eMedicine Specialties > Obstetrics and Gynecology > Infections
Pelvic Inflammatory Disease: Treatment & Medication
Updated: Aug 27, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
- 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
- Inpatient treatment6
- 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 of therapy. 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 to 3 weeks.
- In April 2007, the Centers for Disease Control and Prevention (CDC) updated treatment guidelines for gonococcal infection and associated conditions. Fluoroquinolone antibiotics are no longer recommended to treat gonorrhea in the United States.7 The recommendation was based on analysis of new data from the CDC's Gonococcal Isolate Surveillance Project (GISP). The data from GISP showed the proportion 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; CDC Updated Gonococcal treatment recommendations (April 2007); or Medscape Medical News on CDC Issues New Treatment Recommendations for Gonorrhea.
Surgical Care
The advantage of laparoscopy is that it allows direct visualization of the pelvis and provides a more accurate and 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.
Consultations
- Obstetrician
- Gynecologist
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.
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
Documented hypersensitivity
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)
Documented hypersensitivity
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
Documented hypersensitivity
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
Documented hypersensitivity
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
Documented hypersensitivity
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 |
| References |
| « Previous Page | Next Page » |
References
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].
Short VL, Totten PA, Ness RB, Astete SG, Kelsey SF, Murray P, et al. The demographic, sexual health and behavioral correlates of Mycoplasma genitalium infection among women with clinically suspected pelvic inflammatory disease. Sex Transm Infect. Aug 24 2009;[Medline].
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. [Medline].
Ross JD. Is Mycoplasma genitalium a cause of pelvic inflammatory disease?. Infect Dis Clin North Am. Jun 2005;19(2):407-13. [Medline].
Tukeva TA, Aronen HJ, Karjalainen PT, et al. MR imaging in pelvic inflammatory disease: comparison with laparoscopy and US. Radiology. Jan 1999;210(1):209-16. [Medline].
[Guideline] CDC, Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep. Aug 4 2006;55(RR-11):1-94. [Medline]. [Full Text].
[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. [Medline].
Aledort JE, Hook EW, Weinstein MC, Goldie SJ. The cost effectiveness of gonorrhea screening in urban emergency departments. Sex Transm Dis. Jul 2005;32(7):425-36. [Medline].
Cohen CR, Sinei S, Reilly M, et al. Effect of human immunodeficiency virus type 1 infection upon acute salpingitis: a laparoscopic study. J Infect Dis. Nov 1998;178(5):1352-8. [Medline].
Coonrod D, Collier AC, Ashley R, et al. Association between cytomegalovirus seroconversion and upper genital tract infection among women attending a sexually transmitted disease clinic: a prospective study. J Infect Dis. May 1998;177(5):1188-93. [Medline].
Hillis SD, Owens LM, Marchbanks PA, et al. Recurrent chlamydial infections increase the risks of hospitalization for ectopic pregnancy and pelvic inflammatory disease. Am J Obstet Gynecol. Jan 1997;176(1 Pt 1):103-7. [Medline].
Howell MR, Kassler WJ, Haddix A. Partner notification to prevent pelvic inflammatory disease in women. Cost-effectiveness of two strategies. Sex Transm Dis. May 1997;24(5):287-92. [Medline].
Howell MR, Quinn TC, Brathwaite W, et al. Screening women for chlamydia trachomatis in family planning clinics: the cost-effectiveness of DNA amplification assays. Sex Transm Dis. Feb 1998;25(2):108-17. [Medline].
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].
Jamieson DJ, Duerr A, Macasaet MA, et al. Risk factors for a complicated clinical course among women hospitalized with pelvic inflammatory disease. Infect Dis Obstet Gynecol. 2000;8(2):88-93. [Medline].
Peipert JF, Ness RB, Soper DE. Association of lower genital tract inflammation with objective evidence of endometritis. Infect Dis Obstet Gynecol. 2000;8(2):83-7. [Medline].
Peipert JF, Sweet RL, Walker CK, Bass D. Evaluation of ofloxacin in the treatment of laparoscopically documented acute pelvic inflammatory disease (salpingitis). Infect Dis Obstet Gynecol. 1999;7(3):138-44. [Medline].
Rock JA, Thompson JD. Telinde's Operative Gynecology. 1997. 8th ed. Philadelphia, Pa: Lippincott Williams & Wilkins Publishers; 657-684.
Scholes D, Stergachis A, Heidrich FE, et al. Prevention of pelvic inflammatory disease by screening for cervical chlamydial infection. N Engl J Med. May 23 1996;334(21):1362-6. [Medline].
Wiesenfeld HC, Sweet RL, Ness RB, et al. Comparison of acute and subclinical pelvic inflammatory disease. Sex Transm Dis. Jul 2005;32(7):400-5. [Medline].
Further Reading
Keywords
pelvic inflammatory disease, PID, uterus, fallopian tubes, intrauterine device, IUD, tubal infertility, genital tract, vagina, cervix, sexually transmitted diseases, STD, ectopic pregnancy, tubal pregnancy, pelvic pain, dysuria, vaginal discharge, vaginal bleeding, Chlamydia trachomatis, C trachomatis, Gardnerella vaginalis, G vaginalis, Haemophilus influenzae, H influenzae, Escherichia coli, E coli, Peptococcus species, Streptococcus agalactiae, S agalactiae, Bacteroides fragilis, B fragilis, Neisseria gonorrhoeae, N gonorrhoeae, Mycoplasma genitalium, M genitalium, cytomegalovirus, CMV, endogenous microflora
