eMedicine Specialties > Obstetrics and Gynecology > Infections

Pelvic Inflammatory Disease: Treatment & Medication

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

Updated: Feb 4, 2010

Treatment

Medical Care

To expedite treatment and maximize compliance, the diagnosis of pelvic inflammatory disease (PID) in emergency departments and clinics is often based on clinical criteria, with or without additional laboratory and imaging evidence.33 Due to the relatively poor specificity and sensitivity of historical and physical examination findings, the CDC has established minimal criteria for the diagnosis of PID. Current guidelines suggest that empiric treatment should be initiated in those at risk women who exhibit lower abdominal pain, adnexal tenderness, and cervical motion tenderness. The Centers for Disease Control and Prevention (CDC) regularly reviews sexually transmitted infections research and epidemiology to update guidelines for diagnosis and management.

Current CDC guidelines for PID stratify diagnostic criteria into 3 groups.34

Group I
Minimum criteria: Empirical treatment indicated if no other etiology explains findings.

  • Uterine or adnexal tenderness
  • Cervical motion tenderness

Group 2
Additional criteria improving diagnostic specificity include the following:

  • Oral temperature > 38.3ºC (101ºF)
  • Abnormal cervical or vaginal mucopurulent secretions
  • Elevated erythrocyte sedimentation rate
  • Elevated C-reactive protein
  • Laboratory evidence of cervical infection with N gonorrhea or C trachomatis (culture or DNA probe)

Group 3
Specific criteria for PID based on procedures that may be appropriate for some patients are as follows:

  • Laparoscopic confirmation
  • Transvaginal ultrasonography (or MRI) showing thickened, fluid-filled tubes with/without free pelvic fluid or tubo-ovarian complex
  • Endometrial biopsy showing endometritis


Most patients are now managed as outpatients, but physicians should consider hospitalization for patients with the following conditions, although no clear data suggest that these patients benefit from hospitalization:

  • Uncertain diagnosis
  • Pelvic abscess on ultrasound
  • Pregnancy
  • Failure to respond to outpatient management
  • Inability to tolerate outpatient PO regimen
  • Severe illness or nausea and vomiting precluding outpatient treatment
  • Immunodeficiency (eg, HIV with low CD4 count, using immunosuppressive medications)
  • Failure to improve clinically after 72 hours with outpatient therapy

The treatment of PID addresses the relief of acute symptoms, eradication of current infection, and minimalization of the risk of long-term sequelae. From a public health perspective, treatment is aimed at the expeditious eradication of infection to reduce the risk of transmission of infection to new partners and to identify and treat current and recent partners to prevent the spread of STIs. Early patient diagnosis and treatment appears to be critical in the preservation of fertility.

Due to diagnostic difficulties and the potential of serious sequelae, the CDC advises that physicians should maintain a low threshold for aggressive patient treatment, with overtreatment preferred to no or delayed treatment. Treatment initiated in the emergency department, clinic, or office setting, should be expeditiously begun and includes empiric broad-spectrum antibiotics to cover the full complement of common causes. All regimens must thus be effective against gram-negative facultative organisms, anaerobes, and streptococci, as well as C trachomatis and N gonorrhoeae.

 A number of studies (1992-2006) have demonstrated effectiveness of a variety of parenteral and oral regimens in both the elimination of acute symptoms and microbiologic cure.35 Only a single, large, randomized multicenter clinical study has effectively compared inpatient and outpatient oral and parenteral antibiotic regimens in the documented elimination of endometrial and tubal infection.36 This study found no differences in outcome between inpatient and outpatient management in the study population.

Currently accepted treatment regimens are listed below. Physicians should be aware of current guidelines and current national and local patterns of drug resistance in their patient populations to avoid inappropriate treatment.37 If an IUD is present, it should be removed after the initiation of antibiotic treatment. Worldwide, more than 90% of individuals who are HIV positive are treated as outpatients.38 A 2006 study, with the investigators blinded to patient HIV status, of HIV-infected women in Nairobi, demonstrated that severe PID was more common in all women who were HIV positive. This group, irrespective of CD4 count, took longer to achieve clinical improvement; however, no change in antibiotic regimen was necessary.39

Admission of those infected with HIV and adolescents should be reviewed on an individual basis. Admission decisions are based on diagnostic certainty; illness severity; likelihood of compliance with outpatient regimen; pregnancy; likelihood of significant anaerobic infection including the presence of tubo-ovarian abscess, IUD, or history of recent pelvic procedure; coexisting immunosuppression or illness; and major fertility issues.

  • Inpatient treatment34
    • Regimen A: Administer cefoxitin 2 g IV q6h or cefotetan 2 g IV q12h plus doxycycline 100 mg PO/IV q12h. Cefotetan is no longer distributed in the United States. 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 tubo-ovarian abscess is present, use clindamycin or metronidazole with doxycycline for more effective anaerobic coverage.
    • Regimen B: Administer clindamycin 900 mg IV q8h plus 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 tubo-ovarian abscess is present, use clindamycin or metronidazole with doxycycline for more effective anaerobic coverage.
  • Outpatient treatment
    • Regimen A: 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 for vaginitis or gynecologic instrumentation in the past 2-3 weeks.
    • Regimen B: 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 gynecological instrumentation in the past 2-3 weeks.
  • Note: Oral doxycycline has the same bioavailability as intravenous 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 those individuals who have cephalosporin allergy, spectinomycin is recommended in Europe and Canada; however, this is currently unavailable in the United States. A 2-gram 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 antibiotic40,41 and potential intolerance of this dose. For more information, see the CDC’s Antibiotic-Resistant Gonorrhea Web site and CDC Updated Gonococcal treatment recommendations (April 2007).
  • In April 2007, the CDC updated treatment guidelines for gonococcal infection and associated conditions.42
    • Fluoroquinolone antibiotics are no longer recommended to treat gonorrhea in the United States. The recommendation was based on analysis of new 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 reached 6.7%, an 11-fold increase from 0.6% in 2001. The data were published in the April 13, 2007 issue of the Morbidity and Mortality Weekly Report.
    • This limits treatment of gonorrhea to drugs in the cephalosporin class (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.
    • For more information, see the CDC’s Antibiotic-Resistant Gonorrhea Web site and CDC Updated Gonococcal treatment recommendations (April 2007).
  • Patients on an intravenous PID regimen can be transitioned to oral antibiotics 24 hours after clinical improvement. These should be continued for a total of 14 days. Oral therapy usually involves doxycycline; however, azithromycin can also be used.43 In patients who have developed tubo-ovarian abscess, oral therapy should include clindamycin or metronidazole. All patients should be reevaluated in 72 hours for evidence of clinical improvement and compliance with their antibiotic regimen. Multiple studies have shown poor compliance with doxycycline therapy and approximately 20-25% of patients have never filled their prescriptions. Women should be counseled to abstain from sexual activity or educated to strictly and appropriately use barrier protection, until their symptoms have fully abated and they have completed their entire treatment regimen. Partner treatment should be ensured before resuming sexual activity with this individual.
  • Appropriate treatment also includes adequate emesis control, analgesia, antipyrexia and fluid management in those with nausea, vomiting, and dehydration and in those who exhibit SIRS criteria or appear toxic. Anti-inflammatory drugs have no clear role at this time; however, they may appropriately be used in the analgesic regimen. Studies have shown that patients with PID are inadequately treated for pain on a routine basis and that only a minority of patients receive narcotic analgesia.

Surgical Care

Patients who do not improve in 72 hours should be reevaluated for possible laparoscopic or surgical intervention and to reconsider other possible diagnoses. Laparoscopic pelvic lavage, abscess drainage, and lysis of adhesions may be necessary.

Most tubo-ovarian abscesses (60-80%) resolve with antibiotic administration. If patients do not respond appropriately, laparoscopy may be useful to identify loculations of pus requiring drainage. An enlarging pelvic mass may indicate bleeding secondary to vessel erosion or a ruptured abscess. Unresolved abscesses may be drained percutaneously via posterior colpotomy, or via CT or ultrasonographic guidance, laparoscopically, or by laparotomy.

The advantages of laparoscopy include direct visualization of the pelvis and more accurate bacteriologic diagnosis if cultures are obtained. However, laparoscopy is not always available in acute PID. In addition, this procedure is costly and requires general anesthesia. It should be used if the diagnosis is in doubt. However, if operative laparoscopy is used early in the course of the disease, copious irrigation and separation of thin adhesions by blunt dissection may prevent later sequelae.

Laparotomy is usually reserved for surgical emergencies, such as abscesses that have ruptured, abscesses that have not responded to medical management and laparoscopic drainage, or in those who are not candidates for laparoscopic management. Intraoperative findings, and the patient's desire for fertility maintenance, guide treatment. Treatment may involve unilateral salpingo-oophorectomy or hysterectomy and bilateral salpingo-oophorectomy. Ideally, surgery is performed after the acute infection and inflammation have resolved. In patients with recurrent PID, dense pelvic adhesions may render surgery difficult.

For more information, see eMedicine articles Gynecologic Laparoscopy and Hysterectomy.

Consultations

  • Obstetrician/gynecologist
  • Surgeon (especially if appendicitis or another intra-abdominal process can not be excluded)
  • Infectious disease consultant (especially in those patients who are HIV positive and may be on highly active antiretroviral treatment [HAART])

Diet

Patients should take nothing by mouth (NPO) if the diagnosis is uncertain or if the patient is scheduled for surgery.

Medication

See Medical Care for treatment regimens.

Antibiotics

Therapy must be comprehensive and cover all likely pathogens in the context of this clinical setting.


Azithromycin (Zithromax, Zmax, AzaSite)

Acts by binding to 50S ribosomal subunit of susceptible micro-organisms and blocks dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Nucleic acid synthesis is not affected.
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.
Treats mild-to-moderate microbial infections.
Plasma concentrations are very low, but tissue concentrations are much higher, giving it value in treating intracellular organisms. Has a long tissue half-life.
Related to erythromycin; considered by many to be treatment of choice of C trachomatis genitourinary infection because it may be administered as 1-dose treatment, which improves adherence to treatment.

Adult

2 g PO once

Pediatric

Not applicable

May increase toxicity of theophylline, warfarin, and digoxin; effects are reduced with coadministration of aluminum and/or magnesium antacids; nephrotoxicity and neurotoxicity may occur when coadministered with cyclosporine

Documented hypersensitivity; hepatic impairment; do not administer with pimozide

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Site reactions can occur with IV route; bacterial or fungal overgrowth may result from prolonged antibiotic use; may increase hepatic enzymes and cholestatic jaundice; caution in patients with impaired hepatic function or prolonged QT intervals


Ceftriaxone (Rocephin)

Third-generation cephalosporin with broad-spectrum gram-negative activity. Lower efficacy against gram-positive organisms and higher efficacy against resistant organisms. Arrests bacterial growth by binding to 1 or more penicillin-binding proteins.

Adult

250 mg IM once

Pediatric

50-75 mg/kg/d IV/IM q12h; not to exceed 2 g/d

Probenecid may increase levels; coadministration with ethacrynic acid, furosemide, or aminoglycosides may increase nephrotoxicity

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal impairment; caution in breastfeeding women and in people with allergy to penicillin


Cefoxitin (Mefoxin)

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.

Adult

2 g IV q6h

Pediatric

80-160 mg/kg/d IV divided q4-6h; higher doses for severe or serious infections; not to exceed 12 g/d

Probenecid may increase effects; coadministration with aminoglycosides or furosemide may increase nephrotoxicity (closely monitor renal function)

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged use or repeated treatment; caution in patients with previously diagnosed colitis


Cefotetan (Cefotan)

Second-generation cephalosporin indicated for infections caused by susceptible gram-positive cocci and gram-negative rods. Dose and route of administration depend on condition of patient, severity of infection, and susceptibility of causative organism.

Adult

2 g IV q12h

Pediatric

20-40 mg/kg/dose IV/IM q12h for 5-10 d

Consumption of alcohol within 72 h may produce disulfiramlike reactions; may increase hypoprothrombinemic effects of anticoagulants; coadministration with potent diuretics (eg, loop diuretics) or aminoglycosides may increase nephrotoxicity

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Reduce dosage by one half if CrCl is 10-30 mL/min and by one fourth if CrCl <10 mL/min; bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged or repeated therapy


Doxycycline (Vibramycin)

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

Adult

100 mg PO/IV q12h

Pediatric

<8 years: Not recommended
>8 years: 2-5 mg/kg/d PO/IV qd or divided bid; not to exceed 200 mg/d

Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of PO contraceptives, causing breakthrough bleeding and increased risk of pregnancy

Documented hypersensitivity; severe hepatic dysfunction

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Photosensitivity may occur with prolonged exposure to sunlight or tanning facilities; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development ( <8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines


Clindamycin (Cleocin)

Lincosamide for treatment of serious skin and soft tissue staphylococcal infections. Also effective against aerobic and anaerobic streptococci (except enterococci). Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest.

Adult

900 mg IV q8h; if administered with ofloxacin, 450 mg PO qid for 14 d

Pediatric

8-20 mg/kg/d PO as hydrochloride and 8-25 mg/kg/d as palmitate tid/qid
20-40 mg/kg/d IV/IM tid/qid

Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects; antidiarrheals may delay absorption

Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis by allowing overgrowth of Clostridium difficile


Metronidazole (Flagyl)

Imidazole ring–based antibiotic active against various anaerobic bacteria and protozoa. Used in combination with other antimicrobial agents (except for C difficile enterocolitis).

Adult

Loading: 15 mg/kg, or 1 g for 70-kg adult, IV over 1 h
Maintenance: 6 h following loading dose, infuse 7.5 mg/kg IV, or 500 mg for 70-kg adult, IV over 1 h, q6-8h; not to exceed 4 g/d
If administered with ofloxacin PO: 500 mg PO bid for 14 d

Pediatric

Administer as in adults

May increase toxicity of anticoagulants, lithium, and phenytoin; cimetidine may increase toxicity; disulfiramlike reaction may occur with PO ethanol

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in hepatic disease; monitor for seizures and development of peripheral neuropathy


Gentamicin (Gentacidin, Garamycin)

Aminoglycoside antibiotic for gram-negative coverage. Used in combination with an agent against gram-positive organisms and one that covers anaerobes. Dosing regimens are numerous. Adjust dose based on CrCl 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); may draw a peak level 0.5 h after 30-min infusion.

Adult

Loading: 2 mg/kg IV/IM
Maintenance: 1.5 mg/kg IV/IM q8h

Pediatric

<5 years: 2.5 mg/kg per dose IV/IM q8h
>5 years: 1.5-2.5 mg/kg per dose IV/IM q8h or 6-7.5 mg/kg/d divided q8h; not to exceed 300 mg/d

Coadministration with other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; aminoglycosides enhance effects of neuromuscular blocking agents; thus, prolonged respiratory depression may occur; coadministration with loop diuretics may increase auditory toxicity; irreversible hearing loss of varying degrees may occur (monitor regularly)

Documented hypersensitivity; non–dialysis-dependent renal insufficiency

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (not on dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment


Meropenem (Merrem)

Bactericidal broad-spectrum carbapenem antibiotic that inhibits cell wall synthesis. Effective against most gram-positive and gram-negative bacteria.

Adult

1 g IV q8h

Pediatric

40 mg/kg IV q8h

Probenecid may inhibit renal excretion of meropenem, increasing meropenem levels

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Pseudomembranous colitis and thrombocytopenia may occur, requiring immediate discontinuation of medication

Uricosuric agents

Reduce clearance of some types of antibiotics, increasing their plasma levels.


Probenecid

Inhibits tubular secretion of penicillin and usually increases penicillin plasma levels by any route the antibiotic is administered. Adjuvant to therapy with penicillin, ampicillin, methicillin, oxacillin, cloxacillin, or nafcillin. Two- to 4-fold elevation of penicillin plasma levels demonstrated.

Adult

1 g PO once

Pediatric

<2 years: Not recommended
>2 years: Not established

Salicylates at high dosages and nitrofurantoin may decrease effects; increases levels/toxicity of methotrexate, beta-lactam antibiotics, acyclovir, thiopental, clofibrate, dyphylline, pantothenic acid, ketorolac, benzodiazepines, rifampin, sulfonamide, dapsone, zidovudine, and sulfonylureas

Documented hypersensitivity; blood dyscrasia; uric acid kidney stones; coadministration of ketorolac

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Crosses placental barrier; caution in history of peptic ulcer

More on Pelvic Inflammatory Disease

Overview: Pelvic Inflammatory Disease
Differential Diagnoses & Workup: Pelvic Inflammatory Disease
Treatment & Medication: Pelvic Inflammatory Disease
Follow-up: Pelvic Inflammatory Disease
Multimedia: Pelvic Inflammatory Disease
References
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Further Reading

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Keywords

pelvic inflammatory disease, PID, salpingitis, pelvic inflammation, PID treatment, PID symptoms, STD guidelines, tuboovarian abscess, intrauterine device, IUD, tubal infertility, Fitz-Hugh-Curtis syndrome, Neisseria gonorrhoeae, Chlamydia trachomatis

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Contributor Information and Disclosures

Author

Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM, Associate Professor, 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.

Medical Editor

Ronald Levine, MD, Director, Section of Gynecologic Endoscopy, Professor, Department of Obstetrics and Gynecology, University of Louisville School of Medicine
Ronald Levine, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American College of Obstetricians and Gynecologists, American Medical Association, and Society of Laparoendoscopic Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

CME Editor

Frederick B Gaupp, MD, Consulting Staff, Department of Family Practice, Hancock Medical Center
Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians
Disclosure: Nothing to disclose.

Chief Editor

Michel E Rivlin, MD, Professor, Coordinator of Quality Assurance/Quality Improvement, 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.

 
 
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