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

Treatment of Pelvic Inflammatory Disease (PID)

The recommended treatment for Pelvic Inflammatory Disease (PID) includes broad-spectrum antibiotics with coverage against Neisseria gonorrhoeae, Chlamydia trachomatis, anaerobes, gram-negative rods, and streptococci, with hospitalization for severe cases and outpatient management for mild to moderate cases. 1, 2

Diagnostic Criteria

• Minimum criteria for PID diagnosis include lower abdominal tenderness, adnexal tenderness, and cervical motion tenderness 2, 3
• Additional supporting criteria include:
  • Oral temperature >38.3°C (>101°F) 2, 3
  • Abnormal cervical or vaginal discharge 2
  • Elevated erythrocyte sedimentation rate or C-reactive protein 2, 3
  • Laboratory documentation of cervical infection with N. gonorrhoeae or C. trachomatis 2, 3

Hospitalization Criteria

Hospitalization for parenteral therapy is recommended when:

• The diagnosis is uncertain or surgical emergencies cannot be excluded 2, 1
• A pelvic abscess is suspected 2, 1
• The patient is pregnant 2
• The patient is an adolescent 2, 1
• Severe illness precludes outpatient management 2
• The patient is unable to tolerate an outpatient regimen 2, 1
• The patient has failed to respond to outpatient therapy 2
• Clinical follow-up within 72 hours cannot be arranged 2, 1

Inpatient Treatment Regimens

Recommended Regimen A

• Cefoxitin 2 g IV every 6 hours or cefotetan 2 g IV every 12 hours 2
• PLUS Doxycycline 100 mg oral or IV every 12 hours 2
• Continue for at least 48 hours after clinical improvement 2, 1
• After discharge, continue doxycycline 100 mg orally twice daily to complete 10-14 days of therapy 2

Recommended Regimen B

• Clindamycin 900 mg IV every 8 hours 2, 1
• PLUS Gentamicin loading dose IV or IM (2 mg/kg) followed by maintenance dose (1.5 mg/kg) every 8 hours 2
• Continue for at least 48 hours after clinical improvement 2, 1
• After discharge, continue doxycycline 100 mg orally twice daily for 10-14 days 2
• Alternative: clindamycin 450 mg orally 4 times daily for 10-14 days 2

Outpatient Treatment for Mild to Moderate PID

• Cefoxitin 2 g IM plus probenecid 1 g orally administered concurrently as a single dose 1
• OR Ceftriaxone 250 mg IM as a single dose 2, 4
• PLUS Doxycycline 100 mg orally twice daily for 10-14 days 2, 1

Treatment Considerations

• Empiric treatment should be initiated promptly in sexually active women at risk for STDs who have uterine, adnexal, or cervical motion tenderness with no other explanation 2, 5
• Immediate administration of appropriate antibiotics has been linked to prevention of long-term sequelae 2, 6
• Patients who do not respond to oral therapy within 72 hours should be reevaluated and given parenteral therapy 2, 7
• Clindamycin has more complete anaerobic coverage than doxycycline, which is important in polymicrobial infections 2, 3
• When C. trachomatis is strongly suspected, ensure doxycycline is included in the regimen 2, 1

Partner Management

• Male sex partners should be examined and treated if they had sexual contact with the patient during the 60 days before symptom onset 2
• Partner evaluation and treatment are crucial due to the risk of reinfection and the likelihood of urethral gonococcal or chlamydial infection in the partner 2

Common Pitfalls to Avoid

• Discontinuing IV therapy too early before clinical improvement is established 3, 7
• Not screening for and treating sexually transmitted infections that may be the underlying cause 3, 6
• Delaying empiric treatment when PID is suspected, as this can increase risk of long-term sequelae including infertility, ectopic pregnancy, and chronic pelvic pain 5, 8
• Failing to consider PID in women with subtle symptoms such as abnormal vaginal discharge, metrorrhagia, or urinary frequency, particularly in women at risk of STIs 6, 8