What is the initial workup and treatment for a suspected uterine infection?

Workup for Suspected Uterine Infection

For suspected pelvic inflammatory disease (PID), initiate empiric antibiotic treatment immediately based on minimum clinical criteria without waiting for laboratory or imaging results, as early treatment prevents long-term reproductive sequelae including tubal infertility and ectopic pregnancy. 1, 2

Minimum Diagnostic Criteria

Begin treatment if all three of the following are present in a sexually active woman, with no other identifiable cause: 1

• Lower abdominal tenderness
• Bilateral adnexal tenderness
• Cervical motion tenderness

The CDC explicitly recommends maintaining a "low threshold for diagnosis" to prevent reproductive damage, accepting that this approach will result in some overtreatment. 1, 2

Essential Initial Laboratory Testing

Obtain these tests immediately, but do not delay treatment while awaiting results: 1

• Cervical cultures for Neisseria gonorrhoeae 1
• Cervical culture or NAAT for Chlamydia trachomatis 1
• Urine or serum pregnancy test (to exclude ectopic pregnancy) 2
• Wet mount of vaginal secretions (presence of white blood cells supports diagnosis; if cervical discharge appears normal and no WBCs are present, PID is unlikely) 1

Additional Criteria That Increase Diagnostic Specificity

Use these findings to strengthen diagnostic certainty in severe cases: 1

• Oral temperature >38.3°C (>101°F) 1
• Abnormal cervical or vaginal mucopurulent discharge 1
• Elevated erythrocyte sedimentation rate 1
• Elevated C-reactive protein 1

Definitive Diagnostic Studies (For Severe or Uncertain Cases)

Consider these more invasive studies when clinical presentation is severe or diagnosis remains uncertain: 1

• Endometrial biopsy showing histopathologic evidence of endometritis 1
• Transvaginal ultrasound or MRI demonstrating thickened, fluid-filled tubes with or without free pelvic fluid or tubo-ovarian complex 1, 2
• Laparoscopy showing abnormalities consistent with PID 1

Immediate Empiric Treatment Regimens

Outpatient Treatment (For Mild-Moderate Cases)

Regimen A (Preferred): 1

• Ceftriaxone 250 mg IM once (or cefoxitin 2 g IM plus probenecid 1 g PO once)
• PLUS Doxycycline 100 mg PO twice daily for 14 days 1
• Consider adding metronidazole 500 mg PO twice daily for 14 days for enhanced anaerobic coverage 1

Regimen B (Alternative): 1

• Ofloxacin 400 mg PO twice daily for 14 days
• PLUS Metronidazole 500 mg PO twice daily for 14 days (or clindamycin 450 mg PO four times daily) 1

Mandatory Hospitalization Criteria

Admit for parenteral antibiotics if any of the following are present: 1, 3

• Pregnancy (pregnant women with suspected PID must be hospitalized) 1, 3
• Tubo-ovarian abscess suspected 1, 2
• Severe illness, nausea/vomiting precluding oral therapy 1
• HIV infection 1
• Adolescent patient (due to unpredictable compliance) 1
• Failure to respond to outpatient therapy within 72 hours 1
• Diagnostic uncertainty with inability to exclude surgical emergencies (appendicitis, ectopic pregnancy) 1

Inpatient Parenteral Treatment

For hospitalized patients, use broad-spectrum IV antibiotics covering N. gonorrhoeae, C. trachomatis, anaerobes, gram-negative bacteria, and streptococci: 1

• Ceftriaxone plus doxycycline (or azithromycin if pregnant, as doxycycline is contraindicated) 3
• Continue parenteral therapy until 24 hours after clinical improvement, then transition to oral doxycycline to complete 14 days 3

Critical Follow-Up Requirements

Reassess within 72 hours of initiating outpatient treatment: 1

• If no clinical improvement (persistent fever, worsening abdominal tenderness), reconsider alternate diagnoses (appendicitis, endometriosis, ruptured ovarian cyst, adnexal torsion) or consider hospitalization for IV antibiotics 1
• Expected substantial improvement within 3-5 days for hospitalized patients 1, 3

Perform microbiologic re-examination 7-10 days after completing therapy, with repeat screening for C. trachomatis and N. gonorrhoeae at 4-6 weeks 1

Management of Sexual Partners

All sexual partners within 60 days before symptom onset must be examined and treated empirically for gonorrhea and chlamydia, regardless of the woman's test results or apparent etiology. 1, 3 Negative endocervical screening does not exclude upper reproductive tract infection. 1

Special Pregnancy Considerations

In pregnant women with suspected PID: 3

• Hospitalization is mandatory 1, 3
• Use ceftriaxone plus azithromycin (doxycycline is contraindicated) 3
• Continue parenteral therapy until 24 hours after clinical improvement 3
• High risk for maternal morbidity, fetal loss, and preterm delivery necessitates aggressive treatment 3

Common Pitfalls to Avoid

• Do not wait for culture results before initiating treatment—immediate antibiotic administration is directly linked to prevention of long-term sequelae 1
• Do not withhold treatment in patients who fail to meet all minimum criteria if clinical suspicion remains high 1
• Do not use antibiotics without anaerobic coverage—anaerobes cause tubal and epithelial destruction, and bacterial vaginosis is present in many PID cases 1
• Explain diagnostic uncertainty carefully to patients—the low specificity of clinical criteria means some women without PID will be treated, but this is preferable to missing cases 1