Approach
The main goal of treatment is the eradication of pathogenic organisms that are associated with infections commonly implicated in PID. This is essential because the long-term sequelae of untreated or incompletely treated PID include tubal damage, infertility, and ectopic pregnancy. Treatment should be initiated as soon as the presumptive diagnosis has been made because prevention of long-term sequelae is dependent on immediate administration of appropriate antibiotics. Consideration for treatment regimen selection includes cost, availability, patient acceptance, local antimicrobial sensitivity patterns, local epidemiology of specific infections, and severity of disease.[26]
General advice
The following advice should be given to women with PID.[1][26]
Rest is advised for those with severe disease.
Appropriate analgesia should be provided.
Intravenous therapy is recommended for patients with more severe clinical disease (e.g., pyrexia >38.3°C [>101°F], clinical signs of tubo-ovarian abscess, signs of pelvic peritonitis).
Patients should be advised to avoid unprotected intercourse until they, and their partner(s), have completed treatment and follow-up.
A detailed explanation of their condition with particular emphasis on the long-term implications for the health of themselves and their partner(s) should be provided and reinforced with clear and accurate written information.
When giving information to patients, the clinician should consider the following:
An explanation of what treatment is being given and its possible adverse effects
Following treatment, fertility is usually maintained but there remains a risk of future infertility, chronic pelvic pain, or ectopic pregnancy
Clinically more severe disease is associated with a greater risk of sequelae
Repeat episodes of PID are associated with an exponential increase in the risk of infertility
The earlier treatment is given, the lower the risk of future fertility problems
Future use of barrier contraception will significantly reduce the risk of PID
The patient's sexual contacts need to be screened for infection to prevent the patient becoming re-infected
All contraceptive methods can be continued during treatment.
Antibiotic therapy
All treatment regimens should be effective against Neisseria gonorrhoeae and Chlamydia trachomatis because negative results of endocervical screening for these organisms does not rule out upper reproductive tract infection. Regimens with anaerobic activity are also recommended.[1]
In the US, the Centers for Disease Control and Prevention (CDC) recommends parenteral antibiotic therapy with a cephalosporin (ceftriaxone, cefotetan, or cefoxitin) plus doxycycline for patients with severe PID.[1] Metronidazole should be used with ceftriaxone, as ceftriaxone is less active against anaerobic bacteria than cefotetan or cefoxitin.[1] Alternative parenteral regimens include ampicillin/sulbactam plus doxycycline, or clindamycin plus gentamicin. Women receiving a parenteral regimen of clindamycin plus gentamicin who show clinical improvement within 24-48 hours can be switched to an appropriate oral regimen or oral doxycycline to complete the 14 days of therapy.[1] There are limited data to support the use of other parenteral second- or third-generation cephalosporins. Doxycycline should be given orally if possible to avoid pain associated with intravenous infusion. The bioavailability of oral and intravenous doxycycline and metronidazole are similar. If treatment is started with a parenteral agent, the patient can be switched to oral therapy within 24-48 hours of clinical improvement.[1]
A combination of intramuscular plus oral therapy can be considered in patients with mild-to-moderate PID; however, patients who do not respond within 72 hours should be re-evaluated. Parenteral and oral antibiotics seem to have similar clinical efficacy in women with mild-to-moderate PID; one Cochrane review did not find any conclusive evidence that one regimen of antibiotics was safer or more effective than another for PID.[1][44]
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Recommended regimens include intramuscular ceftriaxone or cefoxitin plus oral doxycycline plus metronidazole. Metronidazole provides extended coverage against anaerobic bacteria and will also effectively treat bacterial vaginosis, a common co-infection in women with PID. Oral metronidazole is well absorbed and should be considered instead of intravenous infusion in the absence of severe illness or tubo-ovarian abscess. Probenecid should be used with cefoxitin. Other parenteral third-generation cephalosporins may also be used.[1]
Because of increasing and widespread resistance, the CDC no longer routinely recommends using fluoroquinolone antibiotics for the treatment of PID. However, if allergy precludes the use of cephalosporins, if the community prevalence and individual risk for gonorrhoea are low, and follow-up is likely, use of a fluoroquinolone or azithromycin (with or without metronidazole) can be considered. Diagnostic tests for gonorrhoea should be obtained before initiating therapy. If a patient is positive for gonorrhoeal infection, treatment should be based on results of antimicrobial susceptibility testing. Consultation with an infectious disease specialist is recommended if fluoroquinolone-resistant N gonorrhoeae is detected, or if antimicrobial susceptibility cannot be assessed.[1]
In the UK, fluoroquinolones should be avoided as first-line empirical treatment for PID in patients who are at high risk of gonococcal PID (e.g., clinically severe disease, partner has gonorrhoea, history of sexual contact abroad).[34][45] However, as N gonorrhoeae is an uncommon cause of PID in the UK, fluoroquinolones can be used as second-line empirical treatment among those not at high risk of gonorrhoea.[26]
If Mycoplasma genitalium testing is available and M genitalium is detected, guidelines recommend treatment with moxifloxacin.[1][26][30]
Systemic fluoroquinolone antibiotics may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to, tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycaemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behaviour.[46]
Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics, that are commonly recommended for the infection, are inappropriate (e.g., resistance, contraindications, treatment failure, and unavailability).
Consult your local guidelines and drug formulary for more information on suitability, contraindications, and precautions.
Patients should be re-assessed within 72 hours of initiation of treatment. Clinical improvement should be apparent (e.g., defervescence; reduction in direct or rebound abdominal tenderness; and reduction in uterine, adnexal, and cervical motion tenderness). If the patient's symptoms are worsening or not improving <72 hours after initiation of therapy, the diagnosis of PID should be re-assessed. Laparoscopy or ultrasonography should be considered, as should the hospitalisation of patients being treated as outpatients.[1][14]
Evidence is insufficient to recommend the removal of IUDs in women diagnosed with acute PID. However, caution should be exercised if the IUD remains in place; close clinical follow-up is mandatory, and consideration should be given to removal if symptoms have not resolved within 48 to 72 hours.[1][34][47]
Pregnant women with PID are at high risk for maternal morbidity and preterm delivery, and should be hospitalised and treated with intravenous antibiotics in consultation with an infectious disease specialist.[1]
There are currently no data to suggest that women with HIV infection and PID co-infection require more aggressive clinical management (e.g., hospitalisation or intravenous antibiotic regimens).[1]
Hospitalisation
Most women with mild-to-moderate PID are treated as outpatients. If no clinical improvement has occurred within 72 hours after outpatient oral or parenteral therapy, further assessment should be performed. Subsequent hospitalisation and an assessment of the antimicrobial regimen and diagnostics (including the consideration of diagnostic laparoscopy for alternative diagnoses) are recommended. Hospitalisation is particularly recommended when:[1]
Possibility of surgical emergencies (e.g., appendicitis) cannot be excluded
Tubo-ovarian abscess is suspected
Patient is pregnant
Severe illness (e.g., nausea and vomiting, high fever) precludes outpatient management
Patient is unable to follow or tolerate an outpatient oral regimen
Patient has not responded to outpatient therapy.
The decision to hospitalise adolescents should be based on the same criteria used for older women.
Patients should be re-assessed 24 to 48 hours after treatment has begun and the decision about changing from parenteral to oral therapy, if appropriate, can be based on clinical improvement.[1]
Treatment of sexual partners
Men who have had sexual contact with a woman diagnosed with PID during the 60 days prior to the onset of symptoms should be evaluated and treated with regimens that are effective against chlamydia and gonorrhoea. If a patient's last sexual intercourse was >60 days before onset of symptoms or diagnosis, the patient's most recent sexual partner should be treated.[1]
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Women should be advised to avoid sexual intercourse until they and their partners have completed the treatment course. If adequate screening for gonorrhoea and chlamydia in the sexual partner(s) is not possible, empiric therapy for gonorrhoea and chlamydia should be prescribed.[1] If their partners are unlikely to seek evaluation and treatment, a patient-delivered partner therapy (PDPT), a form of expedited partner therapy (EPT) in which partners of infected persons are treated without previous medical evaluation or prevention counselling, should be offered.[1][48] EPT might be prohibited in some states in the US and is the topic of ongoing legislation in others; updated information is available from the Centers for Disease Control and Prevention (CDC).
CDC: expedited partner therapy
Opens in new window Any medication or prescription provided for PDPT should be accompanied by treatment instructions, appropriate warnings about taking medications, and general health counselling.[48]
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