Treatment of Pelvic Inflammatory Disease (PID) from Gonorrhea Infection
The recommended treatment for PID caused by gonorrhea infection consists of ceftriaxone 250 mg IM as a single dose plus doxycycline 100 mg orally twice daily for 14 days, with the addition of metronidazole 500 mg orally twice daily for 14 days to provide anaerobic coverage. 1
Outpatient Treatment Regimens
For patients with mild to moderate PID who can be treated as outpatients, the CDC recommends the following regimens:
Regimen A
- Ceftriaxone 250 mg IM in a single dose 1, 2
- PLUS
- Doxycycline 100 mg orally twice daily for 14 days
- WITH
- Metronidazole 500 mg orally twice daily for 14 days
Alternative Regimen B
- Cefoxitin 2 g IM in a single dose 1, 3
- PLUS
- Probenecid 1 g orally in a single dose
- PLUS
- Doxycycline 100 mg orally twice daily for 14 days
- WITH
- Metronidazole 500 mg orally twice daily for 14 days
Inpatient Treatment Regimens
For patients with severe PID requiring hospitalization, the CDC recommends:
Regimen A
- Cefoxitin 2 g IV every 6 hours OR Cefotetan 2 g IV every 12 hours 1
- PLUS
- Doxycycline 100 mg IV or orally every 12 hours
Regimen B
- Clindamycin 900 mg IV every 8 hours 4, 1
- PLUS
- Gentamicin loading dose IV or IM (2 mg/kg) followed by maintenance dose (1.5 mg/kg) every 8 hours
Parenteral therapy should be continued for at least 24 hours after clinical improvement, then complete a 14-day course with oral antibiotics.
Indications for Hospitalization
Patients should be hospitalized for PID treatment if they have:
- Severe illness with high fever
- Nausea/vomiting preventing oral medication
- Suspected tubo-ovarian abscess
- Pregnancy
- Failed outpatient therapy
- Inability to follow or tolerate outpatient regimen 1
Important Clinical Considerations
Dual pathogen coverage: Since PID is often polymicrobial, treatment must cover both N. gonorrhoeae and C. trachomatis, even when only gonorrhea is confirmed 1, 5
Anaerobic coverage: Metronidazole is added to provide coverage against anaerobic bacteria and bacterial vaginosis, which are frequently associated with PID 1, 6
Partner treatment: Sex partners should be evaluated and treated empirically for both C. trachomatis and N. gonorrhoeae to prevent reinfection 1
Follow-up: Patients should be reassessed within 72 hours of starting treatment. If no clinical improvement is seen, hospitalization for parenteral therapy should be considered 1
Retesting: The CDC recommends retesting for C. trachomatis and N. gonorrhoeae approximately 3 months after treatment completion due to high rates of reinfection 1
Complications and Prevention
Untreated or inadequately treated PID can lead to serious complications including:
- Infertility due to tubal scarring
- Chronic pelvic pain
- Ectopic pregnancy
- Tubo-ovarian abscess formation 1, 6
Early and appropriate antibiotic therapy is essential to prevent these long-term sequelae. Screening for chlamydial and gonococcal infections in high-risk women can reduce PID incidence 6.