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

From the Guidelines

Pelvic inflammatory disease (PID) treatment should prioritize parenteral therapy with gentamicin and clindamycin or alternative regimens such as ofloxacin or levofloxacin with metronidazole, to prevent complications like infertility and chronic pelvic pain, as recommended by the Centers for Disease Control and Prevention 1. The recommended regimen includes either outpatient or inpatient treatment depending on severity.

• For inpatient treatment, options include gentamicin loading dose IV or IM (2 mg/kg of body weight) followed by a maintenance dose (1.5 mg/kg) every 8 hours, plus clindamycin 450 mg orally four times a day to complete a total of 14 days of therapy.
• 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.
• Hospitalization is recommended for severe illness, pregnancy, inability to tolerate oral medications, failed outpatient treatment, or tubo-ovarian abscess, as suggested by the guidelines 1. Key considerations in PID treatment include:
• Prompt initiation of antibiotic therapy to prevent long-term sequelae 1
• Coverage of polymicrobial etiology, including Neisseria gonorrhoeae, Chlamydia trachomatis, and anaerobic bacteria
• Patient education on the importance of completing the full treatment course and abstaining from sexual intercourse until treatment completion and symptom resolution
• Evaluation and treatment of sexual partners from the past 60 days for chlamydia and gonorrhea, as recommended by the guidelines 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

• PID treatment: Ceftriaxone is indicated for the treatment of Pelvic Inflammatory Disease (PID) caused by Neisseria gonorrhoeae.
• However, since ceftriaxone has no activity against Chlamydia trachomatis, antichlamydial coverage should be added when Chlamydia trachomatis is suspected as one of the pathogens.
• Additionally, cefoxitin is also indicated for the treatment of gynecological infections, including pelvic inflammatory disease, caused by various bacteria, including Neisseria gonorrhoeae and Bacteroides species, but it also requires antichlamydial coverage when Chlamydia trachomatis is suspected 2 3.

From the Research

PID Treatment Overview

• Pelvic inflammatory disease (PID) is a serious infection that affects women of reproductive age, and its management is directed at containment of infection 4.
• The goals of therapy for PID include the resolution of clinical symptoms and signs, the eradication of pathogens from the genital tract, and the prevention of sequelae such as infertility, ectopic pregnancy, and chronic pelvic pain 4.

Antibiotic Regimens for PID

• The choice of an antibiotic regimen for PID relies on the appreciation of the polymicrobial etiology of the infection, including Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium, and other lower genital tract endogenous anaerobic and facultative bacteria 4.
• Currently available evidence and CDC treatment recommendations support the use of broad-spectrum antibiotic regimens that adequately cover the above-named microorganisms 4.
• 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 4.
• 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 4.

Comparison of Antibiotic Regimens

• A study comparing azithromycin and doxycycline for the treatment of PID found no clear evidence of a difference between the two drugs in rates of cure for mild-moderate PID, but moderate-quality evidence suggested that azithromycin may be more effective than doxycycline for curing mild-moderate PID 5, 6.
• Another study found no conclusive evidence that one regimen of antibiotics was safer or more effective than any other for the cure of PID, but suggested that a macrolide (azithromycin) may be more effective than a tetracycline (doxycycline) for curing mild-moderate PID 5, 6.
• A randomized controlled trial comparing ceftriaxone and doxycycline with or without metronidazole for the treatment of acute PID found that the addition of metronidazole resulted in reduced endometrial anaerobes, decreased M. genitalium, and reduced pelvic tenderness compared to ceftriaxone and doxycycline alone 7.

Treatment Recommendations

• The CDC recommends that mild to moderate PID be treated in an outpatient setting with a single intramuscular injection of a recommended cephalosporin followed by oral doxycycline for 14 days, and that metronidazole be added for 14 days in the setting of bacterial vaginosis, trichomoniasis, or recent uterine instrumentation 8.
• 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 8.