Learning Objectives and CME/Disclosure Information
This activity is intended for healthcare providers delivering care to women and their families.
After completing this activity, the participant should be better able to:
1. Outline oral/IM regimens for treating PID 2. Name the reasons to hospitalize for parental IV antibiotics
Estimated time to complete activity: 0.25 hours
Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project
Disclosure of Conflicts of Interest
Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.
The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.
Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.
Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.
Method of Participation and Request for Credit
Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from Dec 31 2017 through Jan 25 2023, participants must read the learning objectives and faculty disclosures and study the educational activity.
If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.
For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.
Joint Accreditation Statement
In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Physician Continuing Medical Education
Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Continuing Nursing Education
The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.
Designated for 0.1 contact hours of pharmacotherapy credit for Advance Practice Registered Nurses.
Pelvic Inflammatory Disease (PID) includes any inflammatory disorder of the female genital tract, including endometritis, salpingitis, tubo-ovarian abscess, or pelvic peritonitis. Historically, it was thought that sexually transmitted organisms, especially N. gonorrhoeae and C. trachomatis, were implicated in up to 50% of clinical cases diagnosed however recent reports show that the proportion of PID cases attributable to a specific organism is decreasing. More often, bacterial vaginosis (BV) and microorganisms that comprise the vaginal flora, such as G. vaginalis, H. influenzae, enteric gram-negative rods, and Streptococcus agalactiae, have been associated with symptoms
There should be a low threshold to treat. Recommendations include that presumptive treatment for PID should be initiated for sexually active women if they are experiencing pelvic or lower abdominal pain or if no cause for the illness other than PID can be identified. If one or more of the following three minimum clinical criteria are present on pelvic examination, such as (1) cervical motion tenderness (2) uterine tenderness, or (3) adnexal tenderness then treatment is indicated
Outpatient Oral/IM regimens are first-line
Hospitalization may be warranted for the following
Cannot rule out surgical emergencies such as appendicitis
Severe illness, nausea/vomiting, or oral temperature >101F
Unable to follow or tolerate an outpatient oral regimen
No clinical response to oral/IM antimicrobial therapy after 72 hours
Ceftriaxone 500 mg IM plus Doxycycline 100 mg po BID x 14 days with Metronidazole 500 mg po BID x 14 days
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
May substitute another third generation cephalosporin (ceftizoxime/cefotaxime) for ceftriaxone plus Doxycycline 100mg PO BID x14 with Metronidazole 500mg PO BID x13 days
Note: Patients weighing >150 kg with documented gonococcal infection, treatment with 1 gram of ceftriaxone should be administered, not 500mg
Cephalosporin Allergy: If community prevalence and individual risk for gonorrhea are low, and follow-up is likely
Levofloxacin 500mg PO once daily or
Moxifloxacin 400mg PO once daily with metronidazole 500mg PO BID x 14 days or
Azithromycin 500 mg IV daily for 1 to 2 doses, followed by 250 mg orally daily in combination with metronidazole 500 mg 2 times/day for 12 to 14 days
Note: If a culture for gonorrhea is positive, treatment should be based on results of antimicrobial susceptibility testing | If isolate is quinolone-resistant N. gonorrhoeae or antimicrobial susceptibility cannot be assessed (e.g., if only NAAT testing is available), consultation with an infectious disease specialist is recommended
Ceftriaxone 1g IV q24h plus Doxycycline 100mg PO/IV q12h plus Metronidazole 500mg PO/IV q12h
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
‘Alternative Parenteral Regimen’
Ampicillin/Sulbactam 3 g IV q 6 hrs plus Doxycycline 100 mg po/IV q 12 hours
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)
After clinical improvement, transition to oral therapy of Doxycycline 100mg PO BID plus Metronidazole 500mg BID to complete 14 days of treatment
If using alternative parenteral regimens (clindamycin and gentamicin) transition to Clindamycin 450mg PO QID or Doxycycline 100mg BID PO
When TOA is present, with Alternative Parenteral Regimen, Doxycycline 100mg PO BID should be used with either Clindamycin 450mg PO QID or Metronidazole 500mg PO BID for more effective anaerobic coverage
Note: Doxycycline should be administered orally when possible due to pain with IV infusion and similar bioavailability both PO and IV. Similarly, metronidazole has similar IV and PO bioavailability and can be considered PO for women without severe illness or tubo-ovarian abscess
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 total of 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
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 treatment dose has been increased and the addition of metronidazole is recommended
Parenteral and oral regimens have similar outcomes in mild/moderate PID
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
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Disclosure of Unlabeled Use
This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.
The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
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