You will no doubt see pelvic inflammatory disease in the Emergency Department. PID is polymicrobial infection of the upper genital tract in females. The most common organisms include C. trachomatis and N. gonorrhoeae, but vaginal flora (gram negatives/anaerobes – Escherichia coli, Klebsiella spp, and Proteus spp) are implicated as well. Recall that the diagnosis is made in sexually active young women with pelvic or lower abdominal pain and cervical motion, uterine, or adnexal tenderness on exam.
In general you should have a very low threshold to treat given the significant complications of longterm untreated PID
Many patients are appropriate candidates for outpatient treatment. Those that should be admitted include:
- Pregnant patients (always get a pregnancy test in the Pediatric Emergency Department)
- Nonresponders or intolerance (vomiting) to oral meds – can’t swallow the pills shouldn’t could BTW
- Severe clinical illness (high fever, vomiting, dehydration, severe abdominal pain)
- Complicated PID with tuboovarian abscess
- Possible need for surgery because of competing diagnosis (is it an appy?)
What is the best antibiotic regimen?
First of all, you should not be using fluorquinolones. Based on emerging N. gonorrhoeae resistance patterns the CDC stopped recommending their use in 2007. There is no consensus on what exactly is the best regimen. Individual patient factors and local resistance patterns play a role. That being said, here are some recommended treatment plans divided by outpatient and inpatient.
Ceftriaxone 250 mg IM once plus doxycycline 100mg PO bid x14 days
Cefoxitin 2g IM + Probenecid 1g once plus doxycycline 100mg PO bid x14 days
You could potentially substitute azithromycin for doxycycline. Note that azithromycin has a much longer half life and you can do once a week dosing for two weeks. A randomized controlled trial from Savaris et al noted that in 120 women with mild PID that clinical cure rates for 100 mg bid doxycycline for 2 weeks or azithromycin 1g one per week for two weeks were equivalent. All patients got IM ceftriaxone first. In a modified intention to treat analysis (14 of their patients had intolerance to oral antibiotics), clinical cure rate was 90.3% (56 of 62; 95% CI, 0.80-0.96) with azithromycin, and 72.4% (42 of 58; 95% CI, 0.58-0.82) with doxycycline (P=.01). This netted a relative risk of 0.35, and a number needed to treat of 6 for benefit with azithromycin. The microbiology data was limited and the sample size was relatively small though.
Metronidazole can cause significant GI upset that may negatively impact compliance with oral meds. So unless their has been recent gynecological instrumentation (a surgery) metronidazole for presumed anaerobic coverage probably isn’t necessary. If you do think you need it though, prescribe 500mg PO bid x14days.
In the penicillin allergic patient – the kind of allergy that has been life threatening, not the might’ve had a rash kind – or cephalosporin allergic patient
Cefoxitin 2g IV q6h or cefotetan 2g IV q6h plus doxycycline 100mg PO q12h
Clindamycin 900mg (or 10/mg/kg) IV q8h plus gentamicin 1.5mg/kg q8h
The first regimen is more tolerable by most patients, and as soon as 24 hours in you can transition to oral therapy. The overall length of the course should equal 14 days. If you have discovered a pelvic abscess then clindamycin or metronidazole should be added.
There are also a couple of alternative regimens that the CDC notes:
- Ampicillin-sulbactam IV q6h plus doxycycline 100mg bid
- Azithromycin 500mg IV qday for 1-2 days followed by 250mg orally day to complete 7 days plus metronidazole x12 days
Savaris RF, Teixeira LM, Torres TG, Edelweiss MI, Moncada J, Schachter J. Comparing ceftriaxone plus azithromycin or doxycycline for pelvic inflammatory disease: a randomized controlled trial. Obstet Gynecol. 2007 Jul;110(1):53-60.