Pelvic%20inflammatory%20disease Treatment
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
- N gonorrhoeae, C trachomatis, anaerobes (Bacteroides, Gram-positive cocci), Mycoplasma hominis, facultative Gram-negative rods & Gram-positive aerobes
- 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
Pharmacotherapy
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
Azithromycin
- Data regarding use as monotherapy for PID is limited & should not be used w/o Ceftriaxone
Cephalosporins
- 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
Clindamycin
- Good anaerobic coverage
- Usually given when there is associated tubo-ovarian abscess
Doxycycline
- Effective against C trachomatis
- Contraindicated in pregnancy
- Should be administered orally when possible due to infusion-associated pain
Gentamicin
- Effective against enteric Gram-negative rods
- Single daily dosing may be used
Metronidazole
- 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