Pelvic inflammatory disease: Treatment
- Harold C Wiesenfeld, MD, CM
Harold C Wiesenfeld, MD, CM
- Associate Professor, Department of Obstetrics, Gynecology and Reproductive Sciences
- University of Pittsburgh School of Medicine
Pelvic inflammatory disease (PID) refers to acute infection of the upper genital tract structures in women, involving any or all of the uterus, fallopian tubes, and ovaries and may involve the neighboring pelvic organs. Early diagnosis and treatment are believed to be key elements in the prevention of long-term sequelae, such as infertility and ectopic pregnancy. (See "Pelvic inflammatory disease: Clinical manifestations and diagnosis".)
The treatment of PID will be reviewed here. The pathogenesis of, risk factors for, and sequelae following PID are discussed separately. The management of tubo-ovarian abscess is discussed separately. (See "Pelvic inflammatory disease: Pathogenesis, microbiology, and risk factors" and "Long-term complications of pelvic inflammatory disease" and "Management and complications of tubo-ovarian abscess".)
INDICATIONS FOR TREATMENT
Clinicians should maintain a low threshold of suspicion for the diagnosis of PID. The presumptive clinical diagnosis of PID is made in sexually active young women or women at risk for sexually transmitted infections (STIs) who present with pelvic or lower abdominal pain and have evidence of cervical motion, uterine, or adnexal tenderness on exam . Occasionally, acute PID may be encountered in women without recent sexual activity. Treatment is indicated for patients with this presumptive clinical diagnosis of PID, even if findings are subtle or minimal, since long-term complications are more common if treatment is withheld or delayed [1,2]. Information regarding the diagnostic criteria for PID is found elsewhere. (See "Pelvic inflammatory disease: Clinical manifestations and diagnosis".)
PATHOGENS OF CONCERN
PID is primarily a disease of sexually active women. The two most important sexually transmitted organisms associated with acute PID, Chlamydia trachomatis and Neisseria gonorrhoeae, should be targeted for treatment; however, negative endocervical screening for either of these pathogens does not rule out upper tract infection . (See "Pelvic inflammatory disease: Pathogenesis, microbiology, and risk factors", section on 'Microbiology'.)
PID is a polymicrobial infection, which generally requires broad coverage, particularly among those with severe disease requiring hospitalization. Acute PID is an ascending infection caused by cervical microorganisms (including C. trachomatis and N. gonorrhoeae), as well as the vaginal microflora, including anaerobic organisms, enteric gram-negative rods, streptococci, genital mycoplasmas, and Gardnerella vaginalis, which is associated bacterial vaginosis . Bacterial vaginosis results in complex alterations of the normal vaginal flora, which may alter host defense mechanisms in the cervicovaginal environment [2-5]. Mycoplasma genitalium is recognized as a cause of urethritis in men, but its role in pelvic inflammatory disease is less well-defined. (See "Mycoplasma genitalium infection in men and women", section on 'Pelvic inflammatory disease'.)
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- INDICATIONS FOR TREATMENT
- PATHOGENS OF CONCERN
- AVAILABLE ANTIMICROBIAL AGENTS
- CLINICAL TRIAL DATA
- Defining treatment response
- Limitations of current data sets
- - Clinical efficacy
- - Microbiologic efficacy
- Efficacy of inpatient versus outpatient therapy
- INDICATIONS FOR HOSPITALIZATION
- RECOMMENDED REGIMENS
- General approach
- - Gonococcal drug resistance
- - Role for anaerobic coverage
- - Role for M. genitalium coverage
- Inpatient therapy
- - First-line therapies
- - Alternative regimens
- Outpatient therapy
- - First-line regimens
- - Alternative agents
- TREATMENT OF THE PENICILLIN-ALLERGIC PATIENT
- Patients at risk for gonorrhea
- - History of mild allergy
- - History of severe allergy
- Patients at low risk of gonorrhea
- HIV-INFECTED PATIENTS
- PREGNANT PATIENTS
- DURATION OF THERAPY
- PATIENT RELATED ISSUES
- Patient monitoring
- Medication adherence
- Counseling and screening
- Sex partners
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS