Recommendations and Rationale for the Treatment of Pelvic Inflammatory Disease

Oluwatosin Jaiyeoba; Gweneth Lazenby; David E Soper


Expert Rev Anti Infect Ther. 2011;9(1):61-70. 

In This Article


Optimal therapy for PID must take into consideration the severity of disease, the polymicrobial etiology of disease, the availability and costs of the antimicrobials, and their ease of administration. For this reason we recommend regimens for use in the treatment of those women who are candidates for outpatient therapy that can be administered as single or infrequent oral doses. Cefixime or a similar oral extended-spectrum cephalosporin can be used to cover the gonococcus, while azithromycin can be recommended to cover chlamydia and M. genitalium. Both agents together appear to have satisfactory anaerobic coverage to render women with the clinical diagnosis of mild-to-moderate PID asymptomatic. Moxifloxacin is a good alternative regimen for acute PID but it is costly, and its use should be restricted to areas were gonococcal PID is uncommon. Gonococcal culture and sensitivity testing is required to ensure N. gonorrhoeae is sensitive to moxifloxacin. A repeat gonococcal test is also required post-treatment to document eradication of the pathogen.

Women with more severe disease, particularly in the context of an associated TOA, must have the non-sexually transmitted microorganisms covered. This will include anaerobic bacteria and aerobic Gram-negative bacteria, especially E. coli. In addition, broad-spectrum therapy should include those microorganisms commonly associated with BV. A combination of parenteral ceftriaxone and metronidazole or clindamycin provides this coverage.

It is unclear how long therapy need continue but most studies (Box 8) and the CDC recommendations suggest 14 days. It is unlikely that most patients will adhere to such a long regimen after their symptoms resolve. It is most likely safe to discontinue antibiotic therapy once the patient's fever has lysed, her white blood cell count has normalized and her pelvic exam is non-tender, or at most reflects mild tenderness.


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