What is the recommended medication regimen for Pelvic Inflammatory Disease (PID)?

Recommended Medication Regimens for Pelvic Inflammatory Disease (PID)

For outpatient treatment of PID, the recommended regimens include either a cephalosporin plus doxycycline with or without metronidazole, or a fluoroquinolone with metronidazole for 14 days. 1

Outpatient Treatment Options

Regimen A:

• Ofloxacin 400 mg orally twice daily for 14 days OR Levofloxacin 500 mg orally once daily for 14 days 1
• WITH metronidazole 500 mg orally twice daily for 14 days 1

Regimen B:

• Ceftriaxone 250 mg IM in a single dose OR Cefoxitin 2 g IM with Probenecid 1 g orally in a single dose OR other parenteral third-generation cephalosporin 1
• PLUS Doxycycline 100 mg orally twice daily for 14 days 1
• WITH metronidazole 500 mg orally twice daily for 14 days 1, 2

Rationale for Treatment Components

• Ceftriaxone/Cefoxitin: Provides coverage against N. gonorrhoeae (ceftriaxone has better coverage) 1
• Ofloxacin/Levofloxacin: Effective against both N. gonorrhoeae and C. trachomatis 1
• Doxycycline: Targets C. trachomatis 1
• Metronidazole: Provides anaerobic coverage and treats bacterial vaginosis (BV) which is frequently associated with PID 1

Important Clinical Considerations

• The addition of metronidazole is strongly recommended as recent evidence shows it results in reduced endometrial anaerobes, decreased M. genitalium, and reduced pelvic tenderness compared to ceftriaxone and doxycycline alone 2
• Patients should demonstrate substantial clinical improvement (defervescence, reduction in abdominal tenderness, reduction in cervical motion tenderness) within 3 days of starting therapy 1
• If no improvement within 72 hours, patients should be reevaluated, hospitalized for parenteral therapy, and further diagnostic tests should be performed 1

Inpatient Treatment Options

For patients requiring hospitalization:

Parenteral Regimen A:

• Cefotetan 2 g IV every 12 hours OR Cefoxitin 2 g IV every 6 hours 1
• PLUS Doxycycline 100 mg IV or orally every 12 hours 1

Parenteral Regimen B:

• Clindamycin 900 mg IV every 8 hours 1
• PLUS Gentamicin loading dose IV or IM (2 mg/kg) followed by maintenance dose (1.5 mg/kg) every 8 hours (single daily dosing may be substituted) 1

Alternative Parenteral Regimens:

• Ofloxacin 400 mg IV every 12 hours OR Levofloxacin 500 mg IV once daily 1
• WITH or WITHOUT Metronidazole 500 mg IV every 8 hours 1
• OR Ampicillin/Sulbactam 3 g IV every 6 hours PLUS Doxycycline 100 mg orally or IV every 12 hours 1

Management of Sex Partners

• Sex partners of patients with PID should be examined and treated if they had sexual contact with the patient during the 60 days preceding onset of symptoms 1
• Treatment is necessary due to risk of reinfection and likelihood of urethral gonococcal or chlamydial infection in sex partners 1
• Sex partners should be treated empirically with regimens effective against both C. trachomatis and N. gonorrhoeae, regardless of the etiology of PID 1

Follow-Up Recommendations

• A follow-up examination should be performed within 72 hours for patients on outpatient therapy 1
• Some specialists recommend rescreening for C. trachomatis and N. gonorrhoeae 4-6 weeks after therapy completion 1
• Parenteral therapy can be discontinued 24 hours after clinical improvement; continuing oral therapy should complete a total of 14 days 1

Common Pitfalls and Caveats

• Cefotetan, like other cephalosporins, has no activity against C. trachomatis, necessitating additional coverage with doxycycline 3
• Delay in treatment can increase risk of long-term sequelae including infertility, ectopic pregnancy, and chronic pelvic pain 4
• Gastrointestinal symptoms may limit compliance with some regimens, particularly amoxicillin/clavulanic acid plus doxycycline 1
• Approximately half of Prevotella species may not be susceptible to ceftriaxone, highlighting the importance of metronidazole in the treatment regimen 5