What are the recommended antibiotics for Pelvic Inflammatory Disease (PID)?

From the Guidelines

For pelvic inflammatory disease (PID), the recommended antibiotic treatment is typically a combination regimen to cover the multiple potential pathogens, with the most effective regimen being cefotetan 2 g every 12 hours or cefoxitin 2 g every 6 hours plus doxycycline 100 mg orally or IV every 12 hours for hospitalized patients, as this provides broad coverage against Neisseria gonorrhoeae, Chlamydia trachomatis, anaerobes, and other bacteria commonly involved in PID 1.

Key Considerations

• The treatment should continue for at least 24-48 hours after clinical improvement, followed by oral therapy to complete the 14-day course.
• For patients with tubo-ovarian abscess, many health-care providers use clindamycin or metronidazole with doxycycline for continued therapy rather than doxycycline alone, because it provides more effective anaerobic coverage 1.
• Alternative regimens for patients with penicillin allergy include clindamycin 900 mg IV every 8 hours plus gentamicin loading dose of 2 mg/kg followed by 1.5 mg/kg every 8 hours 1.
• It's essential to treat sexual partners to prevent reinfection, and patients should abstain from sexual intercourse until treatment is completed and symptoms have resolved.

Treatment Options

• Parenteral Regimen B: Clindamycin 900 mg IV every 8 hours, PLUS Gentamicin loading dose IV or IM (2 mg/kg of body weight) followed by a maintenance dose (1.5 mg/kg) every 8 hours 1.
• Alternative Parenteral Regimens: Ofloxacin 400 mg IV every 12 hours, OR Levofloxacin 500 mg IV once daily, WITH or WITHOUT Metronidazole 500 mg IV every 8 hours 1.

Importance of Treatment

• The goal of treatment is to reduce the risk of complications like infertility, chronic pelvic pain, and ectopic pregnancy, while also improving the patient's quality of life and reducing morbidity and mortality.

From the FDA Drug Label

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 Pelvic Inflammatory Disease caused by Neisseria gonorrhoeae

Antibiotics for Pelvic Inflammatory Disease:

• Cefoxitin (2) is indicated for the treatment of pelvic inflammatory disease caused by susceptible organisms, including Neisseria gonorrhoeae and Bacteroides species.
• Ceftriaxone (3) is indicated for the treatment of pelvic inflammatory disease caused by Neisseria gonorrhoeae.
• It is essential to note that both cefoxitin and ceftriaxone have no activity against Chlamydia trachomatis, and therefore, appropriate anti-chlamydial coverage should be added when treating pelvic inflammatory disease.
• The choice of antibiotic should be based on the suspected causative organisms and local epidemiology and susceptibility patterns.

From the Research

Antibiotics for Pelvic Inflammatory Disease

• The treatment of pelvic inflammatory disease (PID) typically involves the use of antibiotics to cover a range of potential pathogens, including Chlamydia trachomatis, Neisseria gonorrhoeae, anaerobes, and other bacteria 4, 5, 6, 7, 8.
• A study published in 2021 found that the addition of metronidazole to ceftriaxone and doxycycline was well tolerated and resulted in reduced endometrial anaerobes, decreased M. genitalium, and reduced pelvic tenderness compared to ceftriaxone and doxycycline alone 4.
• Another study from 1988 found that the combination of cefoxitin and doxycycline was effective for ambulatory treatment of PID, with 92% of patients with probable PID achieving clinical cure or improvement 5.
• A comparison of cefotetan plus doxycycline and cefoxitin plus doxycycline in hospitalized patients with acute PID found that both regimens demonstrated high rates of initial clinical response, with clinical cure noted in 94% and 92% of patients, respectively 6.
• A multicentre, randomised controlled trial published in 2021 compared the efficacy and safety of a short-course azithromycin-based regimen versus ofloxacin plus metronidazole for the treatment of mild-to-moderate PID, and found that the azithromycin-based regimen was likely to be less effective than the standard treatment with ofloxacin plus metronidazole 7.
• Guidelines for the treatment of uncomplicated PID recommend the use of a ceftriaxone-doxycycline-metronidazole combination as the first line regimen, with fluoroquinolones (such as moxifloxacin, levofloxacin, or ofloxacin combined with metronidazole) proposed as alternatives 8.

Recommended Antibiotic Regimens

• Ceftriaxone and doxycycline, with or without metronidazole, for the treatment of acute PID 4.
• Cefoxitin and doxycycline for ambulatory treatment of PID 5.
• Cefotetan plus doxycycline or cefoxitin plus doxycycline for hospitalized patients with acute PID 6.
• Ofloxacin plus metronidazole for the treatment of mild-to-moderate PID 7.
• Ceftriaxone-doxycycline-metronidazole combination as the first line regimen for uncomplicated PID, with fluoroquinolones as alternatives 8.

Considerations for Antibiotic Choice

• The need for anaerobic coverage in the treatment of PID is still debated, but the use of metronidazole or other anaerobic agents may be beneficial in certain cases 4, 8.
• The increasing prevalence of antibiotic resistance, including resistance to fluoroquinolones, should be taken into account when selecting an antibiotic regimen for PID 7, 8.
• The potential for side effects and ecological impact of antibiotic use should also be considered when choosing an antibiotic regimen for PID 8.