CLINICAL  ACTIONS:

Start broad spectrum antibiotic treatment for PID immediately if clinically suspected

• Oral/IM regimens
  • Ceftriaxone 250 mg IM plus Doxycycline 100 mg po BID x 14 days with/without Metronidazole 500 mg po BID x 14 days
    • May substitute another third generation cephalosporin (ceftizoxime/cefotaxime) for ceftriaxone  or
  • Cefoxitin 2 gm IM and Probenicid 1 gram po plus Doxycycline 100 mg BID x 14 days with/without Metronidazole 500 mg po BID x 14 days
• Note: The CDC states “The recommended third-generation cephalsporins are limited in the coverage of anaerobes. Therefore, until it is known that extended anaerobic coverage is not important for treatment of acute PID, the addition of metronidazole to treatment regimens with third-generation cephalosporins should be considered”

• If no improvement in 72 hours, or unable to tolerate PO admit for parenteral regimens below
  • Cefotetan 2 g IV q 12 hours plus Doxycycline 100 mg po/IV q 12 hrs or
  • Cefoxitin 2 g IV q 6 hrs plus Doxycycline 100 mg po/IV q 12 hrs or
  • Clindamycin 900 mg IV q 8 hr plus Gentamycin 2 mg/kg IV/IM load then 1.5 mg/kg q 8 hr (or single daily dosing Gentamycin 3-5 mg/kg  q 24 hours) or
  • ‘Alternative Parenteral Regimen’
    • Ampicillin/Sulbactam 3 g IV q 6 hrs plus Doxycycline 100 mg po/IV q 12 hours

SYNOPSIS:

Timely treatment of suspected PID is warranted.  Failure to clinically improve in 72 hours should prompt reconfirmation of the diagnosis and admission for intravenous antibiotic therapy.  Transition to oral therapy can usually be accomplished within 24-48 hours of clinical improvement.  Women should complete a 14 day regimen of antibiotics.  They should be advised to abstain from sexual intercourse until symptoms have resolved, therapy has been completed,  and partners have been treated, if needed.  If tests for gonorrhea or chlamydia are positive, women should be retested 3 months after treatment.

KEY POINTS:

• Antibiotic regimen should be broad spectrum with coverage of anaerobes, gonorrhea and chlamydia even if endocervical screening is negative
• The recommended third-generation cephalsporins are limited in the coverage of anaerobes
  • Therefore, until it is known that extended anaerobic coverage is not important for treatment of acute PID, the addition of metronidazole to treatment regimens with third-generation cephalosporins should be considered
• Parenteral and oral regimens have similar outcomes in mild/moderate PID
• Consider hospitalization for parental (IV) antibiotics if any of the following
  • Surgical emergencies such as appendicitis cannot be ruled out
  • Presence of a tubo-ovarian abscess
  • Pregnancy
  • Severe illness, nausea, vomiting, high fever
  • Unable to follow or tolerate an outpatient regime
  • Not responding to oral antimicrobial treatment
• Use the same criteria for adolescents and older women
• Test all patients with suspected PID for gonorrhea, chlamydia and HIV

IUD and PID

• The CDC states that “IUDs are one of the most effective contraceptive methods”
• PID associated with IUD use is primarily confined to the first 3 weeks after insertion

PID Diagnosis with IUD present

• IUD does not need to be removed but does require close clinical follow-up
• Consider hospitalization and parental treatment (see above)
• Note: Consider removing IUD if no clinical improvement occurs within 48–72 hours of initiating treatment

Learn More – Primary Sources:

CDC 2015 PID/STD Treatment Guidelines

Related ObG Topics:

The ABCs of PID Diagnosis – What You Need to Know