazole 500mg orally twice daily for 14 days.
• Inpatient treatment: IV cefotetan 2g every 12 hours or cefoxitin 2g every 6 hours plus doxycycline 100mg orally or IV every 12 hours, or IV clindamycin 900mg every 8 hours plus gentamicin loading dose of 2mg/kg followed by 1.5mg/kg every 8 hours.
• Alternative parenteral regimens: ofloxacin 400 mg IV every 12 hours, or levofloxacin 500 mg IV once daily, with or without metronidazole 500 mg IV every 8 hours, or ampicillin/sulbactam 3 g IV every 6 hours plus doxycycline 100 mg orally or IV every 12 hours 1.

Follow-up and Prevention

• Patients should abstain from sexual intercourse until treatment is complete and symptoms resolve.
• Partners from the past 60 days should be evaluated and treated for sexually transmitted infections.
• Hospitalization is recommended for severe illness, pregnancy, inability to tolerate oral medications, failed outpatient treatment, or if surgical emergencies cannot be excluded.
• Follow-up within 72 hours is essential to ensure symptom improvement 1.

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

The treatment for Pelvic Inflammatory Disease (PID) causing pelvic infection is ceftriaxone for infections caused by Neisseria gonorrhoeae. However, if Chlamydia trachomatis is suspected, additional antichlamydial coverage should be provided, as ceftriaxone has no activity against this organism 2.

From the Research

Treatments for Pelvic Inflammatory Disease (PID)

The treatments for PID include:

• Broad-spectrum antibiotics that cover Chlamydia trachomatis, Neisseria gonorrhoeae, and anaerobic bacteria, administered intravenously, intramuscularly, or orally 3, 4, 5
• Outpatient treatment of mild-to-moderate PID with tolerated antibiotic regimens consisting of an extended-spectrum cephalosporin in conjunction with either azithromycin or doxycycline 4, 5
• Hospitalization and parenteral broad-spectrum antibiotic therapy with activity against a polymicrobial flora, particularly Gram-negative aerobes and anaerobes, for clinically severe PID 4, 5
• Azithromycin versus doxycycline: moderate-quality evidence from a single study at low risk of bias suggested that a macrolide (azithromycin) may be more effective than a tetracycline (doxycycline) for curing mild-moderate PID 3, 6
• Quinolone versus cephalosporin: there was no clear evidence of a difference between the two drugs in rates of cure for mild-moderate PID or severe PID 3, 6
• Nitroimidazole versus no use of nitroimidazole: there was no conclusive evidence of a difference between the nitroimidazoles (metronidazole) group and the group receiving other drugs with activity over anaerobes 3, 6
• Clindamycin plus aminoglycoside versus quinolone or cephalosporin: there was no clear evidence of a difference between the two groups in rates of cure for mild-moderate PID or severe PID 3, 6

Antibiotic Regimens

Some of the antibiotic regimens used to treat PID include:

• Azithromycin versus doxycycline: azithromycin may be more effective than doxycycline for curing mild-moderate PID 3, 6
• Quinolone versus cephalosporin: there was no clear evidence of a difference between the two drugs in rates of cure for mild-moderate PID or severe PID 3, 6
• Ofloxacine+metronidazole association: can be proposed in first intention for the treatment of PID 7
• Ceftriaxone injection: must be associated with other antibiotics in case of Neisseria gonorrhoeae infection 7

Duration of Treatment

• Two weeks treatment seems to be a sufficient duration for the treatment of PID 7