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

From the Guidelines

Pelvic Inflammatory Disease (PID) treatment should be initiated promptly with broad-spectrum antibiotics to cover Neisseria gonorrhoeae, Chlamydia trachomatis, and anaerobes, as recommended by the Centers for Disease Control and Prevention (CDC) in 2002 1. The goal of treatment is to prevent long-term sequelae such as infertility and chronic pelvic pain.

Key Considerations

• The decision to hospitalize a patient with PID should be based on the discretion of the healthcare provider, considering factors such as surgical emergencies, pregnancy, and severity of illness.
• Parenteral treatment is not necessarily required, and oral regimens can be effective, with the option to transition to oral therapy within 24 hours of clinical improvement.
• The recommended regimen includes either ceftriaxone 500mg IM once plus doxycycline 100mg orally twice daily for 14 days, with optional metronidazole 500mg orally twice daily for 14 days; or cefoxitin 2g IM with probenecid 1g orally once plus doxycycline for 14 days.

Treatment Approach

• Treatment should be initiated as soon as the presumptive diagnosis is made, and should continue for 24-48 hours after clinical improvement, then complete the 14-day course with oral antibiotics.
• Sexual partners from the past 60 days should be evaluated and treated for STIs.
• Patients should abstain from sexual intercourse until treatment completion and symptom resolution.
• Follow-up evaluation is recommended 2-3 days after starting treatment to ensure improvement.

Rationale

• The CDC guidelines emphasize the importance of providing anaerobic coverage, as anaerobic bacteria have been isolated from the upper reproductive tract of women with PID, and data from in vitro studies have revealed that certain anaerobes can cause tubal and epithelial destruction 1.
• The guidelines also recommend considering availability, cost, patient acceptance, and antimicrobial susceptibility when selecting a treatment regimen 1.

From the FDA Drug Label

Ceftriaxone for injection USP is indicated for the treatment of the following infections when caused by susceptible organisms Pelvic Inflammatory Disease caused by Neisseria gonorrhoeae Cefoxitin for Injection, USP is indicated for the treatment of serious infections caused by susceptible strains of the designated microorganisms in the diseases listed below Gynecological infections, including endometritis, pelvic cellulitis, and pelvic inflammatory disease caused by Escherichia coli, Neisseria gonorrhoeae (including penicillinase-producing strains)

PID Treatment:

• Ceftriaxone for injection USP is indicated for the treatment of Pelvic Inflammatory Disease (PID) caused by Neisseria gonorrhoeae 2.
• Cefoxitin for Injection, USP is also indicated for the treatment of gynecological infections, including PID caused by Neisseria gonorrhoeae (including penicillinase-producing strains) 3.
• It is essential to note that both ceftriaxone and cefoxitin have no activity against Chlamydia trachomatis, so appropriate antichlamydial coverage should be added when treating PID if Chlamydia trachomatis is suspected 2 3.

From the Research

Pid Treatment Overview

• Pelvic inflammatory disease (PID) is an infection of the upper genital tract that can be acute, chronic, or subclinical and is often underdiagnosed 4.
• The diagnosis of PID is made primarily on clinical suspicion, and empiric treatment is recommended in sexually active young women or women at risk for sexually transmitted infections who have unexplained lower abdominal or pelvic pain and cervical motion, uterine, or adnexal tenderness on examination 4.

Treatment Options

• Mild to moderate disease can be treated in an outpatient setting with a single intramuscular injection of a recommended cephalosporin followed by oral doxycycline for 14 days 4.
• Metronidazole is recommended for 14 days in the setting of bacterial vaginosis, trichomoniasis, or recent uterine instrumentation 4.
• Hospitalization for parenteral antibiotics is recommended in patients who are pregnant or severely ill, in whom outpatient treatment has failed, those with tubo-ovarian abscess, or if surgical emergencies cannot be excluded 4, 5.
• A short-course azithromycin-based regimen may be less effective than the standard treatment with ofloxacin plus metronidazole 6.
• The combination of cefoxitin and doxycycline is effective for ambulatory treatment of pelvic inflammatory disease 7.

Treatment Considerations

• The choice of an antibiotic regimen used to treat PID relies upon the appreciation of the polymicrobial etiology of this ascending infection, including Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium, and other lower genital tract endogenous anaerobic and facultative bacteria 5.
• Treatment does not change in patients with intrauterine devices or those with HIV 4.
• Sex partner treatment is recommended, and expedited partner treatment is recommended where legal 4.
• Prevention of PID includes screening for C. trachomatis and N. gonorrhoeae in all women younger than 25 years and those who are at risk or pregnant, plus intensive behavioral counseling for all adolescents and adults at increased risk of sexually transmitted infections 4.