Treatment of Pelvic Inflammatory Disease (PID)
The recommended treatment for Pelvic Inflammatory Disease (PID) requires broad-spectrum antibiotic coverage that includes protection against Chlamydia trachomatis, Neisseria gonorrhoeae, anaerobes, gram-negative rods, and streptococci, with treatment decisions based on severity and hospitalization criteria. 1, 2
Hospitalization Criteria
Hospitalization should be considered in the following situations:
- Uncertain diagnosis 1
- Inability to exclude surgical emergencies (appendicitis, ectopic pregnancy) 1
- Suspected pelvic abscess 1
- Pregnancy 1
- Adolescent patients 1
- Severe illness preventing outpatient management 1
- Inability to tolerate outpatient regimen 1
- Failed outpatient therapy 1
- Inability to arrange clinical follow-up within 72 hours 1
Inpatient Treatment Regimens
Recommended Regimen A:
- Cefoxitin 2 g IV every 6 hours or cefotetan 2 g IV every 12 hours 1, 2
- Plus doxycycline 100 mg orally or IV every 12 hours 1, 2
- Continue for at least 48 hours after clinical improvement 1, 2
- After discharge, continue doxycycline 100 mg orally twice daily for a total of 10-14 days 1, 2
Recommended Regimen B:
- Clindamycin 900 mg IV every 8 hours 1, 2
- Plus gentamicin loading dose IV or IM (2 mg/kg body weight) followed by maintenance dose (1.5 mg/kg) every 8 hours 1, 2
- Continue for at least 48 hours after improvement 1, 2
- After discharge, continue doxycycline 100 mg orally twice daily for 10-14 days total 1, 2
- Alternative: clindamycin 450 mg orally 4 times daily for 10-14 days 1, 2
Outpatient Treatment for Mild to Moderate PID
- Cefoxitin 2 g IM plus probenecid 1 g orally simultaneously, or ceftriaxone 250 mg IM 2, 3
- Plus doxycycline 100 mg orally twice daily for 10-14 days 2, 4
Treatment Considerations
- Continuation of medication after hospital discharge is crucial, particularly for treating C. trachomatis infection 1, 2
- Clindamycin provides more complete anaerobic coverage than doxycycline 1, 2
- Doxycycline remains the treatment of choice for patients with chlamydial disease 1, 2
- When C. trachomatis is strongly suspected, doxycycline is the preferred treatment 1, 2
- Azithromycin may be more effective than doxycycline for mild-moderate PID according to some evidence 5
Rationale for Treatment Approach
- PID is a polymicrobial infection requiring broad-spectrum coverage 4, 6
- Treatment goals include resolution of clinical symptoms, eradication of pathogens, and prevention of sequelae (infertility, ectopic pregnancy, chronic pelvic pain) 4, 7
- Ceftriaxone is FDA-approved for PID caused by N. gonorrhoeae, but requires additional coverage for C. trachomatis 3
- Regimens containing nitroimidazoles (metronidazole) show little difference in cure rates compared to regimens without them 5
Important Caveats
- PID can present with minimal symptoms - consider abnormal vaginal discharge, metrorrhagia, postcoital bleeding, and urinary frequency as potential symptoms, particularly in women at risk for STIs 6
- Failure to adequately treat PID can result in long-term sequelae including infertility, ectopic pregnancy, and chronic pelvic pain 7
- Penicillin plus metronidazole has shown unacceptably high failure rates (53%) compared to doxycycline plus metronidazole (19%) 8
- Treatment of sexual partners is essential to prevent reinfection 1