Infectious Disease Compendium

Pelvic Inflammatory Disease

Diagnosis

1) uterine or adnexal tenderness or
2) cervical motion tenderness and a PID diagnosis is considered for women with any pelvic tenderness and any signs of lower genital tract inflammation.

Additional diagnostic criteria to enhance the specificity include oral temperature greater than 101°F (38.3°C); abnormal cervical or vaginal mucopurulent discharge; white blood cells on saline microscopy of vaginal secretions; elevated erythrocyte sedimentation rate; elevated C-reactive protein; and laboratory documentation of cervical infection with N. gonorrhea or C. trachomatis.

Epidemiologic Risks

Sexually transmitted disease.

If with an IUD, remove if less than three weeks after placement.

Microbiology

N. gonorrhoeae, C. trachomatis, anaerobes, Gram-negative bacteria (E. coli), and streptococci.

Mycoplasma genitalium can cause a milder form of PID with less elevation in inflammatory markers like ESR (PubMed).

Empiric Therapy

from the CDC Guidelines/NEJM 2015 review:

Outpatient regimen for mild-to-moderate pelvic inflammatory disease

Doxycycline 100 mg po bid x 14d with or without metronidazole 500 mg bid x 1 d, PLUS one of the following:

Ceftriaxone 250 mg im single dose.

Cefoxitin 2 g im with probenicid 1 g po.

Other iv third-generation cephalosporin: cefotaxime or ceftizoxime.

Inpatient regimen for moderate-to-severe pelvic inflammatory disease with or without tubo-ovarian abscess

One of the following:

Cefotetan 2 g iv q 12 hr plus doxycycline 100 mg po or iv q 12 hr.

Cefoxitin 2 g iv q 6 hr plus doxycycline 100 mg po or iv q 12 hr.

Clindamycin 900 mg iv q 8 hr plus gentamicin 3 to 5 mg/kg iv qd.

Pearls

Don't be creative. Follow the CDC guidelines. But. See below.

Patients who get treated for C. trachomatis up front do better than those who do not get treatment(Pubmed).

Rants

I would suggest that given 2019 susceptibilities and toxicities, clindamycin/gentamicin is so last century. Sure, it is state of the art. In 1992 (PubMed). As best I can tell, there are no studies of PID that use optimal, modern antibiotics and look at the most important long term outcome: fertility (PubMed).

Last Update: 07/20/19.