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

From the Guidelines

Pelvic Inflammatory Disease (PID) treatment requires prompt antibiotic therapy to prevent complications like infertility and chronic pelvic pain, and 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. The choice of antibiotic regimen should be based on the severity of the disease, patient compliance, and the presence of any underlying medical conditions 1.

Key Considerations

• The treatment regimen should provide broad-spectrum coverage of likely pathogens, including Neisseria gonorrhoeae, Chlamydia trachomatis, anaerobes, Gram-negative facultative bacteria, and streptococci 1.
• Hospitalization is recommended for patients with severe illness, nausea and vomiting, or high fever, as well as those who are pregnant or have a tubo-ovarian abscess 1.
• The optimal choice of a cephalosporin for PID treatment is unclear, but ceftriaxone has better coverage against N. gonorrhoeae, while cefoxitin has better anaerobic coverage 1.
• Clinical data are limited regarding the use of other second- or third-generation cephalosporins, but they may be effective therapy for PID and may replace cefotetan or cefoxitin 1.

Treatment Regimens

• For outpatient treatment, 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.
• For hospitalized patients, IV antibiotics are used: either cefotetan 2g IV every 12 hours or cefoxitin 2g IV every 6 hours, plus doxycycline 100mg orally/IV every 12 hours.
• Treatment should continue for 24-48 hours after clinical improvement, then complete the 14-day course with oral medications.

Additional Recommendations

• Sexual partners from the past 60 days should be evaluated and treated for STIs.
• Patients should abstain from sexual intercourse until treatment is complete and symptoms resolve.
• Follow-up evaluation is recommended 2-3 days after starting treatment to ensure improvement.

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 Options for Pelvic Inflammatory Disease (PID)

The treatment for PID typically involves the use of broad-spectrum antibiotics that cover a range of bacteria, including Chlamydia trachomatis, Neisseria gonorrhoeae, and anaerobic bacteria 5, 6, 7, 8, 9. The choice of antibiotic regimen depends on the severity of the disease and the patient's overall health.

Antibiotic Regimens

• Azithromycin versus doxycycline: There is no clear evidence of a difference between the two drugs in rates of cure for mild-moderate PID, but azithromycin may be more effective than doxycycline in achieving cure in mild-moderate PID 5, 9.
• Quinolone versus cephalosporin: There is no clear evidence of a difference between the two drugs in rates of cure for mild-moderate PID or severe PID 5, 9.
• Nitroimidazole (metronidazole) versus no use of nitroimidazole: There is no conclusive evidence of a difference between the two groups in rates of cure for mild-moderate PID or severe PID 5, 9.
• Clindamycin plus aminoglycoside versus quinolone or cephalosporin: There is no clear evidence of a difference between the two groups in rates of cure for mild-moderate PID or severe PID 5, 9.

Treatment Recommendations

• Mild to moderate PID can be treated in an outpatient setting with a single intramuscular injection of a recommended cephalosporin followed by oral doxycycline for 14 days 7.
• Metronidazole is recommended for 14 days in the setting of bacterial vaginosis, trichomoniasis, or recent uterine instrumentation 7.
• 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 6, 7.

Key Considerations

• 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 7.
• Sex partner treatment is recommended, and expedited partner treatment is recommended where legal 7.
• 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 7.