Pelvic Inflammatory Disease Treatment & Management
- Author: Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM; Chief Editor: Michel E Rivlin, MD more...
Treatment of pelvic inflammatory disease (PID) addresses the relief of acute symptoms, eradication of current infection, and minimization of the risk of long-term sequelae. These sequelae, including chronic pelvic pain, ectopic pregnancy, tubal factor infertility (TFI), and implantation failure with in vitro fertilization attempts, may occur in as many as 25% of patients.
From a public health perspective, treatment is aimed at the expeditious eradication of infection in order to reduce the risk of transmission of infection to new sexual partners. In addition, identification and treatment of current and recent partners are indicated for further reduction of sexually transmitted infections (STIs).
Early diagnosis and treatment appear to be critical in the preservation of fertility. Current guidelines suggest that empirical treatment should be initiated in at-risk women who have lower abdominal pain, adnexal tenderness, and cervical motion tenderness. In view of the diagnostic difficulties and the potential for serious sequelae, the Centers for Disease Control and Prevention (CDC) advises that physicians maintain a low threshold for aggressive patient treatment, with overtreatment preferred to no or delayed treatment.
Therapy with antibiotics alone is successful in 33-75% of cases. If surgical treatment is warranted, the current trend is toward conservation of reproductive potential with simple drainage, adhesiolysis, and copious irrigation or unilateral adnexectomy, if possible. Further surgical therapy is needed in 15-20% of cases so managed.
The CDC advises that there is insufficient evidence to recommend removal of intrauterine devices (IUDs) in women diagnosed with acute PID. However, close clinical follow-up is mandatory if the IUD is left in place.
Current evidence suggests that adherence to clinical guidelines for PID diagnosis and management is less than optimal.[68, 69, 70] A systematic review of the literature revealed limited research on strategies to improve patient and practitioner adherence to guidelines. Interventions that make it easier to manage patients and provision of the entire treatment course to the patient at the time of evaluation improved compliance.
Patients who do not improve in 72 hours should be reevaluated for possible laparoscopic or surgical intervention and for reconsideration of other possible diagnoses. Laparoscopy should be used if the diagnosis is in doubt. Laparoscopic pelvic lavage, abscess drainage, and adhesion lysis may be necessary.
Most TOAs (60-80%) resolve with antibiotic administration. If patients do not respond appropriately, laparoscopy may be useful for identifying 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, under computed tomographic (CT) or ultrasonographic guidance, laparoscopically, or through laparotomy. For more information on treatment of TOA, see Fallopian Tube Disorders.
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; moreover, it is costly and requires general anesthesia.
Laparotomy is usually reserved for patients experiencing surgical emergencies (eg, abscesses that have ruptured or that have not responded to medical management and laparoscopic drainage) and for patients who are not candidates for laparoscopic management. Treatment is guided by intraoperative findings and the patient’s desire for fertility maintenance.
Surgical treatment may involve unilateral salpingo-oophorectomy or hysterectomy and bilateral salpingo-oophorectomy. Ideally, the operation is performed after the acute infection and inflammation have resolved. In patients with recurrent PID, dense pelvic adhesions may render surgery difficult.
Randomized, controlled trials suggest that preventing chlamydial infection reduces the incidence of PID. In addition, anyone who has had sexual contact with a woman with PID in the 60 days preceding the onset of her symptoms should be treated empirically for C trachomatis and N gonorrhoeae. CDC guidelines recommend that even if a patient last had sexual intercourse more than 60 days before symptom onset or diagnosis, the most recent sex partner should be treated.
Urethral gonococcal or chlamydial infection in the partner of an infected woman is highly likely and is frequently asymptomatic in men. Even in clinical settings where men do not receive treatment, arrangements for care or referral of male sex partners should be made.
Regardless of whether a woman’s sex partners were treated, women diagnosed with chlamydial or gonococcal infection should follow up with repeat testing within 3-6 months. These women have a high rate of reinfection within 6 months of treatment. Adolescents are more likely to have recurrent PID than adults are and so may require a different approach to follow-up.
Improved education, routine screening, diagnosis, and empirical treatment of these infections should reduce the incidence and prevalence of these processes and the development of long-term sequelae. Education should concentrate on strategies to prevent PID and STIs, including reducing the number of sexual partners, avoiding unsafe sexual practices, and routinely using appropriate barrier protection. Adolescents, being at an increased risk for PID, should be advised to delay the onset of sexual intercourse until age 16 years or older.
Women with PID should be counseled to abstain from sexual activity or use barrier protection strictly and appropriately until their symptoms and those of their partner have fully abated and they have completed their entire treatment regimen.
The US Preventive Services Task Force (USPSTF) recommends screening for chlamydial infection in all sexually active nonpregnant women up to age 25 years and in nonpregnant women aged 25 years or older who are at increased risk (grade A recommendation), as well as in all pregnant women up to age 25 years and in pregnant women aged 25 years or older who are at increased risk (grade B recommendation). The USPSTF recommends against routine screening for women aged 25 years and older if they are not at increased risk (grade C recommendation).
The USPSTF does not provide recommendations for Chlamydia screening in men; the available evidence is insufficient to allow accurate weighing of benefits and risks. However, a 2008 demonstration project suggested that the combination of (a) partner notification and (b) screening of men with a relatively high prevalence of chlamydial infection and a larger number of partners would be more cost-effective than expanding screening to low-risk women would be.
Some patients treated for STIs and PID fail to comply with medication regimens because of low medical literacy and a poor understanding of their diagnosis. These individuals frequently do not follow up or notify partners. Patients should be fully educated about these issues, as well as about the advisability of testing and treatment for other STIs, including HIV infection, hepatitis, and syphilis. In particular, the 2010 CDC guidelines state that HIV testing should be offered to all women diagnosed with acute PID.
Outpatient Versus Inpatient Treatment
Most patients with PID are managed as outpatients, and the available data do not clearly indicate that patients benefit from hospitalization. However, hospitalization should be considered for patients with the following conditions:
Pelvic abscess on ultrasonographic scanning
Inability to tolerate outpatient oral antibiotic regimen
Immunodeficiency (eg, patients with HIV infection who have a low CD4 count or patients who are using immunosuppressive medications)
Failure to improve clinically after 72 hours of outpatient therapy
Worldwide, more than 90% of HIV-positive individuals with PID are treated as outpatients. A 2006 study in Nairobi, with investigators blinded to patient HIV status, demonstrated that HIV-infected women were more likely to have severe PID and that clinical improvement in PID took longer in HIV-infected women, irrespective of their CD4 count; however, no change in antibiotic regimen was necessary.
Most patients show a clinical response within 48-72 hours after initiation of medical therapy. If a patient continues to have fever, chills, uterine tenderness, adnexal tenderness, and cervical motion tenderness, consider other possible causes and consider performing a diagnostic laparoscopy.
Hospital admission of HIV-infected patients and of adolescents should be reviewed on an individual basis. Admission decisions are based on the following factors:
Likelihood of compliance with an outpatient regimen
Whether or not the patient is pregnant
Coexisting immunosuppression or illness
Risk factors for significant anaerobic infection (eg, IUD use, a recent pelvic procedure, or the presence of a tubo-ovarian abscess [TOA])
The following consultations may be helpful:
Surgeon (especially if appendicitis or another intra-abdominal process cannot be excluded)
Infectious disease consultant (especially in patients who are HIV-positive and may be on highly active antiretroviral treatment [HAART])
In the emergency department, clinic, or office setting, treatment should be expeditiously initiated and should include empirical broad-spectrum antibiotics to cover the full complement of common organisms. All regimens must be effective against C trachomatis and N gonorrhoeae, as well as against gram-negative facultative organisms, anaerobes, and streptococci.
To avoid inappropriate treatment, physicians should be aware of current guidelines and current national and local patterns of drug resistance in their patient populations. The Royal College of Obstetricians and Gynaecologists (RCOG) recommends treating women with PID who are infected with HIV with the same antibiotic regimens used to treat women who are HIV-negative.
A number of studies carried out between 1992 and 2006 demonstrated the effectiveness of various parenteral and oral regimens in eliminating acute symptoms and achieving microbiologic cure. No differences in outcome were identified between inpatient and outpatient management in a large, randomized, multicenter clinical study that compared inpatient and outpatient oral and parenteral antibiotic regimens in the documented elimination of endometrial and tubal infection.
Patients on an intravenous (IV) 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. In patients who have developed a TOA, 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.
Outpatient and inpatient regimens
The Centers for Disease Control and Prevention (CDC) has outlined antibiotic regimens for outpatient and inpatient treatment of PID.
For outpatient treatment, the CDC lists 2 currently accepted treatment regimens, labeled as A and B. Regimen A consists of the following:
Ceftriaxone 250 mg intramuscularly (IM) once as a single dose plus
Doxycycline 100 mg orally twice daily for 14 days
Metronidazole 500 mg orally twice daily for 14 days can be added if there is evidence or suspicion of vaginitis or if the patient underwent gynecologic instrumentation in the preceding 2-3 weeks
Regimen B consists of the following:
Cefoxitin 2 g IM once as a single dose concurrently with probenecid 1 g orally in a single dose, or another single-dose parenteral third-generation cephalosporin (eg, ceftizoxime or cefotaxime) plus
Doxycycline 100 mg orally twice daily for 14 days
Metronidazole 500 mg orally twice daily for 14 days can be added if there is evidence or suspicion of vaginitis or if the patient underwent gynecologic instrumentation in the preceding 2-3 weeks
For inpatient treatment of PID, the CDC also lists 2 currently accepted treatment regimens, again labeled as A and B. Regimen A consists of the following:
Cefoxitin 2 g IV every 6 hours or cefotetan 2 g IV every 12 hours plus
Doxycycline 100 mg orally or IV every 12 hours
This regimen is continued for 24 hours after the patient remains clinically improved, after which doxycycline 100 mg is given orally twice daily for a total of 14 days. If a TOA is present, clindamycin or metronidazole is used with doxycycline for more effective anaerobic coverage.
Regimen B consists of the following:
Clindamycin 900 mg IV every 8 hours plus
Gentamicin IV in a loading dose of 2 mg/kg, followed by a maintenance dosage of 1.5 mg/kg q8h
IV therapy may be discontinued 24 hours after the patient improves clinically, and oral therapy with 100 mg doxycycline twice daily should be continued for a total of 14 days. If TOA is present, clindamycin or metronidazole may be used with doxycycline for more effective anaerobic coverage.
An alternative parenteral regimen is ampicillin-sulbactam 3 g IV every 6 hours in conjunction with doxycycline 100 mg orally or IV every 12 hours.
Additional information on antibiotic therapy
Oral doxycycline has the same bioavailability as the IV form and avoids the painful infusion and vein sclerosis associated with the latter. Gentamicin dosing may be every 24 hours. Other third-generation cephalosporins may be substituted for cefoxitin and ceftriaxone.
For individuals who are allergic to cephalosporins, spectinomycin is recommended in Europe and Canada; however, this agent is currently unavailable in the United States. A 2-g azithromycin dose may also be used in these patients, but it is not routinely recommended, because of concerns about rapid development of resistance to this antibiotic[81, 82] and about potential intolerance of this dose. For more information, see the CDC’s Antibiotic-Resistant Gonorrhea Web site and Gonococcal Infections.
In April 2007, the CDC ceased to recommend fluoroquinolone antibiotics for treatment of gonorrhea in the United States. This change was based on analysis of data from the CDC’s Gonococcal Isolate Surveillance Project (GISP), which showed that the prevalence of fluoroquinolone-resistant gonorrhea cases in heterosexual men had reached 6.7%, an 11-fold increase from 0.6% in 2001. Fluoroquinolones may be a treatment option for disseminated gonococcal infection if antimicrobial susceptibility can be documented.
With fluoroquinolones no longer advocated, the drugs recommended for treatment of gonorrhea are limited to cephalosporins. However, gonococcal resistance to cephalosporins has also been increasing in the United States. GISP data showed that from 2000 to 2010, the percentage of isolates with elevated minimum inhibitory concentrations rose from 0.2% to 1.4% for cefixime and from 0.1% to 0.3% for ceftriaxone.
Consequently, the CDC no longer recommends the use of oral cephalosporins for gonococcal infections. For treatment of uncomplicated urogenital, anorectal, and pharyngeal gonorrhea, the CDC recommends a single IM dose of ceftriaxone 250 mg together with either a single oral dose of azithromycin 1 g or twice-daily oral administration of doxycycline 100 mg for 7 days.
If ceftriaxone is not readily available, cefixime 400 mg can be given orally in combination with either azithromycin or doxycycline; if ceftriaxone cannot be given because of severe allergy, azithromycin 2 g can be given orally in a single dose. However, patients treated with one of these alternative regimens should return 1 week after treatment for a test of cure.
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