From the Guidelines
For treating pelvic inflammatory disease (PID) without ceftriaxone, an effective alternative regimen is cefoxitin 2 g IM in a single dose and Probenecid 1 g orally administered concurrently in a single dose, plus doxycycline 100 mg orally twice a day for 14 days, with or without metronidazole 500 mg orally twice a day for 14 days. This regimen is based on the guidelines from the Centers for Disease Control and Prevention, as outlined in the 2002 sexually transmitted diseases treatment guidelines 1. The use of cefoxitin provides coverage against Neisseria gonorrhoeae and anaerobic bacteria, while doxycycline covers Chlamydia trachomatis, and metronidazole targets anaerobes and provides additional coverage against bacterial vaginosis, which is frequently associated with PID 1. Key considerations in selecting a treatment regimen include the need for coverage against common causative organisms, including N. gonorrhoeae, C. trachomatis, and anaerobes, as well as the importance of initiating treatment as soon as the presumptive diagnosis is made to prevent long-term sequelae 1. Other parenteral third-generation cephalosporins, such as ceftizoxime or cefotaxime, may also be effective alternatives to ceftriaxone, but cefoxitin is specifically recommended for its anaerobic coverage 1. Patients should be advised to abstain from sexual intercourse until treatment is completed, and partners should be evaluated and treated, with follow-up recommended within 72 hours to ensure clinical improvement 1.
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 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
PID treatment without ceftriaxone can be done with Cefoxitin for infections caused by susceptible strains of microorganisms. However, it is essential to note that Cefoxitin has no activity against Chlamydia trachomatis, so anti-chlamydial coverage should be added when treating pelvic inflammatory disease if Chlamydia trachomatis is suspected 2.
- Key points to consider:
- Cefoxitin is effective against various bacteria, including Neisseria gonorrhoeae and Bacteroides species
- Cefoxitin has no activity against Chlamydia trachomatis
- Anti-chlamydial coverage should be added when treating PID with Cefoxitin if Chlamydia trachomatis is suspected
From the Research
Alternative Treatment Options for PID
If ceftriaxone is not available, there are alternative treatment options for Pelvic Inflammatory Disease (PID).
- Ciprofloxacin and metronidazole can be used as an alternative treatment for PID, as shown in a study published in 1994 3.
- Another option is levofloxacin plus metronidazole, which was found to be effective and well-tolerated in the treatment of uncomplicated PID in a study published in 2009 4.
- A combination of cefoxitin and doxycycline can also be used, as demonstrated in the 1994 study 3.
- Azithromycin-based regimens have also been studied, but a 2021 trial found that a short-course azithromycin-based regimen was likely to be less effective than the standard treatment with ofloxacin plus metronidazole 5.
Considerations for Treatment
When choosing an alternative treatment, it is essential to consider the severity of the PID and the potential presence of anaerobic organisms.
- A 2021 study 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 6.
- The choice of antibiotic regimen should be based on the polymicrobial etiology of PID, including Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium, and other lower genital tract endogenous anaerobic and facultative bacteria 7.