What are the diagnostic criteria and treatment options for Pelvic Inflammatory Disease (PID)?

From the Guidelines

Pelvic inflammatory disease (PID) should be diagnosed and treated promptly with a combination of clinical assessment, laboratory tests, and imaging, and treatment should include broad-spectrum antibiotic coverage, such as the CDC-recommended regimen of ceftriaxone 500 mg IM once plus doxycycline 100 mg orally twice daily for 14 days, with optional metronidazole 500 mg orally twice daily for 14 days 1.

Diagnosis of PID

Diagnosis of PID typically involves a pelvic examination to check for cervical motion tenderness, adnexal tenderness, or uterine tenderness; laboratory tests including complete blood count, C-reactive protein, and tests for gonorrhea and chlamydia; and sometimes imaging such as ultrasound or CT scan to rule out other conditions.

• The minimum criteria for diagnosing PID include uterine/adnexal tenderness or cervical motion tenderness 1.
• Additional criteria that support a diagnosis of PID include oral temperature >101 F (>38.3 C), abnormal cervical or vaginal mucopurulent discharge, presence of white blood cells (WBCs) on saline microscopy of vaginal secretions, elevated erythrocyte sedimentation rate, elevated C-reactive protein, and laboratory documentation of cervical infection with N. gonorrhoeae or C. trachomatis 1.

Treatment of PID

Treatment of PID requires prompt antibiotic therapy, typically with a combination regimen.

• The CDC-recommended outpatient regimen includes ceftriaxone 500 mg IM once plus doxycycline 100 mg orally twice daily for 14 days, with optional metronidazole 500 mg orally twice daily for 14 days 1.
• For inpatient treatment, options include cefotetan 2 g IV every 12 hours or cefoxitin 2 g IV every 6 hours plus doxycycline 100 mg orally or IV every 12 hours, followed by oral doxycycline to complete 14 days 1.

Hospitalization and Partner Treatment

Hospitalization is recommended for severe illness, pregnancy, inability to tolerate oral medications, or failure to respond to outpatient therapy 1.

• Partners should be treated to prevent reinfection, and patients should abstain from sexual intercourse until treatment is complete and symptoms have resolved 1. Prompt treatment is crucial as delayed treatment can lead to complications including chronic pelvic pain, ectopic pregnancy, and infertility due to scarring of the fallopian tubes 1.

From the FDA Drug Label

Pelvic Inflammatory Disease caused by Neisseria gonorrhoeae Ceftriaxone sodium, like other cephalosporins, has no activity against Chlamydia trachomatis. Therefore, when cephalosporins are used in the treatment of patients with pelvic inflammatory disease and Chlamydia trachomatis is one of the suspected pathogens, appropriate antichlamydial coverage should be added Gynecological infections, including endometritis, pelvic cellulitis, and pelvic inflammatory disease caused by Escherichia coli, Neisseria gonorrhoeae (including penicillinase-producing strains), Bacteroides species including B. fragilis, Clostridium species, Peptococcus niger, Peptostreptococcus species, and Streptococcus agalactiae Cefoxitin for Injection, USP, like cephalosporins, has no activity against Chlamydia trachomatis. Therefore, when Cefoxitin for Injection, USP is used in the treatment of patients with pelvic inflammatory disease and C. trachomatis is one of the suspected pathogens, appropriate anti-chlamydial coverage should be added

To diagnose Pelvic Inflammatory Disease (PID), the following steps should be taken:

• Obtain appropriate specimens for isolation of the causative organism and for determination of its susceptibility to the drug.
• Consider the patient's symptoms, medical history, and physical examination results.
• Use imaging studies or laparoscopy if necessary to confirm the diagnosis.

To treat PID, the following antibiotics may be used:

• Ceftriaxone (2) for the treatment of PID caused by Neisseria gonorrhoeae.
• Cefoxitin (3) for the treatment of gynecological infections, including endometritis, pelvic cellulitis, and pelvic inflammatory disease. It is essential to note that:
• Chlamydia trachomatis is a common cause of PID, and cephalosporins like ceftriaxone and cefoxitin have no activity against this pathogen.
• Appropriate antichlamydial coverage should be added when treating PID with cephalosporins.
• The choice of antibiotic should be based on the suspected or confirmed causative organism and its susceptibility to the drug.

From the Research

Diagnosis of PID

• 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.
• Genital assessment for signs of inflammation or infection, blood test, and imaging evaluation can be used to confirm the suspicion of PID 5.
• Laparoscopic approach is considered the gold standard for diagnosing PID 5.
• A high index of suspicion for PID is advised in any woman of reproductive age with pelvic or abdominal pain 6.

Treatment of PID

• 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 7.
• Broad-spectrum antibiotic regimens that adequately cover the above-named microorganisms are recommended 7.
• Outpatient treatment of mild-to-moderate PID should include tolerated antibiotic regimens consisting of an extended-spectrum cephalosporin in conjunction with either azithromycin or doxycycline 7.
• Clinically severe PID should prompt hospitalization and imaging to rule out a tubo-ovarian abscess, and parenteral broad-spectrum antibiotic therapy with activity against a polymicrobial flora should be implemented 7.
• 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.

Prevention of PID

• 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.
• Sex partner treatment is recommended, and expedited partner treatment is recommended where legal 4.