What is the treatment for Pelvic Inflammatory Disease (PID)?

From the Guidelines

Pelvic inflammatory disease (PID) treatment requires prompt antibiotic therapy to prevent complications like infertility and chronic pelvic pain, and the recommended treatment is a combination of antibiotics that cover common causative organisms including Neisseria gonorrhoeae, Chlamydia trachomatis, and anaerobes. The treatment regimens should cover C. trachomatis, N. gonorrhoeae, anaerobes, gram-negative rods, and streptococci 1. For outpatient treatment, the preferred regimen is ceftriaxone 500 mg IM once, plus doxycycline 100 mg orally twice daily for 14 days, with optional metronidazole 500 mg orally twice daily for 14 days to improve coverage of anaerobes.

Key Considerations

• The optimal choice of a cephalosporin for treatment is unclear, although cefoxitin has better anaerobic coverage, ceftriaxone has better coverage against N. gonorrhoeae 1.
• Sex partners of patients who have PID should be examined and treated if they had sexual contact with the patient during the 60 days preceding onset of symptoms in the patient 1.
• Patients should abstain from sexual intercourse until treatment is completed and symptoms have resolved.
• Follow-up evaluation within 72 hours is important to ensure improvement.

Treatment Regimens

• For patients requiring hospitalization, intravenous therapy with cefotetan 2 g IV every 12 hours or cefoxitin 2 g IV every 6 hours plus doxycycline 100 mg orally or IV every 12 hours is recommended until clinical improvement, followed by oral doxycycline to complete 14 days.
• The antibiotics target different aspects of bacterial cell function - ceftriaxone disrupts cell wall synthesis, doxycycline inhibits protein synthesis, and metronidazole is effective against anaerobic organisms that may contribute to abscess formation 1.

Prevention of Reinfection

• Sex partners should be treated empirically with regimens effective against both of these infections, regardless of the etiology of PID or pathogens isolated from the infected woman 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 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 Cefoxitin for Injection, USP, like cephalosporins, has no activity against Chlamydia trachomatis. Therefore, when Cefoxitin for Injection, USP is used in the treatment of patients with pelvic inflammatory disease and C. trachomatis is one of the suspected pathogens, appropriate anti-chlamydial coverage should be added Gynecologic Infections caused by Staphylococcus aureus (methicillin susceptible), Staphylococcus epidermidis (methicillin susceptible, Streptococcus species, Streptococcus agalactiae, E coli, Proteus mirabilis, Neisseria gonorrhoeae, Bacteroides fragilis, Prevotella melaninogenicaBacteroides vulgatus, Fusobacterium species*, and gram-positive anaerobic cocci (including Peptococcus niger and Peptostreptococcus species).

The treatment for Pelvic Inflammatory Disease (PID) includes:

• Ceftriaxone for injection USP, which is effective against Neisseria gonorrhoeae, but has no activity against Chlamydia trachomatis, so appropriate antichlamydial coverage should be added 2
• Cefotetan, which is effective against various bacteria that cause gynecologic infections, including Neisseria gonorrhoeae, but has no activity against Chlamydia trachomatis, so appropriate antichlamydial coverage should be added 3
• Cefoxitin for injection USP, which is effective against various bacteria that cause gynecological infections, including Neisseria gonorrhoeae, but has no activity against Chlamydia trachomatis, so appropriate anti-chlamydial coverage should be added 4 Key points:
• The choice of antibiotic should be based on the suspected causative organisms and their susceptibility patterns.
• Antichlamydial coverage should be added when cephalosporins are used to treat PID, as they have no activity against Chlamydia trachomatis.

From the Research

Treatment for Pelvic Inflammatory Disease (PID)

The treatment for PID is primarily focused on containing the infection and preventing long-term sequelae. The goals of therapy include:

• Resolution of clinical symptoms and signs
• Eradication of pathogens from the genital tract
• Prevention of sequelae, including infertility, ectopic pregnancy, and chronic pelvic pain 5

Antibiotic Regimens

The choice of antibiotic regimen relies on the appreciation of the polymicrobial etiology of PID, including Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium, and other lower genital tract endogenous anaerobic and facultative bacteria. Currently available evidence and CDC treatment recommendations support the use of broad-spectrum antibiotic regimens that adequately cover these microorganisms 5, 6, 7. Some of the recommended antibiotic regimens include:

• Azithromycin versus doxycycline: moderate-quality evidence suggests that azithromycin may be more effective than doxycycline for curing mild-moderate PID 6, 7
• Quinolone versus cephalosporin: no clear evidence of a difference between the two drugs in rates of cure for mild-moderate PID or severe PID 6, 7
• Nitroimidazole versus no use of nitroimidazole: no conclusive evidence of a difference between the nitroimidazoles group and the group receiving other drugs with activity over anaerobes 6, 7

Treatment Approaches

The treatment approach for PID depends on the severity of the disease and the patient's clinical condition. Some of the treatment approaches include:

• Outpatient treatment: mild-to-moderate PID can be treated with tolerated antibiotic regimens consisting of an extended-spectrum cephalosporin in conjunction with either azithromycin or doxycycline 5
• Inpatient treatment: clinically severe PID should prompt hospitalization and imaging to rule out a tubo-ovarian abscess, and parenteral broad-spectrum antibiotic therapy should be implemented 5, 8
• Percutaneous drain placement: may be necessary to promote efficient source control in cases of large tubo-ovarian abscesses 8

Key Considerations

Some key considerations in the treatment of PID include:

• The need for broad-spectrum antibiotics to cover the polymicrobial etiology of the disease
• The importance of considering the patient's clinical condition and severity of disease in determining the treatment approach
• The potential for long-term sequelae, including infertility, ectopic pregnancy, and chronic pelvic pain, and the need for good health educational programs in the reproductive period 9