Pelvic Inflammatory Disease Medication

  • Author: Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM; Chief Editor: Michel E Rivlin, MD   more...
 
Updated: May 17, 2011
 

Medication Summary

The Centers for Disease Control and Prevention (CDC) has outlined antibiotic regimens for outpatient and inpatient treatment of pelvic inflammatory disease (PID).

Outpatient treatment

For outpatient treatment, there are 2 currently accepted treatment regimens for PID as provided by the CDC, Regimen A and Regimen B.[27]

Regimen A consists of the following:

  • Administer ceftriaxone 250 mg IM once as a single dose plus doxycycline 100 mg PO bid for 14 days, with or without metronidazole 500 mg PO bid for 14 days.
  • Metronidazole can be added if there is evidence or suspicion of vaginitis or gynecologic instrumentation in the past 2-3 weeks.

Regimen B consists of the following:

  • Administer cefoxitin 2 g IM once as a single dose and probenecid 1 g PO concurrently in a single dose or other single-dose parenteral third-generation cephalosporin (ceftizoxime or cefotaxime) plus doxycycline 100 mg PO bid for 14 days with or without metronidazole 500 mg PO bid for 14 days.
  • Metronidazole can be added if there is evidence or suspicion for vaginitis or gynecologic instrumentation in the past 2-3 weeks.

Inpatient treatment

For inpatient treatment, there are 2 currently accepted treatment regimens for PID as provided by the CDC, Regimen A and Regimen B.[27]

Regimen A consists of the following:

  • Administer cefoxitin 2 g IV q6h or cefotetan 2 g IV q12h plus doxycycline 100 mg PO/IV q12h.
  • Continue this regimen for 24 hours after the patient remains clinically improved, and then start doxycycline 100 mg PO bid for a total of 14 days.
  • Administer doxycycline PO when possible because of pain associated with infusion. Bioavailability is similar with PO and IV administrations.
  • If TOA is present, use clindamycin or metronidazole with doxycycline for more effective anaerobic coverage.

Regimen B consists of the following:

  • Administer clindamycin 900 mg IV q8h plus
  • Administer gentamicin 2 mg/kg loading dose IV followed by a maintenance dose of 1.5 mg/kg q8h.
  • IV therapy may be discontinued 24 hours after the patient improves clinically, and PO therapy of 100 mg bid of doxycycline should be continued for a total of 14 days.
  • If TOA is present, use clindamycin or metronidazole with doxycycline for more effective anaerobic coverage.

An alternative parenteral regimen is as follows:

  • Ampicillin/sulbactam 3 g IV every 6 hours plus doxycycline 100 mg orally or IV every 12 hours

Additional information on treatment

Oral doxycycline has the same bioavailability as the intravenous form and avoids painful infusion and vein sclerosis. Gentamicin dosing may be every 24 hours. Other third-generation cephalosporins may be substituted for cefoxitin and ceftriaxone.

In individuals who have cephalosporin allergy, spectinomycin is recommended in Europe and Canada; however, this is currently unavailable in the United States. A 2-g azithromycin dose may also be used in this group; however, it is not routinely recommended because of concerns about rapid development of resistance to this antibiotic[48, 49] and potential intolerance of this dose. For more information, see the CDC's Antibiotic-Resistant Gonorrhea Web site and CDC Updated Gonococcal treatment recommendations.

In April 2007, the CDC updated treatment guidelines for gonococcal infection and associated conditions.[50] Fluoroquinolone antibiotics are no longer recommended to treat gonorrhea in the United States. This change is based on an analysis of data from the CDC's Gonococcal Isolate Surveillance Project (GISP). The data from GISP showed that the prevalence of fluoroquinolone-resistant gonorrhea (QRNG) cases in heterosexual men had reached 6.7%, an 11-fold increase from 0.6% in 2001.

This limits the recommended drugs for treatment of gonorrhea to cephalosporins (eg, ceftriaxone 125 mg IM once as a single dose). Fluoroquinolones may be an alternative treatment option for disseminated gonococcal infection if antimicrobial susceptibility can be documented.

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Antibiotics

Class Summary

Treatment should include empirical broad-spectrum antibiotics to cover the full complement of common causes. Antibiotic therapy should be effective against gram-negative facultative organisms, anaerobes, and streptococci, as well as against Chlamydia trachomatis and Neisseria gonorrhoeae.

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Azithromycin (Zithromax, Zmax)

 

Azithromycin acts by binding to 50S ribosomal subunit of susceptible microorganisms and blocks dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Nucleic acid synthesis is not affected. This drug concentrates in phagocytes and fibroblasts, as demonstrated by in vitro incubation techniques. In vivo studies suggest that concentration in phagocytes may contribute to drug distribution to inflamed tissues.

Azithromycin is used to treat mild-to-moderate microbial infections. Plasma concentrations are very low, but tissue concentrations are much higher, giving it value in treating intracellular organisms. It has a long tissue half-life.

Azithromycin is related to erythromycin. It is considered by many to be treatment of choice for Chlamydia trachomatis genitourinary infection because it may be administered as 1-dose treatment, which improves adherence to treatment.

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Ceftriaxone (Rocephin)

 

Ceftriaxone is a third-generation cephalosporin with broad-spectrum, gram-negative activity. It has a lower efficacy against gram-positive organisms and higher efficacy against resistant organisms. Its bactericidal activity results from inhibiting cell wall synthesis by binding to one or more penicillin-binding proteins.

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Cefoxitin (Mefoxin)

 

Cefoxitin is a second-generation cephalosporin indicated for infections with gram-positive cocci and gram-negative rods. Infections caused by cephalosporin- or penicillin-resistant gram-negative bacteria may respond to cefoxitin.

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Cefotetan (Cefotan)

 

Cefotetan is a second-generation cephalosporin indicated for infections caused by susceptible gram-positive cocci and gram-negative rods. The dose and route of administration depend on the condition of the patient, the severity of infection, and the susceptibility of the causative organism.

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Cefotaxime (Claforan)

 

Cefotaxime is a third-generation cephalosporin with broad gram-negative spectrum, lower efficacy against gram-positive organisms, and higher efficacy against resistant organisms. It arrests bacterial cell wall synthesis by binding to one or more of the penicillin-binding proteins, which in turn inhibits bacterial growth. Cefotaxime is used for septicemia and treatment of gynecologic infections caused by susceptible organisms.

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Doxycycline (Vibramycin)

 

Doxycycline inhibits protein synthesis and, thus, bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria.

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Clindamycin (Cleocin)

 

Clindamycin is a lincosamide for treatment of serious skin and soft tissue staphylococcal infections. It is also effective against aerobic and anaerobic streptococci (except enterococci). It inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest.

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Metronidazole (Flagyl)

 

An imidazole ring–based antibiotic active against various anaerobic bacteria and protozoa, metronidazole is used in combination with other antimicrobial agents (except for Clostridium difficile enterocolitis).

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Gentamicin (Garamycin)

 

Gentamicin is an aminoglycoside antibiotic that provides gram-negative coverage. It is used in combination with an agent against gram-positive organisms and one that covers anaerobes. Dosing regimens are numerous. Adjust dose based on creatinine clearance and changes in volume of distribution. Follow each regimen by at least a trough level drawn on the third or fourth dose (0.5 h before dosing); a peak level may be drawn 0.5 h after 30-min infusion.

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Probenecid

 

Probenecid inhibits tubular secretion of penicillin and usually increases penicillin plasma levels, regardless of the route of penicillin administration. It is used as an adjuvant to therapy with penicillin, ampicillin, methicillin, oxacillin, cloxacillin, or nafcillin. Two- to 4-fold elevation of penicillin plasma levels is demonstrated.

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Ampicillin and sulbactam (Unasyn)

 

This drug combination includes a beta-lactamase inhibitor with ampicillin. It interferes with bacterial cell wall synthesis during active replication, causing bactericidal activity against susceptible organisms.

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Ceftizoxime (Cefizox)

 

Ceftizoxime is a third-generation cephalosporin with broad-spectrum gram-negative activity. It has lower efficacy against gram-positive organisms and higher efficacy against resistant organisms. It arrests bacterial growth by binding to 1 or more penicillin-binding proteins. Gram-negative spectrum includes M catarrhalis. Dose selection depends on the severity of the infection and the susceptibility of the organism.

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Contributor Information and Disclosures
Author

Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM  Associate Professor, Education Officer, Department of Emergency Medicine, Hospital of the University of Pennsylvania; Director of Education and Research, PENN Travel Medicine

Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American Society of Tropical Medicine and Hygiene, International Society of Travel Medicine, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Chief Editor

Michel E Rivlin, MD  Professor, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine

Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Mississippi State Medical Association, and Royal College of Surgeons of Edinburgh

Disclosure: Nothing to disclose.

References

  1. Kinnunen A, Molander P, Morrison R, Lehtinen M, Karttunen R, Tiitinen A, et al. Chlamydial heat shock protein 60--specific T cells in inflamed salpingeal tissue. Fertil Steril. Jan 2002;77(1):162-6. [Medline].

  2. Makepeace BL, Watt PJ, Heckels JE, Christodoulides M. Interactions of Neisseria gonorrhoeae with mature human macrophage opacity proteins influence production of proinflammatory cytokines. Infect Immun. Mar 2001;69(3):1909-13. [Medline]. [Full Text].

  3. den Hartog JE, Ouburg S, Land JA, et al. Do host genetic traits in the bacterial sensing system play a role in the development of Chlamydia trachomatis-associated tubal pathology in subfertile women?. BMC Infect Dis. Jul 21 2006;6:122.

  4. Bakken IJ, Ghaderi S. Incidence of pelvic inflammatory disease in a large cohort of women tested for Chlamydia trachomatis: a historical follow-up study. BMC Infect Dis. Aug 14 2009;9(1):130.

  5. Ross JD. Is Mycoplasma genitalium a cause of pelvic inflammatory disease?. Infect Dis Clin North Am. Jun 2005;19(2):407-13. [Medline].

  6. Koumans EH, Kendrick JS. Preventing adverse sequelae of bacterial vaginosis: a public health program and research agenda. Sex Transm Dis. May 2001;28(5):292-7. [Medline].

  7. Ness RB, Hillier SL, Kip KE, Soper DE, Stamm CA, McGregor JA, et al. Bacterial vaginosis and risk of pelvic inflammatory disease. Obstet Gynecol. Oct 2004;104(4):761-9. [Medline].

  8. Avan BI, Fatmi Z, Rashid S. Comparison of clinical and laparascopic features of infertile women suffering from genital tuberculosis (TB) or pelvic inflammatory disease (PID) or endometriosis. J Pak Med Assoc. Nov 2001;51(11):393-9. [Medline].

  9. Cherpes TL, Wiesenfeld HC, Melan MA, Kent JA, et al. The associations between pelvic inflammatory disease, Trichomonas vaginalis infection, and positive herpes simplex virus type 2 serology. Sex Transm Dis. 2006;33:747-52.

  10. Brunham RC, Kimani J, Bwayo J, Maitha G, Maclean I, Yang C, et al. The epidemiology of Chlamydia trachomatis within a sexually transmitted diseases core group. J Infect Dis. Apr 1996;173(4):950-6. [Medline].

  11. Bjartling C, Osser S, Johnsson A, Persson K. Clinical manifestations and epidemiology of the new genetic variant of Chlamydia trachomatis. Sex Transm Dis. Sep 2009;36(9):529-35. [Medline].

  12. Champion JD, Piper J, Shain RN, Perdue ST, Newton ER. Minority women with sexually transmitted diseases: sexual abuse and risk for pelvic inflammatory disease. Res Nurs Health. Feb 2001;24(1):38-43. [Medline].

  13. Ness RB, Soper DE, Holley RL, Peipert J, Randall H, Sweet RL, et al. Douching and endometritis: results from the PID evaluation and clinical health (PEACH) study. Sex Transm Dis. Apr 2001;28(4):240-5. [Medline].

  14. Ness RB, Hillier SL, Kip KE, Richter HE, Soper DE, Stamm CA, et al. Douching, pelvic inflammatory disease, and incident gonococcal and chlamydial genital infection in a cohort of high-risk women. Am J Epidemiol. Jan 15 2005;161(2):186-95. [Medline].

  15. Ness RB, Soper DE, Holley RL, Peipert J, Randall H, Sweet RL, et al. Hormonal and barrier contraception and risk of upper genital tract disease in the PID Evaluation and Clinical Health (PEACH) study. Am J Obstet Gynecol. Jul 2001;185(1):121-7. [Medline].

  16. Shelton JD. Risk of clinical pelvic inflammatory disease attributable to an intrauterine device. Lancet. Feb 10 2001;357(9254):443. [Medline].

  17. Kelly EK, Rudinsky SW. Intrauterine contraception: current evidence-based recommendations. J Midwifery Womens Health. Sep-Oct 2007;52(5):505-7. [Medline].

  18. Meirik O. Intrauterine devices - upper and lower genital tract infections. Contraception. 2007;06;75(6 Suppl/):S41-7.

  19. Viberga I, Odlind V, Lazdane G, Kroica J, Berglund L, Olofsson S. Microbiology profile in women with pelvic inflammatory disease in relation to IUD use. Infect Dis Obstet Gynecol. Dec 2005;13(4):183-90. [Medline]. [Full Text].

  20. Levgur M, Duvivier R. Pelvic inflammatory disease after tubal sterilization: a review. Obstet Gynecol Surv. Jan 2000;55(1):41-50. [Medline].

  21. Sutton MY, Sternberg M, Zaidi A, St Louis ME, Markowitz LE. Trends in pelvic inflammatory disease hospital discharges and ambulatory visits, United States, 1985-2001. Sex Transm Dis. Dec 2005;32(12):778-84. [Medline].

  22. Ness RB, Smith KJ, Chang CC, Schisterman EF, Bass DC. Prediction of pelvic inflammatory disease among young, single, sexually active women. Sex Transm Dis. Mar 2006;33(3):137-42. [Medline].

  23. Sorbye IK, Jerve F, Staff AC. Reduction in hospitalized women with pelvic inflammatory disease in Oslo over the past decade. Acta Obstet Gynecol Scand. Mar 2005;84(3):290-6. [Medline].

  24. World Health Organization. Sexually transmitted infections. Available at http://www.who.int/mediacentre/factsheets/fs110/en/. Accessed February 2, 2010.

  25. Low N, Broutet N, Adu-Sarkodie Y, Barton P, Hossain M, Hawkes S. Global control of sexually transmitted infections. Lancet. Dec 2 2006;368(9551):2001-16. [Medline].

  26. Toth M, Patton DL, Esquenazi B, Shevchuk M, Thaler H, Divon M. Association between Chlamydia trachomatis and abnormal uterine bleeding. Am J Reprod Immunol. May 2007;57(5):361-6. [Medline].

  27. [Guideline] CDC, Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep. Aug 4 2006;55(RR-11):1-94.

  28. Peipert JF, Ness RB, Blume J, Soper DE, Holley R, Randall H, et al. Clinical predictors of endometritis in women with symptoms and signs of pelvic inflammatory disease. Am J Obstet Gynecol. Apr 2001;184(5):856-63; discussion 863-4. [Medline].

  29. Molander P, Finne P, Sjoberg J, Sellors J, Paavonen J. Observer agreement with laparoscopic diagnosis of pelvic inflammatory disease using photographs. Obstet Gynecol. May 2003;101(5 Pt 1):875-80. [Medline].

  30. Risser WL, Risser JM, Benjamins LJ, Feldmann JM. Incidence of Fitz-Hugh-Curtis syndrome in adolescents who have pelvic inflammatory disease. J Pediatr Adolesc Gynecol. Jun 2007;20(3):179-80. [Medline].

  31. Sanfilippo JS. The silent epidemic of Chlamydia: what are we missing here?. J Pediatr Adolesc Gynecol. Oct 2008;21(5):231-2. [Medline].

  32. [Best Evidence] Haggerty CL, Ness RB. Newest approaches to treatment of pelvic inflammatory disease: a review of recent randomized clinical trials. Clin Infect Dis. Apr 1 2007;44(7):953-60. [Medline].

  33. Tukeva TA, Aronen HJ, Karjalainen PT, Molander P, Paavonen T, Paavonen J. MR imaging in pelvic inflammatory disease: comparison with laparoscopy and US. Radiology. Jan 1999;210(1):209-16. [Medline].

  34. Taylor-Robinson D, Stacey CM, Jensen JS, Thomas BJ, Munday PE. Further observations, mainly serological, on a cohort of women with or without pelvic inflammatory disease. Int J STD AIDS. Oct 2009;20(10):712-8. [Medline].

  35. Horrow MM. Ultrasound of pelvic inflammatory disease. Ultrasound Q. Dec 2004;20(4):171-9. [Medline].

  36. Workowski KA, Berman S. Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep. Dec 17 2010;59:1-110. [Medline]. [Full Text].

  37. Goharkhay N, Verma U, Maggiorotto F. Comparison of CT- or ultrasound-guided drainage with concomitant intravenous antibiotics vs. intravenous antibiotics alone in the management of tubo-ovarian abscesses. Ultrasound Obstet Gynecol. Jan 2007;29(1):65-9. [Medline].

  38. Del Frate C, Girometti R, Pittino M, et al. Deep retroperitoneal pelvic endometriosis: MR imaging appearance with laparoscopic correlation. Radiographics. 2006;26(6):1705-18.

  39. Romero R, Espinoza J, Mazor M. Can endometrial infection/inflammation explain implantation failure, spontaneous abortion, and preterm birth after in vitro fertilization?. Fertil Steril. Oct 2004;82(4):799-804. [Medline].

  40. Irwin KL, Moorman AC, O'Sullivan MJ, Sperling R, Koestler ME, Soto I, et al. Influence of human immunodeficiency virus infection on pelvic inflammatory disease. Obstet Gynecol. Apr 2000;95(4):525-34. [Medline].

  41. Mugo NR, Kiehlbauch JA, Nguti R, Meier A, Gichuhi JW, Stamm WE, et al. Effect of human immunodeficiency virus-1 infection on treatment outcome of acute salpingitis. Obstet Gynecol. Apr 2006;107(4):807-12. [Medline].

  42. [Best Evidence] Ness RB, Soper DE, Holley RL, et al. for the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) Study Investigators. Effectiveness of inpatient and outpatient treatment strategies for women with pelvic inflammatory disease: Results from the pelvic inflammatory disease evaluation and clinical health (PEACH) randomized trial. Am J Obstet Gynecol. 2001;186:929-37.

  43. Trent M, Ellen JM, Walker A. Pelvic inflammatory disease in adolescents: care delivery in pediatric ambulatory settings. Pediatr Emerg Care. Jul 2005;21(7):431-6. [Medline].

  44. Savaris RF, Teixeira LM, Torres TG, Edelweiss MI, Moncada J, Schachter J. Comparing ceftriaxone plus azithromycin or doxycycline for pelvic inflammatory disease: a randomized controlled trial. Obstet Gynecol. Jul 2007;110(1):53-60. [Medline].

  45. Scholes D, Stergachis A, Heidrich FE, Andrilla H, Holmes KK, Stamm WE. Prevention of pelvic inflammatory disease by screening for cervical chlamydial infection. N Engl J Med. May 23 1996;334(21):1362-6. [Medline].

  46. US Preventive Services Task Force. Available at . Screening for Chlamydial Infection. Available at http://www.ahrq.gov/clinic/uspstf/uspschlm.htm. Accessed March 26, 2010.

  47. Gift TL, Gaydos CA, Kent CK, Marrazzo JM, Rietmeijer CA, Schillinger JA, et al. The program cost and cost-effectiveness of screening men for Chlamydia to prevent pelvic inflammatory disease in women. Sex Transm Dis. Nov 2008;35(11 Suppl):S66-75. [Medline].

  48. Bevan CD, Ridgway GL, Rothermel CD. Efficacy and safety of azithromycin as monotherapy or combined with metronidazole compared with two standard multidrug regimens for the treatment of acute pelvic inflammatory disease. J Int Med Res. Jan-Feb 2003;31(1):45-54. [Medline].

  49. Bradshaw CS, Chen MY, Fairley CK. Persistence of Mycoplasma genitalium following azithromycin therapy. PLoS One. 2008;3(11):e3618. [Medline]. [Full Text].

  50. [Guideline] CDC. Update to CDC's sexually transmitted diseases treatment guidelines, 2006. fluoroquinolones no longer recommended for treatment of gonococcal infections. MMWR Morb Mortal Wkly Rep. Apr 13 2007;56(14):332-6.

 
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"Violin-string" adhesions of chronic Fitz-Hugh-Curtis syndrome.
Transabdominal ultrasonogram. This image shows anechoic tubular structures in the adnexa; the finding is compatible with a hydrosalpinx.
Endovaginal ultrasonogram. This image reveals a tubular structure with debris in the left adnexa; the finding is compatible with a pyosalpinx.
This ultrasonogram shows a markedly heterogeneous and thickened endometrium, a finding that is compatible with endometritis.
This ultrasonogram reveals bilateral complex masses in a patient who had pyometrium, a finding that is compatible with tubo-ovarian abscess.
Transabdominal ultrasonogram. This image demonstrates an echogenic region within the endometrium with dirty shadowing, a finding that is compatible with air in the endometrium and endometritis. Additionally, bilateral complex masses are present; this finding is compatible with tubo-ovarian masses.
 
 
 
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