PELVIC INFLAMMATORY DISEASE (PID)
PID is an infection in the upper genital tract and includes endometritis, salpingitis, tubo-ovarian abscesses and pelvic abscesses. Sexually transmitted organisms, such as N. gonorrhoeae or C.trachomatis, are responsible for many cases, but almost half of all PID cases follow procedures such as D&Cs, vaginal delivery and pelvic surgeries. PID is diagnosed clinically. The diagnosis is imprecise; there is no single sign, symptom or laboratory finding that is able to accurately make the diagnosis. Early diagnosis and treatment are critical to reduce the risk of serious infections and long term complications, such as infertility, ectopic pregnancy and chronic pelvic pain. Routine screening of women at risk for STIs has been shown to risk the incidence of PID.
Must include: Lower abdominal or pelvic pain. NOTE: Many women with PID have subtle or mild symptoms.
May include: 1. Fever and/or chills. 2. Vaginal discharge. 3. Nausea, vomiting. 4. Malaise. 5. Dyspareunia. 6. Abnormal bleeding. 7. Risk factors, such as new sex partner or partner with multiple sex partners.
Must exclude: Signs consistent with appendicitis, ectopic pregnancy, torsion (Refer to ER) Must include at least one of the following: 1. Cervical motion tenderness (CMT). 2. Uterine and/or adnexal tenderness. May include any of the following signs to increase the likelihood that the diagnosis of PID is accurate: 1. Temperature >101° F or 38.3° C. 2. Abnormal cervical discharge. 3. Cervical friability.
LABORATORY Must exclude findings suggesting surgical emergency:
1. Ultrasound evidence of adnexal torsion. 2. CT or ultrasound evidence of appendicitis. 3. Ultrasound suggesting ectopic pregnancy if positive pregnancy test. May include: 1. Microscopy (vaginal specimen) revealing leukocytosis with trichomoniasis or clue cells. 2. Elevated erythrocyte sedimentation rate. 3. Elevated C-reactive protein. 4. Laboratory documentation of infection with N. gonorrhoeae or C.trachomatis.
1. Test for all STIs if not already done (trichomoniasis, GC, chlamydia, syphilis, HIV).
a. Surgical emergency (e.g. appendicitis or ovarian torsion) cannot be excluded.
c. Woman has severe illness, nausea and vomiting or high fever.
e. Woman is unable to follow or tolerate an outpatient oral antibiotic regimen.
f. Woman does not respond clinically to oral antimicrobial therapy within 48-72 hours.
3. If patient is able to tolerate oral medications, may attempt outpatient therapy with one of the
a. Ceftriaxone 250 mg IM once (consider administrating with lidocaine)
Doxycycline** 100 mg orally twice a day for 14 days.
WITH OR WITHOUT
Metronidazole* 500 mg orally twice a day for 14 days.
b. Cefoxitin 2 g IM in a single dose AND Probenecid, 1 g orally once
Doxycycline** 100 mg orally twice a day for 14 days.
Metronidazole* 500 mg orally twice a day for 14 days (if BV on wet mount or no wet mount
c. Other parenteral third generation cephalosporins (e.g. ceftizoxime or cefotaxime)
Doxycycline** 100 mg orally twice a day for 14 days.
WITH OR WITHOUT
Metronidazole* 500 mg orally twice a day for 14 days.
d. Ceftriaxone 250 mg 1 IM once (consider administering with lidocaine).
Azithromycin 1 g orally once a week for 2 weeks.
Metronidazole* 500 mg orally twice a day x 14 days (if BV on wet mount or no wet mount
* Oral metronidazole should not be taken by patients:
• Who are breastfeeding unless women are willing to discard breast milk throughout treatment and for 24 hours after last dose of metronidazole.
• Who have hepatic dysfunction (as indicated by symptoms, elevated liver function tests or hepatitis in last 6-12 months) or bleeding disorders.
• Who are using alcohol during treatment (they will experience Antabuse reaction).
• Who have used Antabuse in the last 2 weeks.
• Metronidazole may not be preferred in patients using Coumadin. ** Doxycycline is contraindicated for pregnant and lactating women.
4. If patient is not a candidate for any of above listed therapies, may use fluoroquinolones if
community prevalence of gonorrhea is low. Must test for GC to insure that fluoroquinolone use is
a. Levofloxacin*** 500 mg orally, once daily for 14 days
Ofloxacin*** 400 mg orally twice a day for 14 days.
Metronidazole* 500 mg orally twice a day for 14 days (if BV possible).
* Oral metronidazole should not be taken by patients:
• Who are breastfeeding unless women are willing to discard breast milk throughout treatment and for 24 hours after last dose of metronidazole. Who have hepatic dysfunction (as indicated by symptoms, elevated liver function tests or hepatitis in last 6-12 months) or bleeding disorders. Who are using alcohol during treatment (will experience Antabuse reaction).
• Who have used Antabuse in the last 2 weeks.
• Metronidazole may not be preferred in patients using Coumadin *** Fluoroquinolones are contraindicated in pregnant and breastfeeding women. They can be considered for PID if the risk of GC is low, a NAAT test for GC is performed and a follow-up of the patient can be assured. If GC is documented, the patient should be re-treated with the recommended ceftriaxone and doxycycline regimen. If cephalosporin therapy is not an option, the addition of azithromycin 2 g orally as a single dose to a quinolone-based PID regimen is recommended.
5. Instruct patient to return for re-evaluation within 72 hours. At that time, confirm she has taken
antibiotics. If patient’s symptoms have not decreased and/or she has not improved on clinical exam (decreased abdominal tenderness, reduced uterine, adnexal and cervical motion tenderness), refer to ER for further evaluation and hospitalization for parenteral therapies.
a. Encourage the patient to have all partner(s) in the last 60 days tested for all STIs. If no partner
in last 60 days, then last partner should be tested.
b. In California and in many other states, patient provided partner therapy for laboratory-proven
gonorrhea or chlamydia is legal. See protocols Uncomplicated Gonococcal Infection of Cervix, Urethra, Rectum, Pharynx and Chlamydia Cervicitis/Urethritis and Non-Gonococcal Urethritis.
7. Report case to according to local procedures for case contact tracing and treatment. 8. Schedule patient to return for repeat CT and GC testing in 3 months to identify any reinfection if
patient has laboratory-proven infection.
9. If patient with uncomplicated PID has an IUD, there is no need to remove the IUD, unless the
patient does not respond to outpatient treatment within 72 hours.
1. Advise pelvic rest for one week beyond therapy. No intercourse until 7 days after each partner has
2. Stress importance of completion of course of therapy and reporting/referral of partner.
3. Discuss the implications of PID on future risk of recurrence of PID, ectopic pregnancy, infertility
4. Advise and encourage safer sex practices.
5. Advise patient of pertinent information regarding oral metronidazole use if prescribed:
a. To avoid alcohol while taking these medications and for 24 hours after taking metronidazole
and for 72 hours after taking tinidazole, because drug might cause severe nausea and vomiting (Antabuse reaction).
b. Treatment may cause metallic taste in mouth. c. Treatment may cause seizures or peripheral neuropathy (numbness and tingling on hands and
feet). Metronidazole/tinidazole can also cause liver damage. Patient should discontinue medication and seek emergency medical care if any of these symptoms develop.
d. Medications should be taken with food.
6. Remind patient of need to have testing repeated in 3 months if laboratory-proven GC or CT.
2. Women in whom surgical emergency cannot be excluded. 3. Women with questionable diagnosis. 4. Women who have severe illness, nausea and vomiting, high fever, or adnexal mass(es) (possible
5. Women with inability to tolerate oral medications. 6. Women who do not respond to outpatient therapy.
REFERENCES 1. Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines,
2. California STD/HIV Treatment Guidelines for Adults and Adolescents, 2010:
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