Blind treatment of suspected PID

Blind antibiotic therapy needs to cover the common bacteria C. trachomatis, N. gonorrhoeae and anaerobic infection.

Outpatient antibiotic treatment should be commenced as soon as the diagnosis is suspected (1,2).

Suggested outpatient antibiotic treatment regimes for acute pelvic inflammatory disease are (2):

• First line therapy:
  • ceftriaxone 1000mg IM Stat PLUS
  • metronidazole 400mg BD for 14 days PLUS
  • doxycycline 100mg BD for 14 days
• Second line therapy
  • metronidazole 400mg BD for 14 days PLUS
  • ofloxacin 400mg BD for 14 days
  • OR
  • moxifloxacin alone (first line for M. genitalium associated PID) 400mg OD for 14 days

Key points (2):

• refer women and sexual contacts to GUM
  
  
• raised CRP supports diagnosis, absent pus cells in HVS smear good negative predictive value
  
  
• exclude:
  • ectopic pregnancy, appendicitis, endometriosis, UTI, irritable bowel, complicated ovarian cyst, functional pain
    
    
• moxifloxacin has greater activity against likely pathogens, but always test for gonorrhoea, chlamydia, and M. genitalium
  
  
• If M. genitalium tests positive use moxifloxacin

Notes (1):

• in cases of mild or moderate PID (in the absence of a tubo-ovarian abcess), there is no difference in outcome when patients are treated as outpatients or as inpatients
• although there is evidence that cefoxitin is superior than ceftriaxone in the treatment of PID, ceftriaxone is recommended due to the lack of availability of cefoxitin (1)
• delaying treatment, particularly in chlamydial infections, increases the severity of the condition and the risk of long-term sequelae such as ectopic pregnancy, subfertility and pelvic pain

Reference:

• (1) Royal college of obstetricians and gynaecologists 2008. Managemnet of acute pelvic inflammatory disease
• (2) Public Health England (June 2021). Managing common infections: guidance for primary care