What is the management (Mx) of Pelvic Inflammatory Disease (PID)?

Management of Pelvic Inflammatory Disease (PID)

Treat PID with broad-spectrum antibiotics covering C. trachomatis, N. gonorrhoeae, anaerobes, gram-negative rods, and streptococci, with the decision to hospitalize based on specific clinical criteria including severity of illness, diagnostic uncertainty, pregnancy, adolescent age, or inability to tolerate oral therapy. 1, 2

Hospitalization Criteria

Strongly consider hospitalization in the following situations: 3, 1, 2

• Diagnostic uncertainty or inability to exclude surgical emergencies (appendicitis, ectopic pregnancy, ruptured tubo-ovarian abscess) 3, 2
• Pelvic or tubo-ovarian abscess suspected 3, 1, 2
• Pregnancy 3, 1
• Adolescent patients (due to unpredictable compliance and potentially severe long-term sequelae) 3, 1
• Severe systemic illness including high fever (>38.3°C), toxicity, dehydration, nausea/vomiting, or inability to tolerate oral medications 3, 1, 2
• Failed outpatient therapy 3, 1
• Inability to arrange clinical follow-up within 72 hours of starting antibiotics 3, 1

The rationale for hospitalization is that outpatient regimens provide less complete antimicrobial coverage for shorter duration than inpatient regimens, potentially reducing successful pathogen eradication and increasing risk of late sequelae including infertility, ectopic pregnancy, and chronic pelvic pain. 3, 4, 5

Inpatient Treatment Regimens

Recommended Regimen A

Cefoxitin 2 g IV every 6 hours OR Cefotetan 2 g IV every 12 hours PLUS Doxycycline 100 mg oral or IV every 12 hours 3, 1, 6

• Continue for at least 48 hours after clinical improvement, then transition to oral doxycycline to complete 14 days total 3, 1
• This combination provides broad coverage against polymicrobial infections and has extensive clinical experience demonstrating high effectiveness 1, 4

Recommended Regimen B

Clindamycin 900 mg IV every 8 hours PLUS Gentamicin (loading dose followed by maintenance dosing) 3, 1, 2

• Continue for at least 48 hours after clinical improvement 3, 1
• Clindamycin provides superior anaerobic coverage compared to doxycycline 1
• After parenteral therapy, continue oral doxycycline or azithromycin to ensure adequate chlamydial coverage 1, 2
• Monitor renal function carefully as nephrotoxicity may be potentiated with aminoglycosides 6

Outpatient Treatment Regimens (Mild-to-Moderate PID)

Cefoxitin 2 g IM with Probenecid 1 g oral simultaneously OR Ceftriaxone 250 mg IM PLUS Doxycycline 100 mg oral twice daily for 10-14 days 1, 7, 4, 5

• Alternative macrolide option: Azithromycin probably improves cure rates compared to doxycycline in mild-moderate PID based on high-quality evidence 8
• Consider adding metronidazole for enhanced anaerobic coverage, particularly in patients with bacterial vaginosis, though evidence shows little difference in cure rates 8, 9

Critical Caveat

Ceftriaxone and other cephalosporins have NO activity against C. trachomatis, which is a common pathogen in PID. 7, 6 Therefore, appropriate antichlamydial coverage (doxycycline or azithromycin) must always be added. 1, 7, 6

Essential Microbiological Coverage

Any regimen must cover: 1, 4, 5

• C. trachomatis (requires doxycycline or azithromycin) 1, 4, 10
• N. gonorrhoeae 1, 4, 10
• Anaerobes (including Bacteroides fragilis, Peptostreptococcus) 1, 4, 5
• Gram-negative rods (E. coli, Klebsiella) 1, 4
• Streptococci 1
• Mycoplasma genitalium (covered by azithromycin or doxycycline) 4, 5

Partner Management

Treatment of sex partners is imperative and management is inadequate without it. 3, 2

• All sex partners must be evaluated and empirically treated with regimens effective against C. trachomatis and N. gonorrhoeae 3, 2
• Failure to treat partners places the patient at high risk for reinfection and complications 3, 2
• In settings where only women are seen, arrange referral or special provisions for male partner treatment 3

Clinical Monitoring and Transition to Oral Therapy

• Assess clinical response within 24-48 hours of initiating antibiotics 2
• Transition to oral therapy when patient is afebrile, tolerating oral intake, and clinically improved 2
• If no improvement within 48-72 hours, obtain imaging (transvaginal ultrasound) to evaluate for tubo-ovarian abscess 2
• Complete a total of 14 days of antibiotic therapy 1, 4

Supportive Care for Severe PID

• IV fluid resuscitation for dehydration 2
• Antipyretics and analgesics for fever and pain 2
• Antiemetics for nausea/vomiting 2
• Bed rest during acute phase 2

Key Diagnostic Considerations

Minimum diagnostic criteria include: 2

• Lower abdominal tenderness
• Adnexal tenderness
• Cervical motion tenderness

Additional supportive findings: 2

• Oral temperature >38.3°C
• Abnormal cervical or vaginal discharge
• Cervical friability
• Elevated inflammatory markers (ESR, CRP)

Essential investigations: 2

• Pregnancy test (mandatory) to exclude ectopic pregnancy
• Endocervical swabs for N. gonorrhoeae and C. trachomatis (NAAT)
• Transvaginal ultrasound if abscess suspected or no clinical improvement