Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

suspected or confirmed mild-to-moderate PID at initial presentation

1st line – parenteral cephalosporin plus oral doxycycline plus oral metronidazole

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ACUTE
|
suspected or confirmed mild-to-moderate PID at initial presentation
1st line – 

parenteral cephalosporin plus oral doxycycline plus oral metronidazole

Consideration for treatment regimen selection includes cost, availability, patient acceptance, local antimicrobial sensitivity patterns, local epidemiology of specific infections, and severity of disease.[22]

Patients with mild-to-moderate disease who can tolerate oral fluids, do not have a tubo-ovarian abscess, and lack other factors for hospitalisation (e.g., surgical emergencies cannot be excluded; patient is pregnant; severe illness precludes outpatient management; patient is unable to follow or tolerate an outpatient oral regimen; patient has not responded to outpatient therapy) should be treated with a combination of an intramuscular cephalosporin (e.g., ceftriaxone, cefoxitin) plus oral doxycycline plus metronidazole. Probenecid should be used with cefoxitin. Metronidazole should be used in combination with doxycycline to provide extended coverage against anaerobic bacteria. Metronidazole will also effectively treat bacterial vaginosis, a common co-infection in women with PID. Other parenteral third-generation cephalosporins may also be used.[1]

Clinical and microbiological cure rates of 88% to 100% have been reported with oral antibiotics.[9] However, if the patient does not respond to outpatient antibiotic therapy within 72 hours, hospitalisation and intravenous antibiotics are indicated.[1]

Pregnant women with PID are at high risk for maternal morbidity and preterm delivery, and should be hospitalised and treated with intravenous antibiotics in consultation with an infectious disease specialist.[1]

There are currently no data to suggest that women with HIV infection and PID co-infection require more aggressive clinical management (e.g., hospitalisation or intravenous antibiotic regimens).[1]

Primary options

ceftriaxone: body weight <150 kg: 500 mg intramuscularly as a single dose; body weight ≥150 kg: 1000 mg intramuscularly as a single dose

and

doxycycline: 100 mg orally twice daily for 14 days

and

metronidazole: 500 mg orally twice daily for 14 days

OR

cefoxitin: 2 g intramuscularly as a single dose

and

probenecid: 1 g orally as a single dose

and

doxycycline: 100 mg orally twice daily for 14 days

and

metronidazole: 500 mg orally twice daily for 14 days

Plus – treatment of sexual contact(s)

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ACUTE
|
suspected or confirmed mild-to-moderate PID at initial presentation
Plus – 

treatment of sexual contact(s)

Treatment recommended for ALL patients in selected patient group

Men who have had sexual contact with a woman diagnosed with PID during the 60 days prior to the onset of symptoms should be evaluated and treated with regimens that are effective against chlamydia and gonorrhoea. If a patient's last sexual intercourse was >60 days before onset of symptoms or diagnosis, the patient's most recent sexual partner should be treated. [ Cochrane Clinical Answers logo ] Women should be advised to avoid sexual intercourse until they and their partners have completed the treatment course. If adequate screening for gonorrhoea and chlamydia in the sexual partner(s) is not possible, empirical therapy for gonorrhoea and chlamydia should be prescribed.[1]

Consider – consider removal of IUD

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ACUTE
|
suspected or confirmed mild-to-moderate PID at initial presentation
Consider – 

consider removal of IUD

Additional treatment recommended for SOME patients in selected patient group

Evidence is insufficient to recommend the removal of IUDs in women diagnosed with acute PID. However, caution should be exercised if the IUD remains in place; close clinical follow-up is mandatory, and consideration should be given to removal if symptoms have not resolved within 48 to 72 hours.[1][30][43]

2nd line – fluoroquinolone or azithromycin with or without metronidazole

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ACUTE
|
suspected or confirmed mild-to-moderate PID at initial presentation
2nd line – 

fluoroquinolone or azithromycin with or without metronidazole

Because of increasing and widespread resistance, the Centers for Disease Control and Prevention (CDC) no longer routinely recommends using fluoroquinolone antibiotics for the treatment of PID. However, if allergy precludes the use of cephalosporins, if the community prevalence and individual risk for gonorrhoea are low, and follow-up is likely, use of a fluoroquinolone or azithromycin with or without metronidazole can be considered.[1] Metronidazole provides extended coverage against anaerobic bacteria and will effectively treat bacterial vaginosis, a common co-infection in women with PID.[1]

In the UK, fluoroquinolones should be avoided as first-line empirical treatment for PID in patients who are at high risk of gonococcal PID (e.g., clinically severe disease, partner has gonorrhoea, history of sexual contact abroad).[30][41] However, as Neisseria gonorrhoeae is an uncommon cause of PID in the UK, they can be used as second-line empirical treatment among those not at high risk of gonorrhoea.[22] 

Treatment should be adjusted after testing for gonorrhoea and based on antimicrobial sensitivity.[1][22]

If Mycoplasma genitalium testing is available and M genitalium is detected, guidelines recommend treatment with moxifloxacin.[1][22][26]

Systemic fluoroquinolone antibiotics may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to, tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycaemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behaviour.[42]​ Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics, that are commonly recommended for the infection, are inappropriate (e.g., resistance, contraindications, treatment failure, and unavailability). Consult your local guidelines and drug formulary for more information on suitability, contraindications, and precautions.​

Primary options

levofloxacin: 500 mg orally once daily for 14 days

and

metronidazole: 500 mg orally twice daily for 14 days

OR

moxifloxacin: 400 mg orally once daily for 14 days

OR

azithromycin: 500 mg intravenously once daily for 1-2 days, followed by 250 mg orally once daily for 7 days

OR

azithromycin: 500 mg intravenously once daily for 1-2 days, followed by 250 mg orally once daily for 12-14 days

and

metronidazole: 500 mg orally three times daily for 12-14 days

Plus – treatment of sexual contact(s)

Back
ACUTE
|
suspected or confirmed mild-to-moderate PID at initial presentation
Plus – 

treatment of sexual contact(s)

Treatment recommended for ALL patients in selected patient group

Men who have had sexual contact with a woman diagnosed with PID during the 60 days prior to the onset of symptoms should be evaluated and treated with regimens that are effective against chlamydia and gonorrhoea. If a patient's last sexual intercourse was >60 days before onset of symptoms or diagnosis, the patient's most recent sexual partner should be treated. [ Cochrane Clinical Answers logo ] Women should be advised to avoid sexual intercourse until they and their partners have completed the treatment course. If adequate screening for gonorrhoea and chlamydia in the sexual partner(s) is not possible, empirical therapy for gonorrhoea and chlamydia should be prescribed.[1]

Consider – consider removal of IUD

Back
ACUTE
|
suspected or confirmed mild-to-moderate PID at initial presentation
Consider – 

consider removal of IUD

Additional treatment recommended for SOME patients in selected patient group

Evidence is insufficient to recommend the removal of IUDs in women diagnosed with acute PID. However, caution should be exercised if the IUD remains in place; close clinical follow-up is mandatory, and consideration should be given to removal if symptoms have not resolved within 48 to 72 hours.[1][30][43]

severe PID, complications, or no response to intramuscular/oral therapy

1st line – hospitalisation plus intravenous antibiotic therapy

Back
ACUTE
|
severe PID, complications, or no response to intramuscular/oral therapy
1st line – 

hospitalisation plus intravenous antibiotic therapy

Consideration for treatment regimen selection includes cost, availability, patient acceptance, local antimicrobial sensitivity patterns, local epidemiology of specific infections, and severity of disease.[22]

Patients with severe PID include those with tubo-ovarian abscess, those who cannot tolerate fluids orally, and those with any other factor for hospitalisation (e.g., surgical emergencies cannot be excluded; patient is pregnant; severe illness precludes outpatient management; patient is unable to follow or tolerate an outpatient oral regimen; patient has not responded to outpatient therapy).[1]

In the US, the Centers for Disease Control and Prevention (CDC) recommends parenteral antibiotic therapy with a cephalosporin (ceftriaxone, cefotetan, or cefoxitin) plus doxycycline for patients with severe PID.[1] Metronidazole should be used with ceftriaxone as ceftriaxone is less active against anaerobic bacteria than cefotetan or cefoxitin.[1] Alternative parenteral regimens include ampicillin/sulbactam plus doxycycline, or clindamycin plus gentamicin. Women receiving a parenteral regimen of clindamycin plus gentamicin who show clinical improvement within 24-48 hours can be switched to an appropriate oral regimen or oral doxycycline to complete the 14 days of therapy.[1] There are limited data to support the use of other parenteral second- or third-generation cephalosporins.[1]

Because of the pain associated with intravenous infusion, doxycycline should be administered orally if possible. Oral and intravenous administration of doxycycline and metronidazole provide similar bioavailability. Oral metronidazole is well absorbed and should be considered instead of intravenous infusion in the absence of severe illness or tubo-ovarian abscess. If treatment is started with a parenteral agent, the patient can be switched to oral therapy within 24-48 hours of clinical improvement.[1]

Primary options

ceftriaxone: 1 g intravenously every 24 hours

and

doxycycline: 100 mg orally/intravenously every 12 hours

and

metronidazole: 500 mg orally/intravenously every 12 hours

OR

cefotetan: 2 g intravenously every 12 hours

and

doxycycline: 100 mg orally/intravenously every 12 hours

OR

cefoxitin: 2 g intravenously every 6 hours

and

doxycycline: 100 mg orally/intravenously every 12 hours

Secondary options

ampicillin/sulbactam: 3 g intravenously every 6 hours

More

and

doxycycline: 100 mg orally/intravenously every 12 hours

OR

clindamycin: 900 mg intravenously every 8 hours

and

gentamicin: 2 mg/kg intravenously/intramuscularly as a loading dose, followed by 1.5 mg/kg every 8 hours; or 3-5 mg/kg intravenously/intramuscularly once daily

More

Plus – switch to oral antibiotic therapy following clinical improvement

Back
ACUTE
|
severe PID, complications, or no response to intramuscular/oral therapy
Plus – 

switch to oral antibiotic therapy following clinical improvement

Treatment recommended for ALL patients in selected patient group

Patients should be reassessed 24 to 48 hours after treatment has begun and the decision about changing from parenteral to oral therapy, if appropriate, can be based on clinical improvement.[1]

Parenteral therapy can be discontinued 24-48 hours after clinical improvement; ongoing oral therapy after the parenteral cephalosporin regimen should consist of doxycycline plus metronidazole to complete a total of 14 days of therapy.

Oral clindamycin or oral doxycycline can be used after the alternative parenteral clindamycin/gentamicin regimen.[1] If tubo-ovarian abscess is present, oral clindamycin or oral metronidazole should be used with doxycycline, as this provides better anaerobic coverage.[1]

Primary options

After parenteral cephalosporin regimen

doxycycline: 100 mg orally twice daily to complete 14-day course

and

metronidazole: 500 mg orally twice daily to complete 14-day course

OR

After parenteral clindamycin/gentamicin regimen

clindamycin: 450 mg orally four times daily to complete 14-day course

OR

After parenteral clindamycin/gentamicin regimen

doxycycline: 100 mg orally twice daily to complete 14-day course

OR

After parenteral clindamycin/gentamicin regimen with tubo-ovarian abscess

clindamycin: 450 mg orally four times daily to complete 14-day course

or

metronidazole: 500 mg orally twice daily to complete 14-day course

-- AND --

doxycycline: 100 mg orally twice daily to complete 14-day course

Plus – treatment of sexual contact(s)

Back
ACUTE
|
severe PID, complications, or no response to intramuscular/oral therapy
Plus – 

treatment of sexual contact(s)

Treatment recommended for ALL patients in selected patient group

Men who have had sexual contact with a woman diagnosed with PID during the 60 days prior to the onset of symptoms should be evaluated and treated with regimens that are effective against chlamydia and gonorrhoea. If a patient's last sexual intercourse was >60 days before onset of symptoms or diagnosis, the patient's most recent sexual partner should be treated. [ Cochrane Clinical Answers logo ] Women should be advised to avoid sexual intercourse until they and their partners have completed the treatment course. If adequate screening for gonorrhoea and chlamydia in the sexual partner(s) is not possible, empirical therapy for gonorrhoea and chlamydia should be prescribed.[1]

Consider – consider removal of IUD

Back
ACUTE
|
severe PID, complications, or no response to intramuscular/oral therapy
Consider – 

consider removal of IUD

Additional treatment recommended for SOME patients in selected patient group

Evidence is insufficient to recommend the removal of IUDs in women diagnosed with acute PID. However, caution should be exercised if the IUD remains in place; close clinical follow-up is mandatory, and consideration should be given to removal if symptoms have not resolved within 48 to 72 hours.[1][30][43]

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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