Treatment of Pelvic Inflammatory Disease (PID)
The recommended first-line treatment for uncomplicated PID is a regimen of ceftriaxone 250mg IM in a single dose, PLUS doxycycline 100mg orally twice daily for 14 days, WITH or WITHOUT metronidazole 500mg orally twice daily for 14 days. 1
Diagnosis
PID should be diagnosed based on the following minimum criteria:
Additional criteria that increase diagnostic specificity include:
- Oral temperature >38.3°C
- Abnormal cervical or vaginal discharge
- Elevated erythrocyte sedimentation rate or C-reactive protein
- Laboratory documentation of cervical infection with N. gonorrhoeae or C. trachomatis 2, 1
Treatment Algorithms
Outpatient Treatment (Mild-Moderate PID)
Recommended Regimens:
Regimen A:
- Ceftriaxone 250mg IM in a single dose
- PLUS Doxycycline 100mg orally twice daily for 14 days
- WITH or WITHOUT Metronidazole 500mg orally twice daily for 14 days 1
Regimen B:
- Cefoxitin 2g IM in a single dose AND Probenecid 1g orally in a single dose
- PLUS Doxycycline 100mg orally twice daily for 14 days
- WITH or WITHOUT Metronidazole 500mg orally twice daily for 14 days 1
Inpatient Treatment (Severe PID)
Recommended Regimens:
Regimen A:
Regimen B:
For both inpatient regimens, continue parenteral therapy for at least 48 hours after clinical improvement, then complete a 14-day course with oral therapy (doxycycline 100mg orally twice daily) 2, 1
Hospitalization Criteria
Patients should be hospitalized for PID treatment if any of the following are present:
- Uncertain diagnosis (surgical emergencies like appendicitis or ectopic pregnancy cannot be excluded)
- Suspected pelvic abscess
- Pregnancy
- Adolescence (compliance concerns)
- HIV infection
- Severe illness or nausea/vomiting precluding outpatient management
- Inability to follow or tolerate outpatient regimen
- Failed response to outpatient therapy
- Clinical follow-up within 72 hours cannot be arranged 2, 1
Special Considerations
Tubo-Ovarian Abscess
- If a tubo-ovarian abscess >3cm is present, surgical drainage is indicated if no improvement occurs within 72 hours of antibiotic therapy 1, 3
Partner Treatment
- Sex partners should be examined and treated if they had sexual contact with the patient during the 60 days preceding symptom onset
- Partners should be treated empirically for both N. gonorrhoeae and C. trachomatis regardless of pathogens isolated from the woman 1
Follow-up
- Patients should be reassessed within 72 hours of initiating treatment
- If no improvement is seen, hospitalization, additional diagnostic tests, and surgical intervention may be necessary 1
Antimicrobial Coverage Rationale
PID is a polymicrobial infection requiring broad-spectrum coverage against:
- Neisseria gonorrhoeae
- Chlamydia trachomatis
- Gram-negative facultative bacteria
- Anaerobes
- Streptococci 2, 4, 5, 6
The recommended regimens provide appropriate coverage for these pathogens. Ceftriaxone and cefoxitin have FDA approval for PID treatment 4, 5, with ceftriaxone showing excellent activity against N. gonorrhoeae, including penicillinase-producing strains 4.
Common Pitfalls and Caveats
Delayed treatment: Early treatment is crucial to prevent long-term sequelae such as infertility, ectopic pregnancy, and chronic pelvic pain 6, 7
Inadequate coverage: Ensure antimicrobial coverage includes N. gonorrhoeae, C. trachomatis, and anaerobes 1, 6
Premature discontinuation: Complete the full 14-day course of antibiotics even if symptoms improve quickly 1
Neglecting partner treatment: Failure to treat partners can lead to reinfection 1
Insufficient follow-up: Patients should be reassessed within 72 hours of initiating treatment 1
Overlooking C. trachomatis: When using cephalosporins, remember they have no activity against C. trachomatis, necessitating concurrent doxycycline 4, 5
Ignoring regional resistance patterns: Consider local antimicrobial resistance patterns when selecting treatment 2, 1