TREATMENT OF PELVIC INFLAMMATORY DISEASE – ROYAL COLLEGE OF OBSTETRICIAN AND GYNECOLOGY GUIDELINE SUMMARY
1 Clinical
A low threshold for empiric treatment of PID is recommended because of the lack of definitive clinical diagnostic criteria and because the potential consequences of not treating of PID are significant. In clinically severe cases, referral to hospital for treatment and further investigation is advisable.
2 Microbiological
Women with suspected PID should be tested for gonorrhoea and chlamydia.
3 Starting treatment
4.1 How should PID be managed in the outpatient setting?
Information on current and recent medication should be obtained. Interactions between antibiotic therapy and hormonal contraception and other patient medications should be assessed and appropriate action taken. 48 Outpatient antibiotic treatment should be commenced as soon as the diagnosis is suspected.
Outpatient antibiotic treatment should be based on one of the following regimens:
-oral ofloxacin 400 mg twice daily plus oral metronidazole 400 mg twice daily for 14 days
-intramuscular ceftriaxone 250 mg single dose, followed by oral doxycycline 100 mg twice daily plus metronidazole 400 mg twice daily for 14 days.
-Cefoxitin has a better evidence base for the treatment of PID than ceftriaxone but is not easily available in the. Ceftriaxone is therefore recommended.
When giving information to patients, the clinician should consider the following:
an explanation of what treatment is being given and its possible adverse effects
*that following treatment fertility is usually maintained but there remains a risk of future infertility, chronic pelvic pain or ectopic pregnancy
*repeat episodes of PID are associated with an exponential increase in the risk of infertility
*future use of barrier contraception will significantly reduce the risk of PID
*the need to screen her sexual contacts for infection to prevent her becoming reinfected
*clinically more severe disease is associated with a greater risk of sequelae
*the earlier treatment is given the lower the risk of future fertility problems.
4.2 What hospital treatment should be given and when should it be recommended?
-surgical emergency cannot be excluded
P.I.D. IN PREGNANCY
Inpatient antibiotic treatment should be based on intravenous therapy which should be continued until 24 hours after clinical improvement and followed by oral therapy. Recommended regimens are:
-ceftriaxone 2 g by intravenous infusion daily plus intravenous doxycycline 100 mg twice daily,* followed by oral doxycycline 100 mg twice daily plus oral metronidazole 400 mg twice daily for a total of 14 days * Oral doxycycline may be used if tolerated OR
-intravenous clindamycin 900 mg three times daily plus intravenous gentamicin,* followed by either
oral clindamycin 450 mg four times daily to complete 14 days OR
-oral doxycycline 100 mg twice daily plus oral metronidazole 400 mg twice daily to complete 14 days * Gentamicin should be given as a 2 mg/kg loading dose followed by 1.5 mg/kg three times daily (or a single daily dose of 7 mg/kg may be substituted).
-intravenous ofloxacin 400 mg twice daily plus intravenous metronidazole 500 mg three times daily for 14 days.
Treatment in pregnancy and in young women
A pregnancy test should be performed in all women suspected of having PID to help exclude an ectopic pregnancy. Drugs known to be toxic in pregnancy, such as tetracyclines, should be avoided.
A combination of cefotaxime, azithromycin and metronidazole for 14 days may be used. The risks associated with metronidazole are uncertain but no confirmed associations with adverse outcomes have been reported.
Treatment in a woman with an intrauterine contraceptive device
Consideration should be given to removing an intrauterine contraceptive device (IUD) in women presenting with PID, especially if symptoms have not resolved within 72 hours.
Other modes of treatment
Surgical treatment should be considered in severe cases or where there is clear evidence of a pelvic abscess.
Consider drainage of an abscess and in noting its position, the possibility that the abscess may have arisen from the appendix or colon.
Women who are infected with HIV
Women with PID who are also infected with HIV should be treated with the same antibiotic regimens as women who are HIV negative. Women with HIV should be managed in conjunction with their HIV physician.
Contraception options and PID
Women on hormonal contraception presenting with breakthrough bleeding should be screened for genital tract infection, especially C. trachomatis.
If a woman is likely to be at risk of future PID and requests an IUD for contraception, the LNG-IUS would be the most appropriate choice53.
Treatment in a woman with an intrauterine contraceptive device
Consideration should be given to removing an intrauterine contraceptive device (IUD) in women presenting with PID, especially if symptoms have not resolved within 72 hours.
1 Clinical
A low threshold for empiric treatment of PID is recommended because of the lack of definitive clinical diagnostic criteria and because the potential consequences of not treating of PID are significant. In clinically severe cases, referral to hospital for treatment and further investigation is advisable.
2 Microbiological
Women with suspected PID should be tested for gonorrhoea and chlamydia.
3 Starting treatment
4.1 How should PID be managed in the outpatient setting?
Information on current and recent medication should be obtained. Interactions between antibiotic therapy and hormonal contraception and other patient medications should be assessed and appropriate action taken. 48 Outpatient antibiotic treatment should be commenced as soon as the diagnosis is suspected.
Outpatient antibiotic treatment should be based on one of the following regimens:
-oral ofloxacin 400 mg twice daily plus oral metronidazole 400 mg twice daily for 14 days
-intramuscular ceftriaxone 250 mg single dose, followed by oral doxycycline 100 mg twice daily plus metronidazole 400 mg twice daily for 14 days.
-Cefoxitin has a better evidence base for the treatment of PID than ceftriaxone but is not easily available in the. Ceftriaxone is therefore recommended.
When giving information to patients, the clinician should consider the following:
an explanation of what treatment is being given and its possible adverse effects
*that following treatment fertility is usually maintained but there remains a risk of future infertility, chronic pelvic pain or ectopic pregnancy
*repeat episodes of PID are associated with an exponential increase in the risk of infertility
*future use of barrier contraception will significantly reduce the risk of PID
*the need to screen her sexual contacts for infection to prevent her becoming reinfected
*clinically more severe disease is associated with a greater risk of sequelae
*the earlier treatment is given the lower the risk of future fertility problems.
4.2 What hospital treatment should be given and when should it be recommended?
-surgical emergency cannot be excluded
P.I.D. IN PREGNANCY
Inpatient antibiotic treatment should be based on intravenous therapy which should be continued until 24 hours after clinical improvement and followed by oral therapy. Recommended regimens are:
-ceftriaxone 2 g by intravenous infusion daily plus intravenous doxycycline 100 mg twice daily,* followed by oral doxycycline 100 mg twice daily plus oral metronidazole 400 mg twice daily for a total of 14 days * Oral doxycycline may be used if tolerated OR
-intravenous clindamycin 900 mg three times daily plus intravenous gentamicin,* followed by either
oral clindamycin 450 mg four times daily to complete 14 days OR
-oral doxycycline 100 mg twice daily plus oral metronidazole 400 mg twice daily to complete 14 days * Gentamicin should be given as a 2 mg/kg loading dose followed by 1.5 mg/kg three times daily (or a single daily dose of 7 mg/kg may be substituted).
-intravenous ofloxacin 400 mg twice daily plus intravenous metronidazole 500 mg three times daily for 14 days.
Treatment in pregnancy and in young women
A pregnancy test should be performed in all women suspected of having PID to help exclude an ectopic pregnancy. Drugs known to be toxic in pregnancy, such as tetracyclines, should be avoided.
A combination of cefotaxime, azithromycin and metronidazole for 14 days may be used. The risks associated with metronidazole are uncertain but no confirmed associations with adverse outcomes have been reported.
Treatment in a woman with an intrauterine contraceptive device
Consideration should be given to removing an intrauterine contraceptive device (IUD) in women presenting with PID, especially if symptoms have not resolved within 72 hours.
Other modes of treatment
Surgical treatment should be considered in severe cases or where there is clear evidence of a pelvic abscess.
Consider drainage of an abscess and in noting its position, the possibility that the abscess may have arisen from the appendix or colon.
Women who are infected with HIV
Women with PID who are also infected with HIV should be treated with the same antibiotic regimens as women who are HIV negative. Women with HIV should be managed in conjunction with their HIV physician.
Contraception options and PID
Women on hormonal contraception presenting with breakthrough bleeding should be screened for genital tract infection, especially C. trachomatis.
If a woman is likely to be at risk of future PID and requests an IUD for contraception, the LNG-IUS would be the most appropriate choice53.
Treatment in a woman with an intrauterine contraceptive device
Consideration should be given to removing an intrauterine contraceptive device (IUD) in women presenting with PID, especially if symptoms have not resolved within 72 hours.