 | Pelvic Inflammatory DiseaseJuly 2006; updated July 2007 | Background | | Pelvic inflammatory disease (PID) is the syndrome resulting from the ascent of microorganisms from the vagina and cervix to the uterine endometrium, fallopian tubes, ovaries, or contiguous abdominal structures. Many episodes of PID go unrecognized, because of lack of symptoms or mild, nonspecific symptoms (eg, dyspareunia, abnormal bleeding, and vaginal discharge). Infecting organisms may include Neisseria gonorrhoeae and Chlamydia trachomatis, which are sexually transmitted, and anaerobic bacteria (Gardnerella vaginalis or Haemophilus influenzae), gram-negative rods (Escherichia coli), Streptococcus agalactiae, gastrointestinal flora, and mycoplasmas (Mycoplasma hominis), which may not be sexually transmitted. PID is coepidemic with HIV among some urban populations of reproductive age. Data on PID outcomes in HIV-infected women are limited. Many studies have documented no difference in length or severity of lower
abdominal pain, vaginal discharge, fever, abnormal vaginal bleeding, or low back pain between HIV-positive and HIV-negative women with PID. However, there is a higher rate of tubo-ovarian abscesses and severe salpingitis and pyosalpinx in HIV-positive women. Clinical presentation may include salpingitis, endometritis, tubal and/or ovarian abscess, and pelvic peritonitis, although PID may present with subtle or mild symptoms even in HIV-infected women. Long-term complications of PID may include infertility, ectopic pregnancy, pelvic adhesions, and chronic pain. | |
| SOAP (Subjective, Objective, Assessment, Plan) | | | Plan | | | Diagnostic Evaluation | |  | Gram stain of endocervical discharge | | | Microscopic examination of saline preparation of vaginal secretions | | | Endocervical and rectal cultures, urine for N gonorrhoeae | | | Endocervical and rectal culture, or nucleic acid amplification test, for endocervical swab or first void urine | | | Pregnancy test (if menses is late or pregnancy is possible) | |
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| Pregnancy | | If the patient is pregnant, aggressive treatment is essential to prevent preterm delivery, fetal loss, and maternal morbidity. Certain medications should be avoided to reduce the risk of fetal toxicity; these include doxycycline, fluoroquinolones, and gentamicin. Hospitalization for parenteral antibiotic therapy is recommended. Table 1. Treatment Regimens for Pelvic Inflammatory Disease| Antibiotic Regimens |
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| * Fluoroquinolones should not be used to treat PID infections acquired outside the United States, or in California, Hawaii, or other areas with high rates of fluoroquinolone-resistant gonorrhea. | | Oral / Outpatient Treatment (see CDC STD Treatment Guidelines, referenced below) | | Regimen 1 | | Ofloxacin* 400 mg orally twice daily for 14 days
or | | | Levofloxacin* 500 mg orally once daily for 14 days
with or without | | | Metronidazole 500 mg orally twice daily for 14 days (provides activity against anaerobes) | |
| | Regimen 2 | | Ceftriaxone 250 mg intramuscular (IM) injection in a single dose
or | | | Cefoxitin 2 g IM injection in a single dose, administered concurrently with probenecid 1 g orally in a single dose
or | | | Other parenteral third generation cephalosporin (eg, ceftizoxime or cefotaxime)
plus | | | Doxycycline 100 mg orally twice daily for 14 days
with or without | | | Metronidazole 500 mg orally twice daily for 14 days | |
| | Parenteral / Inpatient Treatment | | Regimen 1 | | Cefotetan 2 g intravenously (IV) every 12 hours
or | | | Cefoxitin 2 g IV every 6 hours
plus | | | Doxycycline 100 mg orally or IV every 12 hours (oral form is preferable because of the irritant qualities of the IV solution) | |
| | Regimen 2 | | Clindamycin 900 mg IV every 8 hours
plus | | | Gentamicin loading dose IV or IM injection (2 mg/kg of body weight) followed by maintenance dose (1.5 mg/kg) IV every 8 hours or 5-7 mg/kg IV daily | |
| | Alternative Parenteral Regimens | | Regimen 1 | | Ofloxacin* 400 mg IV every 12 hours
or | | | Levofloxacin* 500 mg IV daily
with or without | | | Metronidazole 500 mg IV every 8 hours | |
| | Regimen 2 | | Ampicillin/Sulbactam 3 g IV every 6 hours
plus | | | Doxycycline 100 mg orally or IV every 12 hours (oral form is preferable due to the irritant qualities of IV solution) | |
| | Follow-Up | | | Patients should show significant clinical improvement within 3 days of initiation of therapy (eg, improvement in fever, abdominal tenderness, and uterine, adnexal, and cervical motion tenderness). If the patient has not improved, consider hospitalization, additional diagnostic testing, or surgical intervention. Patients who are initially hospitalized for treatment may be switched to an oral regimen and discharged on oral therapy after they have improved clinically. | | | Evaluate sexual partners and offer them treatment if they had sexual contact with the patient during the 60 days preceding the patient's onset of symptoms. Treat empirically for both chlamydia and gonorrhea. | | | Some specialists recommend rescreening for C trachomatis and N gonorrhoeae after therapy is completed in women with documented infection with these pathogens. | | | Provide education about sexual risk reduction. Instruct patients to use condoms with every sexual contact to prevent becoming reinfected with chlamydia or gonorrhea, to prevent other sexually transmitted infections, and to prevent passing HIV to sexual partners. | |
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| Patient Education | | | Instruct patients to take all of their medications. Advise patients to take medications with food if they are nauseated, and to call or return to clinic right away if they have vomiting or are unable to take their medications. | | | Sexual partners from the previous 60 days need to be tested for sexually transmitted pathogens, and treated as soon as possible with a regimen effective against gonorrhea and chlamydia, even if they have no symptoms. Advise patients to inform their partner(s) that they need to be tested and treated. Otherwise, they may be reinfected. | | | Advise patients to avoid sexual contact until the infection has been cured. | | | Provide education about sexual risk reduction. Instruct patients to use condoms with every sexual contact to prevent becoming reinfected, to prevent other sexually transmitted infections, and to prevent passing HIV to sexual partners. | | | Advise patients that PID can recur, and that they should call or return to the clinic if symptoms such as pain or fever develop. | | | Patients must not drink beer, wine, or any other alcoholic beverage during treatment while taking metronidazole, and for at least 24-48 hours after the last dose. Metronidazole may cause a disulfiram reaction, resulting in severe nausea and vomiting. Note that patients taking ritonavir may experience symptoms due to the small amount of alcohol in the capsules; advise patients to call if nausea and vomiting occur. | |
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| References | | | The appearance of external hyperlinks does not constitute endorsement by the Department of Veterans Affairs of the linked Web sites, or the information, products or services contained therein. | | |
| Abularach S, Anderson J. Gynecologic Problems. In: Anderson JR, ed. A Guide to the Clinical Management of Women with HIV. Rockville, MD: Health Resources and Services Administration, HIV/AIDS Bureau; 2005. Available online at hab.hrsa.gov/publications/womencare05/WG05chap6.htm. |  | | Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2006. MMWR 2006;55(No. RR-11):1-100. | | | Cohn SE, Clark RA. Sexually transmitted diseases, HIV, and AIDS in women. In: The Medical Clinics of North America, vol. 87; 2003:971-995. | | | Hatcher RA, Stewart FH, Trussell J, et al. Contraceptive Technology, 17th revised ed. New York: Ardent Media; 1998:204-206. | | | Minkoff HL, DeHovitz JA. Care of women infected with the human immunodeficiency virus. JAMA. 1991 Oct 23-30;266(16):2253-8. | | | Minkoff HL, DeHovitz JA. HIV infection in women. AIDS Clin Care. 1991; 3: 33-5. | | | Ross JDC. Pelvic Inflammatory Disease. Birmingham, UK: University of Birmingham; 2004. | | | Slaven EM, Lopez F, Weintraub SL, et al. The AIDS patient with abdominal pain: a new challenge for the emergency physician. Emerg Med Clin North Am. 2003 Nov;21(4):987-1015. | |
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