Pelvic inflammatory disease (PID) is the ascent of bacteria from the vagina or cervix resulting in infection of the reproductive organs eg uterus, fallopian tubes, ovaries. It may also be a complication of sexually transmitted infections.
The most common symptoms of PID are lower abdominal pain (crampy or dull) that usually starts a few days after the onset of the last menstrual period, dyspareunia, abnormal vaginal or cervical discharge, postcoital or irregular vaginal bleeding, dysuria, fever, nausea and vomiting, although some have minimal symptoms or silent pelvic inflammatory disease.

Principles of Therapy

Antibiotic Therapy

General Principles

  • Goals of therapy are to control the acute infection & to prevent long-term sequelae
  • Initiate antibiotic therapy as soon as presumptive diagnosis has been made because prevention of long-term adverse effect depends on immediate administration of proper antibiotic
    • The risk of tubal infertility or ectopic pregnancy may increase by 3x in female treated >72 hr after symptom onset
    • Treatment w/ antibiotics does not reverse any damage already incurred by the reproductive organs
  • All antibiotic regimens must provide adequate coverage for the following possible etiologic organisms for PID:
    • N gonorrhoeae, C trachomatis, anaerobes (Bacteroides, Gram-positive cocci), Mycoplasma hominis, facultative Gram-negative rods & Gram-positive aerobes
      • Rates of gonorrheal resistance are increasing for quinolones
  • The need to eliminate anaerobes in patients w/ PID has not been definitively determined
    • In vitro studies show that some anaerobes can cause tubal & epithelial destruction & many women w/ PID also have bacterial vaginitis; recommended regimens should therefore include anaerobic coverage
  • Oral vs parenteral therapy
    • Oral & parenteral therapy appear to be similarly effective in patients w/ mild-moderate PID
    • Most trials used parenteral therapy for 48 hr but this time-frame is arbitrary
      • Direct inpatient observation is recommended for at least 24 hr in those who have tubo-ovarian abscesses
    • Time to switch from parenteral to oral therapy should be guided by clinical experience
      • Shift to oral therapy can be started w/in 24 hr of clinical improvement (ie defervescence, decreased abdominal tenderness, & decreased uterine, adnexal, or cervical cervical motion tenderness)
  • Consider drug availability, cost & patient acceptance, together w/ local antimicrobial susceptibility & epidemiology patterns when choosing an antibiotic regimen


Symptomatic Therapy

  • May give analgesics (eg Paracetamol) for pain

Empiric Antibiotic Therapy

Aminopenicillin/Beta-lactamase Inhibitor

  • Effective for patients w/ tubo-ovarian abscess when given w/ Doxycycline


  • Data regarding use as monotherapy for PID is limited & should not be used w/o Ceftriaxone


  • Recommended agents: Cefotetan, Cefoxitin, Ceftizoxime, Cefotaxime, Ceftriaxone
    • Effective against N gonorrhoeae, enteric Gram-negative rods, Streptococci
  • Ceftriaxone is less effective than Cefoxitin or Cefotetan against anaerobic bacteria but Ceftriaxone has better coverage for N gonorrhoeae
  • Limited data on other cephalosporins


  • Good anaerobic coverage
  • Usually given when there is associated tubo-ovarian abscess


  • Effective against C trachomatis
  • Contraindicated in pregnancy
  • Should be administered orally when possible due to infusion-associated pain


  • Effective against enteric Gram-negative rods
  • Single daily dosing may be used


  • Good anaerobic coverage
  • Effective against organisms causing bacterial vaginosis which is often present in PID patients
  • Usually given when there is associated tubo-ovarian abscess

Non-Pharmacological Therapy

Intrauterine Device (IUD) Removal
  • No evidence that removal of the IUD provides any additional benefit
    • Effect of continued use of IUD on treatment failure & recurrence of PID is unknown
  • May remove if the patient does not want to keep the IUD or if symptoms have not resolved w/in 72 hr after start of treatment
    • Caution & close clinical follow-up are needed if IUD will not be removed
    • If IUD will be removed, should wait until after therapy has been initiated & at least 2 doses of antibiotics have been given
  • Provide contraceptive counseling if IUD is removed
  • If patient still requests for an IUD as a contraceptive but is likely to be at risk of future PID, Levonorgestrel-intrauterine system (LNG-IUS) should be recommended

Evaluation & Treatment of Sex Partners

  • Even if asymptomatic, sexual partners of STI patients are likely to be infected & should be offered treatment to prevent further STI transmission & reinfection
  • Examine & treat all partners who had sexual contact w/ the patient during the 60 days preceding the onset of the patient’s symptoms
  • Treat empirically w/ regimens effective against both C trachomatis & N gonorrhoeae
    •  See Gonorrhea- & Chlamydia-Uncomplicated Anogenital Infection management chart for details
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