Pelvic Inflammatory Disease Guidelines

Updated: Aug 16, 2021
  • Author: Kristi A Tough DeSapri, MD; Chief Editor: Nicole W Karjane, MD  more...
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Guidelines

Guidelines Summary

CDC guidelines on treatment of pelvic inflammatory disease

In 2021, the Centers for Disease Control and Prevention (CDC) updated its clinical practice guidelines on the treatment of sexually transmitted infections. [6] These are some of the highlights of the recommendations for the treatment of pelvic inflammatory disease.

The recommended parenteral treatment regimens for pelvic inflammatory disease are as follows:

  • Ceftriaxone 1 g IV every 24 hours PLUS
  • Doxycycline at 100 mg PO or IV every 12 hours PLUS
  • Metronidazole at 500 mg PO or IV every 12 hours

OR

  • Cefotetan at 2 g IV every 12 hours PLUS
  • Doxycycline at 100 mg PO or IV every 12 hours

OR

  • Cefoxitin at 2 g IV every 6 hours PLUS
  • Doxycycline at 100 mg PO or IV every 12 hours

Alternative parenteral treatment regimens are as follows:

  • Ampicillin-sulbactam at 3 g IV every 6 hours PLUS
  • Doxycycline at 100 mg PO or IV every 12 hours

OR

  • Clindamycin at 900 mg IV every 8 hours PLUS
  • Gentamicin loading dose IV or IM (2 mg/kg body weight), followed by a maintenance dose (1.5 mg/kg body weight) every 8 hours; can substitute single daily dosing (3-5 mg/kg body weight)

The recommended intramuscular or oral regimens for pelvic inflammatory disease are as follows:

  • Ceftriaxone at 500 mg IM in a single dose (for persons weighing ≥150 kg, administer 1 g of ceftriaxone) PLUS
  • Doxycycline at 100 mg PO BID for 14 days with metronidazole at 500 mg PO BID for 14 days

OR

  • Cefoxitin at 2 g IM in a single dose and probenecid at 1 g PO administered concurrently in a single dose PLUS
  • Doxycycline at 100 mg PO BID for 14 days with metronidazole at 500 mg PO BID for 14 days

OR

  • Other parenteral third-generation cephalosporin (eg, ceftizoxime, cefotaxime) PLUS
  • Doxycycline at 100 mg PO BID for 14 days with metronidazole at 500 mg PO BID for 14 days
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SPILF/CNGOF Pelvic Inflammatory Disease Guidelines

Diagnosis of Pelvic Inflammatory Disease

Positive diagnosis of pelvic inflammatory disease (PID) is based on adnexal pain or tenderness upon cervical motion, reinforced by associated signs, including fever, leukorrhea, and metrorrhagia. [94]

Pelvic clinical examination is recommended in women with PID-compatible symptoms.

Laboratory Studies

Hyperleukocytosis accompanied by a high C-reactive protein (CRP) level suggests complicated PID or an alternative diagnosis (eg, acute appendicitis). Suspected PID should prompt serum analysis, including complete blood count (CBC) and CRP testing.

Imaging Studies

Pelvic ultrasonography is too insensitive and unspecific for diagnosis of uncomplicated PID, although ultrasonography is recommended to evaluate for signs of complicated PID (eg, polymorphic collection) or an alternate diagnosis. Initiation of antibiotic therapy should not be delayed awaiting ultrasonography.

Abdominal-pelvic CT scanning with contrast is useful to exclude urinary, digestive, or gynecological differential diagnoses.

Laparoscopy is not recommended for PID diagnosis.

Microbiologic Diagnosis

Chlamydia trachomatis is the most common bacterial cause of PID, particularly in women younger than 30 years. [95]

In uncomplicated cases of PID, endocervical sampling during gynecological examination under speculum is recommended to obtain a microbiological diagnosis, as follows:

  • First swab: Direct examination via smear (Gram stain, May-Grünwald Giemsa [MGG] stain)
  • Second swab: Sent via adapted transport for culture ( Neisseria gonorrhoeae and facultative vaginal flora bacteria), with antibiotic susceptibility testing
  • Third swab: Sent by appropriate transport for analysis via nucleic acid amplification techniques (NAATs) (for N gonorrhoeae, C trachomatis, Mycoplasma genitalium).

PID diagnosis is supported by NAAT positive for N gonorrhoeae, C trachomatis, and/or M genitalium from a genital sample. Conversely, negative NAAT results do not exclude a sexually transmitted infection (STI) agent for PID diagnosis.

If speculum use is not possible, vaginal sampling is performed. C trachomatis serology is not useful as a first-line diagnostic test for PID or as a tool for monitoring PID.

Follow-up for Pelvic Inflammatory Disease

The PID recurrence rate is 15%-21%, of which 20%-34% cases are due to recurrent STI. [96]

Follow-up is recommended. Personalized text message reminders improve the likelihood of follow-up compliance.

NAAT of vaginal samples to evaluate for N gonorrhoeae, C trachomatis, and M genitalium should be performed 3-6 months after treatment of STI-associated PID to rule out reinfection. Condom use after STI-associated PID reduces the recurrence risk. Systematic oral contraceptives are not recommended after PID.

Prior to insertion of an intrauterine device, vaginal sampling for microbiological diagnosis is recommended.

Women with PID are at high risk of ectopic pregnancy.

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