Pelvic Inflammatory Disease – CDC Treatment Guidelines

SUMMARY

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

CLINICAL  ACTIONS:

Treatment Considerations

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

Treatment Options

• Outpatient Oral/IM regimens are first-line
• Hospitalization may be warranted for the following
  • Cannot rule out surgical emergencies such as appendicitis
  • Tubo-ovarian abscess
  • Pregnancy
  • 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

Oral/IM regimens

• 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

IV/Parenteral Regimens

• 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

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 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

Learn More – Primary Sources:

CDC 2021 PID Treatment Guidelines

University of Washington (CDC Funded): PID Self-Study Module for Clinicians

The ABCs of PID Diagnosis – What You Need to Know

CLINICAL ACTIONS:

Pelvic inflammatory disease (PID) is an inflammatory disorder of the upper female genital tract that includes endometritis, salpingitis, tubo-ovarian abscess and pelvic peritonitis. Symptoms may be obvious (high fever, severe lower abdominal pain, peritoneal signs), subtle (abnormal bleeding, vaginal discharge, dyspareunia) or absent.

Assume PID in a patient with lower abdominal/pelvic pain if

• Sexually active and/or at risk: adolescents, women attending STD clinics, those in communities with high rates of gonorrhea or chlamydia
• One or more of the following on pelvic exam:
  • Cervical motion tenderness (CMT)
  • Uterine tenderness
  • Adnexal tenderness
• Other causes (ectopic pregnancy, ovarian cyst, appendicitis, functional pain) are unlikely

Additional criteria to support the diagnosis of PID

• Oral temperature >101°F (>38.3°C)
• Abnormal cervical mucopurulent discharge or cervical friability
• Abundant WBCs on saline microscopy of vaginal fluid
• Elevated erythrocyte sedimentation rate (ESR)
• Elevated C-reactive protein (CRP)
• Positive gonorrhea/chlamydia trachomatis culture

Most specific criteria for diagnosing PID

• Endometrial biopsy for evidence of endometritis
• Transvaginal ultrasound or MRI demonstrating thickened fluid filled fallopian tubes, or tubo-ovarian collection, or tubal hyperemia
• Laparoscopic findings consistent with PID
  • The CDC cautions that laparoscopy “is not easily justifiable when symptoms are mild or vague. Moreover, laparoscopy will not detect endometritis and might not detect subtle inflammation of the fallopian tubes.”

SYNOPSIS:

Pelvic inflammatory disease comprises a spectrum of disorders ranging from asymptomatic to debilitating. Acute PID may be difficult to diagnose because of the wide variation in symptoms and signs. The diagnosis of PID is usually based on clinical findings noted above.

KEY POINTS:

• Wet Prep (saline preparation of vaginal fluid)
  • Most women with PID have either mucopurulent cervical discharge or evidence of WBCs on a microscopic evaluation
  • If the cervical discharge appears normal and no WBCs are observed on the wet prep of vaginal fluid, the diagnosis of PID is unlikely
    • Consider alternative causes of pain
    • A wet prep of vaginal fluid also can detect the presence of concomitant infections (e.g., BV and trichomoniasis)
• PID is usually, but not always, seen in the presence of gonorrhea or chlamydia trachomatis infections
  • Typical vaginal flora, cytomegalovirus, mycoplasma may be associated with PID
• Many episodes of PID go unrecognized with potential long-term sequelae of infertility or chronic pain
• Healthcare providers should maintain a low threshold for the diagnosis of PID
  • It is better to overtreat than to undertreat
• All women diagnosed with PID should be tested for HIV as well as gonorrhea and chlamydia
• Treatment should not be delayed until test results are available if there is a clinical suspicion of PID

Learn More – Primary Sources:

CDC 2021 PID Treatment Guidelines