Pelvic%20inflammatory%20disease Treatment

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

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

• 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

• 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