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

From the Guidelines

Pelvic Inflammatory Disease (PID) treatment should be initiated promptly with antibiotics to prevent complications, and the recommended outpatient regimen includes ceftriaxone 500mg IM once plus doxycycline 100mg orally twice daily for 14 days, with optional metronidazole 500mg orally twice daily for 14 days to cover anaerobic bacteria, as suggested by the guidelines from the Centers for Disease Control and Prevention 1.

Key Considerations for Treatment

• 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, inability to follow or tolerate an outpatient oral regimen, severe illness, and the presence of a tubo-ovarian abscess 1.
• Parenteral treatment may be discontinued 24 hours after a patient improves clinically, and continuing oral therapy should consist of doxycycline 100 mg orally twice a day or clindamycin 450 mg orally four times a day to complete a total of 14 days of therapy, as noted in the 1998 guidelines for treatment of sexually transmitted diseases 1.
• The optimal choice of a cephalosporin for treatment is unclear, but ceftriaxone has better coverage against N. gonorrhoeae, while cefoxitin has better anaerobic coverage, and the addition of metronidazole may be necessary to treat anaerobes and bacterial vaginosis, which is frequently associated with PID 1.

Additional Recommendations

• 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.
• PID treatment is crucial because the infection can ascend from the cervix to the upper genital tract, causing inflammation of the uterus, fallopian tubes, and surrounding structures, potentially leading to serious long-term reproductive health consequences if not properly treated.

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 Gynecologic Infections caused by Staphylococcus aureus (methicillin susceptible), Staphylococcus epidermidis (methicillin susceptible, Streptococcus species, Streptococcus agalactiae, E coli, Proteus mirabilis, Neisseria gonorrhoeae, Bacteroides fragilis, Prevotella melaninogenicaBacteroides vulgatus, Fusobacterium species*, and gram-positive anaerobic cocci (including Peptococcus niger and Peptostreptococcus species).

The treatment for Pelvic Inflammatory Disease (PID) includes:

• 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
• Cefotetan (4) for the treatment of gynecologic infections It is essential to note that these cephalosporins have no activity against Chlamydia trachomatis, so appropriate antichlamydial coverage should be added when treating PID.

From the Research

Treatment for Pelvic Inflammatory Disease (PID)

The treatment for PID typically involves broad-spectrum antibiotics that cover a range of microorganisms, including Chlamydia trachomatis, Neisseria gonorrhoeae, and anaerobic bacteria.

• The choice of antibiotic regimen depends on the severity of the disease and the patient's overall health.
• For mild to moderate PID, outpatient treatment with a single intramuscular injection of a recommended cephalosporin followed by oral doxycycline for 14 days is recommended 5.
• In some cases, metronidazole may also be prescribed for 14 days, especially if there is a suspicion of bacterial vaginosis, trichomoniasis, or recent uterine instrumentation 5.
• For more severe cases of PID, hospitalization and parenteral antibiotics may be necessary, especially if the patient is pregnant, severely ill, or has a tubo-ovarian abscess 5.

Antibiotic Regimens

Several antibiotic regimens have been studied for the treatment of PID, including:

• Azithromycin versus doxycycline: some studies suggest that azithromycin may be more effective than doxycycline in achieving cure in mild-moderate PID 6, 7.
• Quinolone versus cephalosporin: there is no clear evidence of a difference between these two drugs in rates of cure for mild-moderate PID or severe PID 6, 7.
• Nitroimidazole (metronidazole) versus no use of nitroimidazole: there is no conclusive evidence of a difference between these two groups in rates of cure for mild-moderate PID or severe PID 6, 7.
• Clindamycin plus aminoglycoside versus quinolone or cephalosporin: there is no clear evidence of a difference between these groups in rates of cure for mild-moderate PID or severe PID 6, 7.

Recommendations

The Centers for Disease Control and Prevention (CDC) recommend the use of broad-spectrum antibiotic regimens that cover Chlamydia trachomatis, Neisseria gonorrhoeae, and anaerobic bacteria for the treatment of PID 8, 5.

• The CDC also recommends screening for C. trachomatis and N. gonorrhoeae in all women younger than 25 years and those who are at risk or pregnant, as well as intensive behavioral counseling for all adolescents and adults at increased risk of sexually transmitted infections 5.