Treatment Guidelines for Pelvic Inflammatory Disease (PID)
The treatment of PID requires broad-spectrum antibiotic coverage targeting multiple pathogens including C. trachomatis, N. gonorrhoeae, anaerobes, gram-negative rods, and streptococci, with hospitalization recommended for severe cases and specific high-risk situations. 1
Hospitalization Criteria
Hospitalization should be considered whenever possible for PID, and is particularly recommended in the following situations:
- Uncertain diagnosis 1
- Inability to exclude surgical emergencies (appendicitis, ectopic pregnancy) 1
- Suspected pelvic abscess 1, 2
- Pregnancy 1
- Adolescent patients (due to unpredictable compliance and potentially severe long-term sequelae) 1
- Severe illness precluding outpatient management 1
- Inability to tolerate oral regimen 1
- Failure to respond to 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, 3
- PLUS Doxycycline 100 mg orally or IV every 12 hours 1
- Continue for at least 48 hours after clinical improvement 1, 2
- After discharge, continue doxycycline 100 mg orally twice daily to complete 10-14 days 1, 2
Recommended 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 1
- Continue for at least 48 hours after clinical improvement 1
- After discharge, continue doxycycline 100 mg orally twice daily for 10-14 days total 1
- Alternative: clindamycin 450 mg orally 4 times daily for 10-14 days 1
Outpatient Treatment Regimens
Recommended Regimen
- Cefoxitin 2 g IM plus probenecid 1 g orally concurrently, OR ceftriaxone 250 mg IM 1, 4
- PLUS Doxycycline 100 mg orally twice daily for 10-14 days 1, 2
- Alternative for patients who cannot tolerate doxycycline: erythromycin 500 mg orally 4 times daily for 10-14 days 1
Recent Evidence and Considerations
- Adding metronidazole (500 mg orally twice daily for 14 days) to ceftriaxone and doxycycline improves outcomes by reducing endometrial anaerobes and decreasing pelvic tenderness 5
- Azithromycin may be more effective than doxycycline for mild-moderate PID according to recent evidence 6
- Clindamycin provides more complete anaerobic coverage than doxycycline, which is important as anaerobes are significant pathogens in PID 1, 5
- Doxycycline remains the treatment of choice for patients with chlamydial disease 1, 7
Partner Management
- Sex partners of women with PID should be evaluated and empirically treated with regimens effective against C. trachomatis and N. gonorrhoeae 1
- Special arrangements should be made to provide care for male sex partners in clinical settings that only see women 1
Important Caveats
- PID is a complex syndrome with various inflammatory manifestations (endometritis, salpingitis, tubo-ovarian abscess) caused by multiple organisms 1, 7
- Patients treated as outpatients need close monitoring and reevaluation within 72 hours 1, 8
- HIV-infected women with PID may have more severe disease and should be monitored closely, with early hospitalization and IV therapy when possible 1
- Cephalosporins and quinolones alone have limited activity against C. trachomatis, requiring additional appropriate antichlamydial coverage 4, 3
- Failure to adequately treat PID can lead to serious long-term sequelae including infertility, ectopic pregnancy, and chronic pelvic pain 7, 8
Bold text indicates the most important recommendation for PID treatment.