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

Five-year View

There are several important areas in which additional investigation could provide important guidance. Despite the revelation of a polymicrobial etiology of acute PID in 1975, we still do not understand the true importance of anaerobic bacteria as etiologic agents of acute PID. Current data suggest that antimicrobial regimens with little to no anaerobic coverage are highly effective in the treatment of mild-to-moderate PID, even in women with concurrent BV. Prospective studies need to be performed that will compare well-tolerated antibiotic regimens with excellent anaerobic coverage with those with little to no such coverage in the treatment of mild-to-moderate PID. In addition, prospective randomized trials are required to study oral cefixime versus other parenteral cephalosporins. We also understand little with respect to the need for duration of treatment and the frequency of dosing. It would be interesting to see if short courses (<1 week) of therapy are as effective as our now recommended longer courses (2 weeks). The reality of prolonged therapy is that compliance is notoriously poor, so shorter therapy may not only turn out to be more cost effective but may have equal efficacy as well. In addition, pulse dosing, for example, 1 g of azithromycin a week apart, appears promising as an alternative dosing schedule and needs further investigation.

Mycoplasma genitalium is an emerging pathogen of importance as an etiologic agent of lower and upper genital tract infection. Evidence suggests that it is associated with persistent endometritis despite doxycycline therapy and its optimal therapy is unknown. M. genitalium could become the next C. trachomatis if widespread testing was undertaken, yet commercially available nucleic acid tests are not available. It will be important to define the epidemiology, sequelae and most effective therapy for this emerging sexually transmitted infection.

It would be preferable to use a single agent that covers all the potential microbial pathogens, can be administered once daily and is inexpensive. Currently, moxifloxacin (not available as a generic in the USA) comes closest to being this agent but quinolone-resistant N. gonorrhoeae and its cost (US$225.60 for 14 tablets) prevent it from being embraced in this regard. Continued antibiotic development could provide us with this agent in the future.


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