Pelvic Inflammatory Disease (PID) - STI Treatment Guidelines (2023)

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PID encompasses a spectrum of inflammatory disorders of the female upper genital tract, including all combinations of endometritis, salpingitis, tuboovar abscess, and pelvic peritonitis.1155–1157). sexually transmitted organisms, in particularN. gonorrhoeaejC. trachomatis, are often implied. Recent studies report that the proportion of PID cases is due to thisN. gonorrhoeaeÖC. trachomatisit decreases About 50% of women diagnosed with acute PID will test positive for one of these organisms (1158–1160). Microorganisms that make up the vaginal flora, such as strict and facultative anaerobes (1160) andvaginal g,H flu, enteric gram-negative bacilli andStreptococcus agalactiaehave been linked to PID (1161). Also cytomegalovirus (CMV),T. vaginalis,M for man, jU. urealyticumcould be associated with certain cases of PID (1072). The data also indicate thisM. genitaliummay play a role in the pathogenesis of PID (765,928) and could be associated with milder symptoms (919,923,928), although one study failed to show a significant increase in PID after detectingM. genitaliumin the lower genital tract (925).

Screening and treatment of chlamydia and gonorrhea in sexually active women reduces risk of PGD (1162,1163). Although BV is associated with PID, it is not clear whether the incidence of PID can be reduced by identifying and treating women with BV.1161). Whether young women are testedM. genitaliumassociated with a decrease in PID is unknown.

Diagnostic Considerations

Acute PID is difficult to diagnose because of the considerable variation in the symptoms and signs associated with this condition. Women with PID often have subtle or nonspecific symptoms, or are asymptomatic. The delay in diagnosis and treatment likely contributes to the inflammatory sequelae in the upper genital tract. Laparoscopy can be used to obtain a more accurate diagnosis of salpingitis and a more complete bacteriological diagnosis. However, this diagnostic tool is often not readily available and its use is not readily justified when symptoms are mild or vague. Also, laparoscopy does not detect endometritis and, possibly, subtle inflammation of the fallopian tubes. Consequently, a PID diagnosis is often based on inaccurate clinical findings.1164–1166).

The data show that a clinical diagnosis of symptomatic PID has a 65% to 90% positive predictive value for salpingitis compared to laparoscopy.1167–1170). The positive predictive value of a clinical diagnosis of acute PID depends on the epidemiological characteristics of the population, with higher positive predictive values ​​in sexually active young women (particularly adolescents), women attending STD clinics, and those living in communities with high rates from gonorrhea or chlamydia. Regardless of the positive predictive value, no historical, physical, or laboratory finding is sensitive and specific for the diagnosis of acute PID. Combinations of diagnostic findings that improve sensitivity (ie, recognize more women with PGD) or specificity (ie, exclude more women without PGD) only do so at the expense of the other. For example, requiring two or more reports excludes more women who do not have PGD and reduces the number of women with PGD who are identified.

PID episodes often go unnoticed. Although some cases are asymptomatic, others go undiagnosed because the patient or physician does not recognize the impact of mild or nonspecific symptoms or signs (eg, abnormal bleeding, dyspareunia, and vaginal discharge). Women with mild or asymptomatic PID may also be at risk for infertility (1157). Because of the difficulty of diagnosis and the potential harm to women's reproductive health, healthcare providers should maintain a low threshold for the clinical diagnosis of PID (1158). The PID diagnosis recommendations are intended to help healthcare providers know when to suspect PID and when to obtain additional information to increase diagnostic certainty. The diagnosis and treatment of other causes of pelvic pain (eg, ectopic pregnancy, acute appendicitis, ovarian cyst, ovarian torsion, or functional pain) are unlikely to be influenced by initiating antimicrobial therapy for PID. Suspected treatment for PGD should be initiated in sexually active young women and other women at risk for sexually transmitted diseases if they have pelvic or pelvic pain, if no cause of disease other than PGD can be identified, or if one or more of the following three are minimal are clinical criteria are present on examination of the pelvis: tenderness of cervical movement, tenderness of the uterus or tenderness of the adnexa.

More specific criteria for the diagnosis of PID include endometrial biopsy with histopathologic evidence of endometritis; transvaginal ultrasonography or magnetic resonance imaging, showing thickened and fluid-filled fallopian tubes with or without free pelvic fluid or tubo-ovarian complex, or Doppler studies suggesting pelvic infection (eg, tubal hyperemia); and laparoscopic findings compatible with PGD. In certain cases, a diagnostic investigation involving some of these more extensive procedures may be warranted. Endometrial biopsy is warranted for women undergoing laparoscopy who have no visual evidence of salpingitis because endometritis is the only sign of PID for certain women.

The requirement that all three minimum criteria be present prior to initiating empiric treatment may result in insufficient sensitivity for a PID diagnosis. After deciding whether to start empiric treatment, physicians must also consider the STI risk profile. More extensive diagnostic evaluation is often required, as incorrect diagnosis and treatment of PID can cause unnecessary morbidity. For example, the presence of signs of lower genital tract inflammation (predominance of leukocytes in vaginal secretions, cervical discharge, or cervical fragility) in addition to any of the three minimum criteria increases the specificity of the diagnosis. One or more of the following additional criteria may be used to improve the specificity of minimum clinical criteria and support a PID diagnosis:

• Oral Temperature >38.3 °C (>101 °F)
• Abnormal cervical mucopurulent discharge or cervical fragility
• Presence of copious amounts of white blood cells in saline microscopy of vaginal fluid
• Increased sedimentation rate of erythrocytes
• high C-reactive protein
• Laboratory documentation of cervical infection withN. gonorrhoeaeÖC. trachomatis

Most women with PID have a mucopurulent cervical discharge or evidence of white blood cells on microscopic examination of a saline solution of vaginal fluid (ie, wet mount). If cervical discharge appears normal and no white blood cells are seen in the wet vaginal fluid, a PID diagnosis is unlikely and alternative causes of pain should be considered. A wet amount of vaginal discharge can also detect the presence of concomitant infections (e.g., BV or trichomoniasis).

Treatment

PGD ​​treatment regimens should cover a broad empirical spectrum of potential pathogens. Several parenteral and oral antimicrobial therapies have been shown to be effective in achieving clinical and microbiological cure in randomized clinical trials with short-term follow-up.1171–1173). However, only a limited number of studies have evaluated and compared these therapies with a view to clearing endometrial and tubal infections or determining the incidence of long-term complications (eg, tubal infertility and ectopic pregnancy) after antimicrobial therapies (1159,1164,1174). The optimal treatment regimen and long-term outcome of early treatment in women with subclinical PID are unknown. All therapies used to treat PID must also be effective against itN. gonorrhoeaejC. trachomatisbecause a negative endocervical examination for these germs does not rule out an infection of the upper genital tract. Anaerobic bacteria have been isolated from the upper genital tract of women with PID, and data from in vitro studies have shown that some anaerobes (eg.Bacteroides fragilis) can lead to destruction of the fallopian tubes and epithelium. BV is commonly present in women with PID (22,1160,1161,1175). The addition of metronidazole to IM or oral PGD regimens more effectively eliminates anaerobic organisms from the upper genital tract.1160). Until it has been shown that regimens that do not target anaerobic microbes are as effective in preventing long-term sequelae (e.g., infertility and ectopic pregnancy) as regimens that are effective against these microbes, the use of regimens that target these microbes should be considered be drawn activity. Treatment should be started as soon as the suspected diagnosis has been made, as prevention of long-term sequelae depends on early administration of the recommended antimicrobial agents. In women with PID of mild or moderate clinical severity, parenteral and oral therapies appear to have similar efficacy. The decision as to whether hospitalization is necessary should be based on the assessment of the care provider and whether the woman meets any of the following criteria:

• Surgical emergencies (e.g. appendicitis) cannot be ruled out
• Tubo-ovarian abscess
• The pregnancy
• Serious illness, nausea and vomiting, or mouth temperature >38.5°C (101°F)
• Outpatient oral treatment cannot be followed or tolerated
• No clinical response to oral antimicrobial therapy

There is no available evidence that adolescents achieve better outcomes when hospitalized for PGD treatment, and clinical response to outpatient treatment is similar in younger and older women. The decision to hospitalize adolescents with acute PID should be based on the same criteria that apply to older women.

parenteral treatment

Randomized trials have shown the effectiveness of parenteral therapies (1160,1171,1172,1176). Clinical experience should guide decisions about transition to oral therapy, which can generally be started within 24 to 48 hours of clinical improvement. In women with tubo-ovarian abscesses, inpatient observation for more than 24 hours is recommended.

Because of the pain associated with intravenous infusion, doxycycline should be administered orally whenever possible. Oral and intravenous administration of doxycycline and metronidazole offer similar bioavailability. Oral metronidazole is well absorbed and may be considered instead of IV in women without severe disease or tubo-ovarian abscess when possible. After clinical improvement with parenteral therapy, transition to oral therapy with doxycycline 100 mg bid and metronidazole 500 mg bid is recommended to complete the 14-day antimicrobial therapy.

Alternative parenteral therapies

Limited data are available to support the use of other second- and third-generation parenteral cephalosporins (eg, ceftizoxime or cefotaxime). Since these cephalosporins are less potent than cefotetan or cefoxitin against anaerobic bacteria, the addition of metronidazole should be considered.

Ampicillin sulbactam plus doxycycline has been studied in at least one clinical study and has a wide range of uses (1177). Against ampicillin sulbactam plus doxycycline is effectiveC. trachomatis,N. gonorrhoeaeand anaerobes for women with tubo-ovarian abscess. Another study showed short-term clinical cure rates with azithromycin monotherapy or in combination with metronidazole (1178).

When using the alternative parenteral regimen of clindamycin and gentamicin, women with clinical improvement after 24 to 48 hours can switch to clindamycin (450 mg orally 4 times a day) or doxycycline (100 mg orally 2 times a day) to complete the 14-day regimen to complete. Therapy. However, if tuboovarian abscess is present, clindamycin (450 mg orally 4 times a day) or metronidazole (500 mg orally 2 times a day) should be used to complete a 14-day course of oral doxycycline to achieve adequate coverage

Intramuscular or oral treatment

IM or oral therapy may be considered for women with mild to moderate acute PID since clinical outcomes in women treated with these regimens are similar to those treated with IV therapy (1158). Women who do not respond to IM or oral therapy within 72 hours should be reevaluated to confirm the diagnosis and receive IV therapy.

These therapies offer protection against the common etiologic agents of PID; however, the optimal choice of a cephalosporin is unclear. Cefoxitin, a second-generation cephalosporin, has better anaerobic coverage than ceftriaxone and, when combined with probenecid and doxycycline, was effective in short-term clinical response in women with PID. Ceftriaxone has better coverage againstN. gonorrhoeae. The addition of metronidazole to these regimens provides extended coverage against anaerobic organisms and also effectively treats BV, which is commonly associated with PID.

Alternative intramuscular or oral therapies

No data have been published on the use of oral cephalosporins to treat PID. As a result of the emergence of resistance to quinolonesN. gonorrhoeae, Therapies containing a quinolone agent are not recommended for the treatment of PID. However, if the patient has cephalosporin allergy, community prevalence and individual risk of gonorrhea are low, and follow-up is likely, alternative therapy may be considered using one of the following alternative regimens: 1) Levofloxacin 500 mg p.o. once-daily in combination with metronidazole 500 mg po. 2 times a day for 14 days, 2) moxifloxacin 400 mg p.o. once daily for 14 days or 3) azithromycin 500 mg po. daily IV for 1 or 2 doses followed by 250 mg p.o. daily for the full duration of azithromycin 7 days or in combination with metronidazole 500 mg 3 times a day for 12-14 days (1178-1181). Moxifloxacin is the preferred quinolone antibiotic forM. genitaliuminfections; however, the importance of providing coverage forM. genitaliumis unknown. Diagnostic testing for gonorrhea should be performed prior to initiating therapy, and patients should be treated as follows:

• If a culture is positive for gonorrhea, treatment should be based on the results of antimicrobial susceptibility testing.
• If the isolate is found to be resistant to quinolonesN. gonorrhoeaeor when antimicrobial susceptibility cannot be assessed (eg, when only NAAT testing is available), consultation with an infectious disease specialist is recommended.

Other Management Considerations

To minimize transmission of the disease, women should be instructed to refrain from sexual intercourse until therapy is complete, symptoms have resolved, and the sexual partner has been treated (see Chlamydial Infections; Gonococcal Infections). All women diagnosed with PID should be tested for gonorrhea, chlamydia, HIV and syphilis. The value of testing women with PGD forM. genitaliumis unknown (cfMycoplasma genitalium). All contraceptive methods can be continued during treatment.

Follow up

Women must demonstrate clinical improvement (eg, defervescence, reduced direct or rebound abdominal tenderness, and reduced tenderness versus uterine, adnexal, and cervical movements) within 3 days of initiating therapy. If clinical improvement has not occurred <72 hours after intramuscular or oral outpatient treatment, hospitalization, antimicrobial regimen evaluation, and further diagnostics are recommended, including consideration of diagnostic laparoscopy for alternative diagnoses. All women diagnosed with chlamydial or gonococcal PID should be retested 3 months after treatment, regardless of whether their sexual partners have been treated (753). If retesting after 3 months is not possible, these women should be retested at their next doctor visit within 12 months of treatment.

Management of sexual partners

Individuals who have had sexual contact with a partner with PID within 60 days prior to the onset of symptoms should be screened, evaluated, and presumably treated for chlamydia and gonorrhea, regardless of the etiology of PID or the pathogen isolated. If last sexual intercourse was > 60 days prior to symptom onset or diagnosis, the last sexual partner should be treated. Sexual partners of people with PID caused byC. trachomatisÖN. gonorrhoeaethey are often asymptomatic. Provision must be made to associate sexual partners with caregiving. When attachment is delayed or unlikely, EPT is an alternative approach to treating sexual partners who have chlamydial or gonococcal infection (125,126) (see partner services). Couples should be instructed to refrain from sexual intercourse until they and their sexual partners have been treated (ie until therapy has been completed and symptoms, if present initially, have resolved).

Special considerations

Allergy, intolerance and adverse drug reactions

The risk of cross-reactivity with penicillin is greatest for first-generation cephalosporins, but negligible for most second-generation cephalosporins (e.g., cefoxitin) and all third-generation cephalosporins (e.g., ceftriaxone).) (619,631,653,656) (see Treatment of people with a history of penicillin allergy).

The pregnancy

Pregnant women with suspected PGD are at high risk for maternal morbidity and preterm birth. These women should be hospitalized and treated with intravenous antimicrobials in consultation with an infectious disease specialist.

HIV infection

Differences in the clinical manifestations of PID between HIV-infected and HIV-negative women have not been well defined (1182). In early observational studies, women with HIV infection and PGD were more likely to need surgery. More extensive observational and controlled studies have shown that women with HIV infection and PGD have similar symptoms compared to HIV negative women (1183–1185), except that they are more likely to have a tuboovarian abscess. HIV-positive women responded as well to recommended parenteral and intramuscular or oral antibiotic therapies as HIV-negative women. The microbiological findings in women with HIV and women without HIV were similar, except that women with HIV had higher rates of co-infection.M for manand streptococcal infections. These data are insufficient to determine whether women with HIV infection and PID require more aggressive management (eg, hospitalization or intravenous antimicrobial therapies).

intrauterine devices

IUDs are one of the most effective birth control methods. Copper-containing levonorgestrel-releasing coils are available in the United States. The risk of PID associated with the use of IUDs is mainly limited to the first 3 weeks after insertion (1186–1188). If an IUD wearer is diagnosed with PID, the IUD does not need to be removed (59,1189). However, the woman should be treated according to these recommendations and closely monitored clinically. If there is no clinical improvement within 48 to 72 hours of starting treatment, the physician should consider removing the IUD. A systematic review of the evidence showed that treatment outcomes did not differ between women with PID who kept the IUD and those who had the IUD removed (1190). These studies mainly included women wearing IUDs containing copper or other non-hormonal IUDs. There are no studies of treatment outcomes in women using levonorgestrel-releasing IUDs.

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