What is Pelvic Inflammatory Disease (PID)?

From the Guidelines

Pelvic Inflammatory Disease (PID) is a serious infection of the female reproductive organs that requires prompt antibiotic treatment, and the recommended regimen is ceftriaxone 500mg IM once plus doxycycline 100mg orally twice daily for 14 days, with metronidazole 500mg orally twice daily for 14 days often added to provide better anaerobic coverage, as suggested by the most recent guidelines 1.

Diagnosis and Treatment

The diagnosis of PID should be suspected in sexually active young women and other women at risk for STDs if they present with uterine/adnexal tenderness or cervical motion tenderness, and no other cause(s) for the illness can be identified 1.

• The treatment regimen should provide empiric, broad-spectrum coverage of likely pathogens, including N. gonorrhoeae, C. trachomatis, anaerobes, Gram-negative facultative bacteria, and streptococci.
• 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.

Management and Prevention

• Treatment should begin immediately upon diagnosis, as delays can lead to complications including infertility, chronic pelvic pain, and ectopic pregnancy.
• Sexual partners from the past 60 days should be evaluated and treated for STIs.
• Patients should abstain from sexual intercourse until treatment is completed and symptoms have resolved.
• PID develops when bacteria from the vagina or cervix ascend into the upper reproductive tract, often following sexually transmitted infections like chlamydia or gonorrhea, which is why broad-spectrum antibiotics are needed to target multiple potential pathogens 1.

From the Research

Definition and Prevalence of PID

• Pelvic inflammatory disease (PID) is an infection that affects 4% to 12% of young women, and is one of the most common causes of morbidity in this age group 2.
• PID can be acute, chronic, or subclinical and is often underdiagnosed 3.

Causes of PID

• The main causes of PID are Chlamydia trachomatis and Neisseria gonorrhoeae, but other pathogens such as Mycoplasma genitalium and anaerobic bacteria may also be involved 2, 4, 3.

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 3.

Treatment of PID

• The main intervention for acute PID is the use of broad-spectrum antibiotics which cover Chlamydia trachomatis, Neisseria gonorrhoeae, and anaerobic bacteria, administered intravenously, intramuscularly, or orally 2.
• 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.
• 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 3.

Comparison of Antibiotic Regimens

• There is no clear evidence of a difference between azithromycin and doxycycline in rates of cure for mild-moderate PID, severe PID, or adverse effects leading to discontinuation of treatment 2, 5.
• A macrolide (azithromycin) may be more effective than a tetracycline (doxycycline) for curing mild-moderate PID, based on a single study at low risk of bias 2, 5.
• There is no conclusive evidence that one regimen of antibiotics is safer or more effective than any other for the cure of PID 2, 5.

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 3.