eMedicine Specialties > Emergency Medicine > Obstetrics & Gynecology
Pelvic Inflammatory Disease: Treatment & Medication
Updated: Feb 4, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Emergency Department Care
- All patients with pelvic inflammatory disease (PID) require antibiotics. The CDC recommends several parenteral and oral regimens in the 2002 Guidelines for Treatment of Sexually Transmitted Diseases.2 These regimens are listed in Medication. A recent study demonstrated that, in conjunction with ceftriaxone, 1 g of azithromycin weekly for 2 weeks is equivalent to a 14-day course of doxycycline for treating mild pelvic inflammatory disease. The ease of dosing and less prohibitive cost makes azithromycin an attractive choice.
- Treatment should not be postponed due to the evidence that prevention of long-term sequelae is linked with timely administration of appropriate antibiotics.
- Analgesics
- Intravenous fluids, if dehydrated
- Recent studies indicate that oral outpatient treatment is as effective as inpatient parenteral treatment for mild-to-moderate cases of pelvic inflammatory disease. However, the CDC has established the following criteria for hospitalization based on observational data and consensus opinion:
- Surgical emergencies, such as appendicitis, cannot be excluded.
- Pregnancy
- The patient does not respond clinically to oral antimicrobial therapy.
- The patient is unable to follow or tolerate an outpatient oral regimen.
- The patient has severe illness, nausea, vomiting, or high fever.
- The patient has a tubo-ovarian abscess.
- The patient is immunodeficient (eg, HIV infection with low CD4 counts, immunosuppressive therapy) or has another disease.
Consultations
- A gynecologist should be consulted if the patient is pregnant or a candidate for admission or if the diagnosis is unclear.
- Surgical consultation is indicated if acute appendicitis or other surgical emergency is being considered.
Medication
The goal of therapy is to resolve the infection. On the basis of recent evidence, the CDC no longer recommends the use of fluoroquinolones for the treatment of gonococcal infections and associated conditions, such as pelvic inflammatory disease (PID).3Antibiotics
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
Cefoxitin (Mefoxin) or cefotetan (Cefotan) plus doxycycline (Bio-Tab, Doryx)
Parenteral regimen A.
Cefoxitin and cefotetan are second-generation cephalosporins indicated for the management of infections caused by susceptible gram-positive cocci and gram-negative rods. Many infections caused by gram-negative bacteria that are resistant to some cephalosporins and penicillins respond to cefoxitin. Doxycycline inhibits protein synthesis and, thus, bacterial growth, by binding with the 30S and, possibly, the 50S ribosomal subunits of susceptible bacteria.
The parenteral therapy may be discontinued 24 h after a patient improves clinically. Continue doxycycline PO for 14 d. When tubo-ovarian abscess is present, clindamycin or metronidazole often is added to the doxycycline for better anaerobic coverage.
Adult
Cefoxitin 2 g IV q6h or cefotetan 2 g IV q6h plus doxycycline 100 mg PO/IV q12h
Pediatric
<8 years: Not recommended
>8 years: Not established
Consumption of alcohol within 72 h of cefotetan may produce disulfiramlike reactions; cefotetan may increase hypoprothrombinemic effects of anticoagulants; coadministration with potent diuretics (eg, loop diuretics) or aminoglycosides may increase nephrotoxicity; 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
Reduce dosage by half if <10-30 mL/min CrCl and by a quarter if <10 mL/min; bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged or repeated therapy; photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last one half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines
Clindamycin (Cleocin) plus gentamicin (Gentacidin, Garamycin)
Parenteral regimen B.
Clindamycin is a 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.
Gentamicin is an aminoglycoside antibiotic for gram-negative coverage. Used in combination with both 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. May be administered IV/IM.
If tubo-ovarian abscess is present, clindamycin is recommended instead of doxycycline.
Adult
Clindamycin 900 mg IV q8h plus gentamicin
Loading dose 2 mg/kg IV/IM, followed by a 1.5 mg/kg maintenance dose IV/IM q8h; single dosing of gentamicin may be substituted; parenteral therapy may be discontinued 24 h after clinical improvement; continue doxycycline 100 mg PO bid or clindamycin 450 mg PO qid for 14 d
Pediatric
Not established
Increases duration of neuromuscular blockade, induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption of clindamycin; 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 of aminoglycosides; possible irreversible hearing loss of varying degrees may occur (monitor regularly)
Documented hypersensitivity; regional enteritis, ulcerative colitis, hepatic impairment, antibiotic-associated colitis; 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
Adjust dose in severe renal and hepatic dysfunction; associated with severe and possibly fatal colitis; narrow therapeutic index (not intended for long-term therapy); caution in myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission
Ampicillin and sulbactam (Unasyn) plus doxycycline (Doryx)
Ampicillin and sulbactam is a combination antimicrobial agent that uses a beta-lactamase inhibitor with ampicillin. It covers skin, enteric flora, and anaerobes. It is not ideal for nosocomial pathogens.
Doxycycline inhibits protein synthesis and, thus, bacterial growth, by binding with the 30S and, possibly, the 50S ribosomal subunits of susceptible bacteria.
Adult
Ampicillin and sulbactam 3 g IV q6h plus doxycycline 100 mg PO/IV q12h
Pediatric
<8 years: Not recommended
>8 years: Not established
Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of PO contraceptives; 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
Evaluate rash and differentiate from hypersensitivity reaction; photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last one half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines
Ceftriaxone (Rocephin) or cefoxitin (Mefoxin) plus doxycycline (Doryx)
This regimen is theoretically limited by poor anaerobic coverage. Depending on the clinical situation, consider adding metronidazole. Use of PO cephalosporins is not recommended for PID, only for cervicitis and urethritis.
Adult
Ceftriaxone 250 mg IM once or cefoxitin 2 g IM plus probenecid 1 g PO in single dose once concurrently plus doxycycline 100 mg PO bid for 14 d
Pediatric
<8 years: Not recommended
>8 years: Not established
Probenecid may increase ceftriaxone levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity; 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 equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last one half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines; caution in breastfeeding women and those with allergy to penicillin
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 |
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References
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Rice R, Schwartz D, Knapp J, et al. Pelvic inflammatory disease. In: Morse, Moreland, Holmes, eds. Atlas of Sexually Transmitted Diseases and AIDS. 1996:134-47.
Sam JW, Jacobs JE, Birnbaum BA. Spectrum of CT findings in acute pyogenic pelvic inflammatory disease. Radiographics. Nov-Dec 2002;22(6):1327-34. [Medline].
Soper DE. Pelvic inflammatory disease. Infect Dis Clin North Am. Dec 1994;8(4):821-40. [Medline].
Suss AL, Homel P, Hammerschlag M, Bromberg K. Risk factors for pelvic inflammatory disease in inner-city adolescents. Sex Transm Dis. May 2000;27(5):289-91. [Medline].
Walker CK, Wiesenfeld HC. Antibiotic therapy for acute pelvic inflammatory disease: the 2006 Centers for Disease Control and Prevention sexually transmitted diseases treatment guidelines. Clin Infect Dis. Apr 1 2007;44 Suppl 3:S111-22. [Medline].
Westrom L, Joesoef R, Reynolds G, Hagdu A, Thompson SE. Pelvic inflammatory disease and fertility. A cohort study of 1,844 women with laparoscopically verified disease and 657 control women with normal laparoscopic results. Sex Transm Dis. Jul-Aug 1992;19(4):185-92. [Medline].
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Further Reading
Keywords
pelvic inflammatory disease, PID, infertility, infections of female upper genital tract, endometritis, tuboovarian abscess, peritonitis, Chlamydia trachomatis, C trachomatis, Neisseria gonorrhoeae, N gonorrhoeae, Peptococcus, Peptostreptococcus species, Bacteroides species, genital Mycoplasma, Ureaplasma species, gut coliforms, chronic pelvic pain, vaginal discharge, low back pain, irregular vaginal bleeding, gonococcal PID, mucopurulent cervical discharge, uterine tenderness, adnexaltenderness, sexually transmitted disease, STD, Gardnerella vaginalis, Streptococcus agalactiae, Haemophilus influenzae, Haemophilus parainfluenzae, Actinomyces species, granulomatous salpingitis, Mycobacterium tuberculosis, Schistosoma species
