Treatment of Pelvic Inflammatory Disease (PID)
The recommended treatment for pelvic inflammatory disease (PID) includes either cefoxitin 2g IV every 6 hours or cefotetan 2g IV every 12 hours plus doxycycline 100mg orally/IV every 12 hours for hospitalized patients, or ceftriaxone 250mg IM plus doxycycline 100mg orally twice daily for 10-14 days for outpatient management. 1, 2
Hospitalization Criteria
Hospitalization should be considered in the following situations:
- Uncertain diagnosis 1
- Surgical emergencies (e.g., appendicitis, ectopic pregnancy) cannot be excluded 1
- Suspected pelvic abscess 1
- Pregnancy 1
- Adolescent patients (compliance concerns) 1
- Severe illness preventing outpatient management 1
- Inability to tolerate oral regimen 1
- Failure to respond to outpatient therapy 1
- Clinical follow-up within 72 hours cannot be arranged 1
Inpatient Treatment Regimens
Recommended Regimen A
- Cefoxitin 2g IV every 6 hours OR cefotetan 2g IV every 12 hours 1
- PLUS doxycycline 100mg orally/IV every 12 hours 1
- Continue for at least 48 hours after clinical improvement 1
- After discharge, continue doxycycline 100mg orally twice daily for a total of 10-14 days 1
Recommended Regimen B
- Clindamycin 900mg IV every 8 hours 1
- PLUS gentamicin loading dose IV/IM (2mg/kg) followed by maintenance dose (1.5mg/kg) every 8 hours 1
- Continue for at least 48 hours after improvement 1
- After discharge, continue doxycycline 100mg orally twice daily for 10-14 days total 1
- Alternative: clindamycin 450mg orally 4 times daily for 10-14 days 1
Outpatient Treatment for Mild to Moderate PID
- Cefoxitin 2g IM plus probenecid 1g orally simultaneously, OR ceftriaxone 250mg IM 2
- PLUS doxycycline 100mg orally twice daily for 10-14 days 2, 3
Antimicrobial Coverage Considerations
Any regimen used should provide broad-spectrum coverage against: 1
- Chlamydia trachomatis
- Neisseria gonorrhoeae
- Anaerobes
- Gram-negative rods
- Streptococci
Ceftriaxone has FDA approval for PID caused by Neisseria gonorrhoeae but requires additional coverage for Chlamydia trachomatis 4
Cefoxitin is indicated for gynecological infections including PID caused by various pathogens including E. coli, N. gonorrhoeae, Bacteroides species, and others 5
Important Clinical Considerations
- Continuation of medication after hospital discharge is crucial, particularly for treating C. trachomatis infection 1
- Clindamycin provides more complete anaerobic coverage than doxycycline 1
- Doxycycline is the treatment of choice for patients with chlamydial disease 1
- Sexual partners should be evaluated and treated empirically with regimens effective against C. trachomatis and N. gonorrhoeae 1
Treatment Efficacy
- Both cefoxitin/doxycycline and clindamycin/aminoglycoside combinations have extensive clinical experience and are highly effective in achieving clinical cures 1
- The therapeutic success rate for these regimens is approximately 90% for uncomplicated PID 6
- Success rates are lower (around 55%) for tubo-ovarian abscesses 6