Early treatment is imperative to prevent the long-term sequelae of PID (Pelvic Inflammatory Disease). Most patients can be treated on an outpatient basis, and only 10% to 25% of patients with PID are now hospitalized for treatment.
Factors that might warrant hospitalization include the following:
- Severe illness with vomiting or high fever
- Tubo-ovarian abscess
- Intolerance to oral antibiotic regimen
- Poor response to oral antibiotics
- Surgical abdomen not excluded
Empiric treatment needs to cover a wide range of bacteria, including N. gonorrhoeae, C. trachomatis, anaerobes, gram-negative facultative bacteria, and streptococci. There are no efficacy data that compare parenteral and oral regimens, but the efficacy of each has been demonstrated in many clinical trials. If treatment is initiated with parenteral drugs, the transition to oral medications can be made within 24 hours of clinical improvement. The total duration of antibiotic treatment should be 14 days.
The decision to use parenteral therapy can be guided by the criteria for hospitalization. The CDC recommends two parenteral regimens: doxycycline plus cefotetan (Cefotan) or cefoxitan (Mefoxin); and clindamycin (Cleocin) plus gentamicin. If possible, doxycycline should be administered orally because of the pain associated with intravenous infusion.
Once a clinical improvement occurs, patients can be switched to an oral regimen of doxycycline (100 mg every 12 hours) or clindamycin (450 mg every 6 hours) for a total of 14 days of therapy. Clindamycin for anaerobic coverage may be more appropriate if a tubo-ovarian abscess is present.
There are limited data to support the use of other parenteral regimens, but the three alternative regimens listed by the CDC are (1) ofloxacin (Floxin) with or without metronidazole (Flagyl); (2) levofloxacin (Levaquin) with or without metronidazole; and (3) ampicillin/sulbactam (Unasyn) plus doxycycline. Although some clinicians treat PID with fluoroquinolones alone, the addition of metronidazole offers better coverage of anaerobes.
Two CDC-recommended oral regimens for PID are ofloxacin with or without metronidazole and levofloxacin with or without metronidazole. Each regimen is administered for 14 days. As with parenteral regimens, the addition of metronidazole offers better coverage of anaerobes.
Combined Oral and Parenteral Regimens
Another set of CDC-recommended regimens combine single-dose intramuscular medications with oral medications.
Patients receiving outpatient therapy should be seen within 3 days for re-evaluation. If there has been no substantial improvement, hospitalization for intravenous antibiotics and further evaluation is warranted. If N. gonorrhoeae or C. trachomatis is detected, many clinicians recommend testing for cure 4 to 6 weeks after therapy is completed. Recent (60 days) sexual partners should also be evaluated. During follow-up evaluations, consideration should be given to testing for other sexually transmitted infections such as human immunodeficiency virus, human papillomavirus, syphilis, and hepatitis В virus.