Broad-spectrum antimicrobial therapy is required to treat acute
bacterial PID. Early antibiotic therapy within 3 days of symptom
onset has been associated with reduced risk for sequelae and therefore
is strongly recommended. Although single-agent regimens have been
used successfully to treat PID, two- and three-drug regimens that
cover gonorrhea, chlamydia, and common aerobic and anaerobic isolates
are recommended by the CDC. Treatment should be empiric and not
based on lower genital tract cultures that are costly, may delay
onset of treatment, and often do not predict pathogens in the upper
genital tract.
A multicenter, randomized, controlled treatment trial of women
with clinical symptoms and signs of mild to moderate PID compared
inpatient intravenous cefoxitin and doxycycline treatment with outpatient
treatment consisting of a single intramuscular injection of cefoxitin
and oral doxycycline. In this trial, rates of short-term clinical
and microbiologic improvement were similar between the two groups,
and subsequent 3-year pregnancy rates were equal (42% in
both arms). Furthermore, there were no statistically significant
differences between inpatient and outpatient groups in time to subsequent
pregnancy or in the proportion of women with PID recurrence, chronic
pelvic pain, or ectopic pregnancy. Based on these findings, inpatient
treatment and hospitalization should be reserved for patients with
an unclear diagnosis (particularly if a serious surgical diagnosis
cannot be excluded), patients with abscesses, or those who have
failed oral antibiotic therapy or are unable to tolerate oral medication.
Although it is reported to be associated with more severe disease,
HIV-1 infection, unless associated with severe immunodeficiency (CD4
T-cell count <200μL), is not
an absolute indication for parenteral antibiotics. In cases requiring
hospitalization, parenteral therapy should continue until the patient
is afebrile for 48 hours or more with a significant reduction (usually
≥50%) in abdominal and pelvic tenderness, and, if present
at admission, a greater than 50% decrease in the diameter
of tubo-ovarian masses. After discontinuation of parenteral therapy,
broad-spectrum oral therapy (eg, doxycycline, 100 mg orally twice
daily for uncomplicated PID; or doxycycline, 100 mg, with metronidazole,
500 mg, twice daily orally, in cases of pyosalpinx and tubo-ovarian
abscess) is continued to complete a full 2-week antibiotic course.
The addition of metronidazole to outpatient treatment regimens
remains controversial, and owing to gastrointestinal and other side
effects may reduce overall treatment adherence. Although more data
are required, metronidazole should be used in patients with PID
and concomitant bacterial vaginosis but may be withheld in those
with clinically mild to moderate PID who do not have bacterial vaginosis.
Outpatient and inpatient PID treatment regimens recommended by
the CDC are outlined in Tables 8–3 and 8–4.