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Pelvic Inflammatory Disease (PID)

Pelvic Inflammatory Disease (PID) is a bacterial inflammation of the fallopian tubes, ovaries, uterus and cervix.

Initial infections are caused by single-agent STDs, such as gonorrhea or chlamydia. Subsequent infections are often caused by multiple non-STD organisms (E. Coli, Bacteroides, etc.). Responsible organisms include STDs, normal vaginal inhabitants, and enteric bacteria.

Most cases of PID have no long-term adverse effects, but some have such serious (or disastrous) consequences as infertility, tubo-ovarian abscess, and sepsis. Women with a history of PID are at increased risk for subsequent tubal ectopic pregnancy.

Symptoms of PID vary from nearly trivial pelvic discomfort and vaginal discharge to incapacitating abdominal pain with nausea and vomiting. Leukocytosis, like fever, is variable in cases of PID. The diagnosis can be based on such imprecise findings as uterine and adnexal tenderness without other explanation, or such precise findings as laparoscopic visualization of inflamed tubes with surrounding purulence. Cervical cultures may or may not be positive. Ultrasound findings may be normal or may include a generalized haziness due to edema. In more advanced cases, hydrosalpinx may be seen with ultrasound, CT or MRI.

From a clinical management point of view, there are two forms of PID:

  • Mild, and

  • Moderate to Severe


CDC Treatment Guidelines

Mild PID
Gradual onset of mild bilateral pelvic pain with purulent vaginal discharge is the typical complaint. Fever <100.4 and deep dyspareunia are common.

Moderate pain on motion of the cervix and uterus with purulent or mucopurulent cervical discharge is found on examination. Gram-negative diplococci or positive chlamydia culture may or may not be present. WBC may be minimally elevated or normal. These cases are treated aggressively, but usually with oral medications. Prompt response is expected. Sexual partners should also be treated.

Moderate to Severe PID
With moderate to severe PID, there is a gradual onset of moderate to severe bilateral pelvic pain with purulent vaginal discharge, fever >100.4 (38.0), lassitude, and headache. Symptoms more often occur shortly after the onset or completion of menses.

Excruciating pain on movement of the cervix and uterus is characteristic of this condition. Hypoactive bowel sounds, purulent cervical discharge, and abdominal dissension are often present. Pelvic and abdominal tenderness is always bilateral except in the presence of an IUD.

Gram-negative diplococci in cervical discharge or positive chlamydia culture may or may not be present. WBC and ESR are elevated.

These more serious infections require more aggressive management, often consisting of bedrest, IV fluids, IV antibiotics, and NG suction if ileus is present. A more gradual recovery is expected and it may be several weeks before the patient is feeling normal.

 

 

2007 CDC Treatment Guidelines

Parenteral Treatment

Parenteral and oral therapy appear to have similar clinical efficacy treating women with PID of mild or moderate severity. Clinical experience should guide decisions regarding transition to oral therapy, which usually can be initiated within 24 hours of clinical improvement.

Recommended Parenteral Regimen A

Cefotetan 2 g IV every 12 hours
   OR
Cefoxitin 2 g IV every 6 hours
   PLUS
Doxycycline 100 mg orally or IV every 12 hours


Recommmended Parenteral Regimen B

Clindamycin 900 mg IV every 8 hours
   PLUS
Gentamicin loading dose IV or IM (2 mg/kg of body weight), followed by a maintenance dose (1.5 mg/kg) every 8 hours. Single daily dosing may be substituted.


Alternative Parenteral Regimens

Ampicillin/Sulbactam 3 g IV every 6 hours
    PLUS
Doxycycline 100 mg orally or IV every 12 hours

Oral Treatment

Oral therapy can be considered for women with mild-to-moderately severe acute PID, as the clinical outcomes among women treated with oral therapy are similar to those treated with parenteral therapy. Women who do not respond to oral therapy within 72 hours should be reevaluated to confirm the diagnosis and should be administered parenteral therapy on either an outpatient or in-patient basis.

Recommended Oral Regimen

Ceftriaxone 250 mg IM in a single dose
   PLUS
Doxycycline 100 mg orally twice a day for 14 days
   WITH OR WITHOUT
Metronidazole 500 mg orally twice a day for 14 days
  
 OR

Cefoxitin 2 g IM in a single dose and Probenecid, 1 g orally administered concurrently in a single dose
   PLUS
Doxycycline 100 mg orally twice a day for 14 days
   WITH OR WITHOUT
Metronidazole 500 mg orally twice a day for 14 days
  
 OR

Other parenteral third-generation cephalosporin (e.g., ceftizoxime or cefotaxime)
   PLUS
Doxycycline 100 mg orally twice a day for 14 days
   WITH OR WITHOUT
Metronidazole 500 mg orally twice a day for 14 days

Alternative Oral Regimens

If parenteral cephalosporin therapy is not feasible, use of fluoroquinolones (levofloxacin 500 mg orally once daily or ofloxacin 400 mg twice daily for 14 days) with or without metronidazole (500 mg orally twice daily for 14 days) may be considered if the community prevalence and individual risk (see “Gonococcal Infections in Adolescents and Adults” in Sexually Transmitted Disease Treatment Guidelines, 2006) of gonorrhea is low.  Tests for gonorrhea must be performed prior to instituting therapy and the patient managed as follows if the test is positive:

  • If NAAT test is positive, parenteral cephalosporin is recommended.

  • If culture for gonorrhea is positive, treatment should be based on results of antimicrobial susceptibility. If isolate is QRNG, or antimicrobial susceptibility can’t be assessed, parenteral cephalosporin is recommended.

Although information regarding other outpatient regimens is limited, amoxicillin/clavulanic acid and doxycycline or azithromycin with metronidazole has demonstrated short-term clinical cure. No data has been published regarding the use of oral cephalosporins for the treatment of PID.

Updated 11/25/2008

OB-GYN 101: Introductory Obstetrics & Gynecology
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