What are the antibiotics for Pelvic Inflammatory Disease (PID)?

From the Guidelines

For pelvic inflammatory disease (PID), the recommended antibiotic regimen typically includes a combination of medications to cover a broad spectrum of potential pathogens, with the most recent guidelines suggesting ceftriaxone 500 mg intramuscularly as a single dose, plus doxycycline 100 mg orally twice daily for 14 days, with optional metronidazole 500 mg orally twice daily for 14 days 1.

Key Considerations

• The choice of antibiotic regimen should be based on the severity of the disease, with outpatient treatment suitable for mild to moderate cases and intravenous therapy recommended for severe cases requiring hospitalization.
• The antibiotics should target the common causative organisms, including Neisseria gonorrhoeae, Chlamydia trachomatis, and anaerobic bacteria.
• Treatment should continue for at least 24-48 hours after clinical improvement, followed by oral therapy to complete 14 days.
• It's essential to treat sexual partners to prevent reinfection, and patients should abstain from sexual intercourse until treatment is completed and symptoms have resolved.
• Follow-up within 72 hours is recommended to ensure clinical improvement, with additional evaluation if symptoms persist.

Alternative Regimens

• For patients with severe PID requiring hospitalization, alternative parenteral regimens include ofloxacin 400 mg IV every 12 hours, or levofloxacin 500 mg IV once daily, with or without metronidazole 500 mg IV every 8 hours 1.
• Another option is ampicillin/sulbactam 3 g IV every 6 hours, plus doxycycline 100 mg IV or orally every 12 hours 1.

Important Notes

• The use of a single daily dose of gentamicin has not been evaluated for the treatment of PID, but it is efficacious in other analogous situations 1.
• Clindamycin provides more effective anaerobic coverage and is often used for continued therapy in patients with tubo-ovarian abscess 1.

From the FDA Drug Label

Ceftriaxone for injection USP is indicated for the treatment of the following infections when caused by susceptible organisms: Lower Respiratory Tract Infections caused by Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus influenzae, Haemophilus parainfluenzae, Klebsiella pneumoniae, Escherichia coli, Enterobacter aerogenes, Proteus mirabilis or Serratia marcescens Acute Bacterial Otitis Media caused by Streptococcus pneumoniae, Haemophilus influenzae (including beta-lactamase producing strains) or Moraxella catarrhalis (including beta-lactamase producing strains). Skin and Skin Structure Infections caused by Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus pyogenes, Viridans group streptococci, Escherichia coli, Enterobacter cloacae, Klebsiella oxytoca, Klebsiella pneumoniae, Proteus mirabilis, Morganella morganii*, Pseudomonas aeruginosa, Serratia marcescens, Acinetobacter calcoaceticus, Bacteroides fragilis* or Peptostreptococcus species Urinary Tract Infections (complicated and uncomplicated) caused by Escherichia coli, Proteus mirabilis, Proteus vulgaris, Morganella morganii or Klebsiella pneumoniae Uncomplicated Gonorrhea (cervical/urethral and rectal) caused by Neisseria gonorrhoeae, including both penicillinase- and nonpenicillinase-producing strains, and pharyngeal gonorrhea caused by nonpenicillinase-producing strains of Neisseria gonorrhoeae. Pelvic Inflammatory Disease caused by Neisseria gonorrhoeae Bacterial Septicemia caused by Staphylococcus aureus, Streptococcus pneumoniae, Escherichia coli, Haemophilus influenzae or Klebsiella pneumoniae. Bone and Joint Infections caused by Staphylococcus aureus, Streptococcus pneumoniae, Escherichia coli, Proteus mirabilis, Klebsiella pneumoniae or Enterobacter species Intra-Abdominal Infections caused by Escherichia coli, Klebsiella pneumoniae, Bacteroides fragilis, Clostridium species (Note: most strains of Clostridium difficile are resistant) or Peptostreptococcus species. Meningitis caused by Haemophilus influenzae, Neisseria meningitidis or Streptococcus pneumoniae

The pid antibiotics are:

• Ceftriaxone for the treatment of various infections, including:
  • Lower Respiratory Tract Infections
  • Acute Bacterial Otitis Media
  • Skin and Skin Structure Infections
  • Urinary Tract Infections
  • Uncomplicated Gonorrhea
  • Pelvic Inflammatory Disease
  • Bacterial Septicemia
  • Bone and Joint Infections
  • Intra-Abdominal Infections
  • Meningitis 2

From the Research

Antibiotics for Pelvic Inflammatory Disease (PID)

• The Centers for Disease Control and Prevention (CDC) recommends outpatient treatment of PID with an intramuscular dose of ceftriaxone plus 14 days of doxycycline, with or without metronidazole 3.
• European guidelines include moxifloxacin plus ceftriaxone as a first-line regimen, particularly for women with Mycoplasma genitalium-associated PID 3.
• A study found that the combination of ceftriaxone plus moxifloxacin provides similar coverage of facultative and anaerobic pathogens compared to the combination of ceftriaxone, metronidazole, and doxycycline 3.

Treatment Regimens

• A review of 39 randomized controlled trials (RCTs) found that regimens containing azithromycin versus regimens containing doxycycline may have little to no difference in rates of cure for mild-moderate PID 4.
• The same review found that regimens containing quinolone versus regimens containing cephalosporin may have little to no difference in rates of cure for mild-moderate PID 4.
• A study found that a short-course azithromycin-based regimen is likely to be less effective than the standard treatment with ofloxacin plus metronidazole 5.

Addition of Metronidazole

• A randomized controlled trial found that the addition of metronidazole to ceftriaxone and doxycycline was well tolerated and resulted in reduced endometrial anaerobes, decreased M. genitalium, and reduced pelvic tenderness compared to ceftriaxone and doxycycline alone 6.
• The same trial found that metronidazole should be routinely added to ceftriaxone and doxycycline for the treatment of women with acute PID 6.

Recommendations

• The CDC recommends empiric treatment of PID 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 7.
• Treatment does not change in patients with intrauterine devices or those with HIV 7.
• Sex partner treatment is recommended, and expedited partner treatment is recommended where legal 7.