Pelvic inflammatory disease: Clinical manifestations and diagnosis

Authors:
Jonathan Ross, MD
Mariam R Chacko, MD
Section Editor:
Noreen A Hynes, MD, MPH, DTM&H
Deputy Editor:
Allyson Bloom, MD
Contributor Disclosures
All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: Nov 2016. | This topic last updated: Jun 13, 2016.
INTRODUCTION Pelvic inflammatory disease (PID) refers to acute and subclinical
infection of the upper genital tract in women, involving any or all of the uterus, fallopian
tubes, and ovaries; this is often accompanied by involvement of the neighboring pelvic
organs.
It
results
in
endometritis,
salpingitis,
oophoritis,
peritonitis,
perihepatitis, and/or tubo-ovarian abscess.
The majority of PID cases (85 percent) are caused by sexually transmitted pathogens or
bacterial vaginosis-associated pathogens. Fewer than 15 percent of acute PID cases are
not sexually transmitted and instead are associated with enteric (eg, Escherichia coli,
Bacteroides fragilis, Group B streptococci, and Campylobacter spp) or respiratory
pathogens (eg, Haemophilus influenzae, Streptococcus pneumoniae, Group A
streptococci, and Staphylococcus aureus) that have colonized the lower genital tract [1].
Post-operative pelvic cellulitis and abscess, pregnancy-related pelvic infection, injury or
trauma-related pelvic infection, and pelvic infection secondary to spread of another
infection (eg, appendicitis, diverticulitis, tumor) can also produce a very similar clinical
picture. However, the etiologic differences among these processes, principally in that they
are not caused by a sexually transmitted infection (STI), have significant implications for
treatment and prevention. Infectious complications of gynecologic surgery and pregnancy
are discussed elsewhere. (See "Posthysterectomy pelvic abscess" and "Septic pelvic
thrombophlebitis" and "Postpartum endometritis".)
PID represents a spectrum of infection and there is no single diagnostic gold standard.
Clinical diagnosis remains the most important practical approach. Several expert
guidelines discuss the clinical approach to the diagnosis of PID. These include the United
States Centers for Disease Control and Prevention guidelines on the management of STIs,
the International Union against STI European guidelines for the management of PID, and
the British Association for Sexual Health and HIV guidelines on the management of PID [24]. The discussion in this topic is generally consistent with these guidelines.

The clinical features and diagnosis of sexually transmitted PID will be reviewed here. The
pathogenesis, microbiology, risk factors for acquisition, treatment, and sequelae
associated with this disorder are discussed separately. (See "Pelvic inflammatory disease:
Pathogenesis, microbiology, and risk factors" and "Pelvic inflammatory disease:
Treatment".)
CLINICAL FEATURES
Patients at risk Any sexually active female is at risk for sexually transmitted infection
(STI) associated pelvic inflammatory disease (PID), but those with multiple sexual partners
are at the highest risk. Additionally, age younger than 25, a partner with a sexually
transmitted infection, and a history of prior PID or a sexually transmitted infection are
important risk factors. The use of barrier contraception is protective. These are discussed
in detail elsewhere. (See "Pelvic inflammatory disease: Pathogenesis, microbiology, and
risk factors", section on 'Risk factors'.)
While it is rare to have PID during pregnancy because the mucus plug and decidua seal off
the uterus from ascending bacteria, PID can occur in the first 12 weeks of gestation before
this occurs.
Women who undergo instrumentation of the cervix (eg, termination of pregnancy) are at
higher risk of infection ascending to cause PID. Older women less commonly present with
PID, but when they do, the cause is more likely to be non-STI-related. Salpingitis, while
very rare, has been reported in premenarcheal girls and adolescents who are not sexually
active. In such situations, respiratory and enteric bacteria should be also considered.
Spectrum of disease The term PID encompasses a wide spectrum of clinical
presentations. The time course of presentation is typically acute over several days, but a
more indolent presentation over weeks to months can also occur. Some women do not
present to care with symptoms of PID but are later suspected to have had it because of
tubal factor infertility. Even acute symptomatic PID represents a spectrum of clinical
disease, from mild, vague pelvic symptoms to tubo-ovarian abscess and, rarely, fatal intraabdominal sepsis. In some women, the inflammatory process can extend to the liver
capsule to cause perihepatitis (the Fitz-Hugh Curtis syndrome).
These varied clinical syndromes are discussed in more detail in the sections that follow.
Acute symptomatic PID Acute symptomatic PID is characterized by the acute onset of
lower abdominal or pelvic pain, pelvic organ tenderness, and evidence of inflammation of
the genital tract. The findings can be subtle and nonspecific.
Symptoms Lower abdominal pain is the cardinal presenting symptom in women with
PID. The abdominal pain is usually bilateral and rarely of more than two weeks' duration
[2-4]. The character of the pain is variable, and in some cases, may be quite subtle. The
recent onset of pain that worsens during coitus or with jarring movement may be the only

presenting symptom of PID. The onset of pain during or shortly after menses is particularly
suggestive [5].
The majority of women with PID have mild to moderate disease and only a minority
develop peritonitis or pelvic abscess, which are usually manifest by more severe pain,
greater tenderness on examination, and systemic features such as fever.
Abnormal uterine bleeding (post-coital bleeding, inter-menstrual bleeding, menorrhagia)
occurs in one-third or more of patients with PID [6,7]. Other non-specific complaints
include urinary frequency and abnormal vaginal discharge.
Examination findings On physical examination, most women with PID have abdominal
tenderness on palpation, greatest in the lower quadrants, which may or may not be
symmetrical. Rebound tenderness, fever, and decreased bowel sounds are usually limited
to women with more severe PID.
Acute cervical motion, uterine, and adnexal tenderness on bimanual pelvic examination
are the defining characteristic of acute symptomatic PID [7,8]. Purulent endocervical
discharge and/or vaginal discharge is also common. However, significant lateralization of
adnexal tenderness is uncommon in PID.
Laboratory findings Most laboratory findings in PID are nonspecific. Although PID is
usually an acute process, only a minority of PID patients with more severe disease exhibit
peripheral blood leukocytosis [9]. Similarly, an elevated erythrocyte sedimentation rate
(ESR) and C-reactive protein (CRP) have poor sensitivity and specificity.
Perihepatitis
Perihepatitis (Fitz-Hugh Curtis Syndrome) occurs in the setting of PID when there is
inflammation of the liver capsule and peritoneal surfaces of the anterior right upper
quadrant. There is generally minimal stromal hepatic involvement. It occurs in
approximately 10 percent of women with acute PID and is characterized by right upper
quadrant abdominal pain with a distinct pleuritic component, sometimes referred to the
right shoulder. Marked tenderness in the right upper quadrant can be seen on exam. The
severity of the pain in this location may mask the diagnosis of PID and lead to concerns
regarding cholecystitis [10]. Aminotransferases are usually normal or only slightly elevated
[11,12].
On laparoscopy or visual inspection, perihepatitis manifests as a patchy purulent and
fibrinous exudate ("violin string" adhesions), most prominently affecting the anterior
surfaces of the liver (not the liver parenchyma).
The syndrome was first associated with gonococcal salpingitis in 1920 [13] and
subsequently with C. trachomatis [14,15].

Tubo-ovarian abscess A tubo-ovarian abscess is an inflammatory mass involving the

fallopian tube, ovary, and, occasionally, other adjacent pelvic organs. Women with a tuboovarian abscess may have a palpable adnexal mass on examination. Other associated
clinical findings are discussed elsewhere. (See "Epidemiology, clinical manifestations, and
diagnosis of tubo-ovarian abscess", section on 'Clinical presentation'.)
Subclinical PID Subclinical infection of the upper reproductive tract that does not
prompt a woman to present to medical care but is severe enough to produce significant
sequelae appears to be relatively common [7]. Women with tubal factor infertility that
appears likely to have been a result of past episodes of PID often give no history of PID
[16-18]. As an example, in one study of 112 infertile women, 36 had adhesions or distal
tube occlusion on laparoscopy suggestive of PID, but only 11 had a documented history of
a PID diagnosis [18].
Previously undiagnosed PID has also been identified in women with a history of previous
mild symptoms, but with an endometrial biopsy that demonstrates excess neutrophils and
plasma cells, consistent with inflammation and PID. Lower genital tract infection with
gonorrhea, chlamydia, or bacterial vaginosis is a risk factor for this finding [19]. As an
example, in a study that included 562 women at risk for but without clinical findings
suggestive of PID, 13 percent of them had endometritis on endometrial biopsy, and rates
of cervical C. trachomatis isolation were similar to women with clinically evident PID [7].
Subclinical episodes of PID may occur more frequently in oral contraceptive users [20,21].
Chronic PID An indolent presentation of PID with low-grade fever, weight loss, and
abdominal pain has been reported with actinomycosis and tuberculosis. An association
between an indwelling IUD and risk of actinomycosis has been suggested, although this
relationship remains unclear. The diagnosis of this pathogen is discussed elsewhere.
(See "Abdominal actinomycosis" and "Clinical manifestations, diagnosis, and treatment of
extrapulmonary and miliary tuberculosis", section on 'Genitourinary and adrenal disease'.)
EVALUATION The evaluation of the woman with acute pelvic pain is discussed in detail
elsewhere (see "Evaluation of acute pelvic pain in women"). Elements of the evaluation
that are specific to female patients with suspected PID are outlined below.
Initial evaluation PID should be suspected in any young or sexually active female
patient who presents with lower abdominal pain and pelvic discomfort. The index of
suspicion for PID should be high, especially in adolescents. The goal of the initial
evaluation of women with suspected PID is to establish a presumptive clinical diagnosis of
PID, assess for additional findings that increase the likelihood of that diagnosis, and
evaluate for other potential causes of pelvic pain.
A presumptive clinical diagnosis of PID can be made on the basis of history and physical
exam findings alone. Although laboratory testing is also done at the initial evaluation of all
patients with suspected PID, empiric treatment should not be delayed while awaiting

results of these supportive tests. (See 'Diagnosis' below and "Pelvic inflammatory disease:
Treatment", section on 'Indications for treatment'.)
For women who are acutely ill and may have complications of PID, who do not improve
with empiric therapy for PID, or in whom the diagnosis remains uncertain, additional
diagnostic tests, such as pelvic imaging, can be useful. (See 'Additional evaluation for
diagnostic uncertainty' below.)
History The history should focus on potential risk factors for PID. In particular, a sexual
history should be taken, assessing for new sexual partners and consistent use of
condoms.
Additionally, the history should clarify the onset (usually recent) and character of pelvic
pain (usually constant and aching), with the understanding that even subtle and mild
symptoms can be consistent with PID (see 'Symptoms' above). Other symptoms such as
prominent urinary or gastrointestinal symptoms that might indicate alternative diagnoses
should also be sought. (See 'Differential diagnosis' below.)
Physical and pelvic exam All women suspected of having PID should undergo
bimanual exam to evaluate for cervical motion, uterine, or adnexal tenderness.
Additionally, speculum exam should be performed to evaluate for cervical mucopurulent
discharge. (See 'Examination findings' above.)
Pelvic organ tenderness is the defining characteristic of acute symptomatic PID. One study
found that adnexal tenderness was the sign that correlated best with the finding of
endometritis on endometrial biopsy [8]. Other diagnoses should also be considered if
uterine and adnexal tenderness are not prominent.
The presence of a palpable adnexal mass may suggest a tubo-ovarian abscess
complicating PID, but it could also reflect other disease processes in the differential
diagnosis of PID. (See "Approach to the patient with an adnexal mass" and "Differential
diagnosis of the adnexal mass" and "Epidemiology, clinical manifestations, and diagnosis
of tubo-ovarian abscess".)
Point-of-care and laboratory tests The following tests should be performed for all
women suspected of having PID:
Pregnancy test
Microscopy of vaginal discharge (where available)
Nucleic acid amplification tests (NAATs) for C. trachomatis and N. gonorrhoeae
HIV screening
Serologic testing for syphilis
Testing for patients suspected of PID should always begin with a pregnancy test to rule out
ectopic pregnancy and complications of an intrauterine pregnancy, the main obstetric

differential diagnoses of PID. Saline microscopy of vaginal discharge is to assess for

increased white blood cells (WBC) in vaginal fluid which is sensitive for PID. The absence
of WBC could thus suggest an alternate diagnosis. However, the finding is not very
specific for PID. Microscopy can also identify coexisting bacterial vaginosis and
trichomoniasis. Positive NAATs for C. trachomatis or N. gonorrhoeae support the diagnosis
of PID, but negative NAATs do not rule out PID. HIV and syphilis testing are to evaluate for
other sexually transmitted infections that share similar risk factors with PID.
Additional tests can be potentially useful in certain situations. A Gram stain from cervical
discharge can also be a useful diagnostic tool, but is often not available in community
settings. If a cervical Gram stain is positive for gram-negative intracellular diplococci
(suggestive of N. gonorrhoeae) when interpreted by an experienced microscopist, the
probability of PID greatly increases [2-4]. However, if the Gram stain is negative, it is of
limited value because most cases of PID are not caused by gonorrhoea, and the sensitivity
of microscopy is only around 60 percent.
A complete blood count, erythrocyte sedimentation rate, and C-reactive protein are often
obtained in patients seen in hospital-based settings who have more severe clinical
presentations, including fever, and may warrant inpatient therapy [4]. These tests have low
sensitivity and specificity for the diagnosis of PID in general, but can be useful in
assessing severity (including cases of suspected tubo-ovarian abscess) and monitoring
the response to treatment. Urinalysis is also checked in women with urinary symptoms.
Hepatitis B virus testing may be appropriate depending on the patient's risk history and
vaccination history.
The role for testing for M. genitalium in the diagnosis of PID has not been established.
Such testing is now becoming available commercially, but management guidelines have
not recommended its routine use [2-4]. If a fully validated assay is available, then testing
for M. genitalium may be useful in women who have a clinical diagnosis of PID but who
have failed to respond to treatment in order to guide the use of specific anti-mycoplasma
therapy.
Additional evaluation for diagnostic uncertainty Additional testing may be warranted
for women who are acutely ill (eg, with fever, peritonitis, or a pelvic mass), whose
symptoms are atypical (eg, with an abnormal site or duration of symptoms) or do not
improve significantly within 72 hours after starting empiric antibiotic therapy, or who have
persisting pain after completing therapy. These findings suggest the possibility of
complications of PID (such as a tubo-ovarian abscess) or alternate diagnosis. Pelvic
imaging can be helpful to evaluate for these. Ultrasound is generally the preferred imaging
modality if an abscess or adnexal pathology is suspected clinically, as it produces highquality images of the upper genital tract and does not expose the patient to radiation.
Otherwise, computed tomography (CT) may be more helpful in identifying gastrointestinal
pathology or alternate diagnoses. (See 'Imaging techniques' below.)

Laparoscopy and transcervical

(See 'Other studies' below.)

endometrial

biopsy

are

uncommonly

performed.

Imaging techniques Pelvic imaging can help evaluate for alternative causes of pelvic
pain or complications of PID (such as a tubo-ovarian abscess). However, the absence of
radiographic findings consistent with PID does not rule out the possibility of PID and
should not be a reason to forgo or delay therapy for presumptive PID. Ultrasound is the
imaging technique that has been most studied for the evaluation of PID. There is limited
evidence for the use of CT or magnetic resonance imaging (MRI) in women with suspected
PID [22-24]; however, they are useful to exclude alternative diagnoses in women with an
atypical and severe presentation.
The interpretation of sonographic findings are operator-dependent, and there are often
minimal changes seen in women with uncomplicated PID. Thickened, fluid-filled fallopian
tubes [25] and the cogwheel sign (cogwheel appearance on a cross-section of the tube)
may be present. Among women who have endometritis, ultrasound may show fluid or gas
within the endometrial canal, heterogeneous thickening, or indistinctness of the
endometrial stripe, but these findings are inconsistent. When a tubo-ovarian abscess is
present, a complex thick-walled, multilocular cystic collection can be seen in the adnexa,
typically with internal echoes or multiple fluid levels. (See "Epidemiology, clinical
manifestations, and diagnosis of tubo-ovarian abscess", section on 'Imaging studies'.)
Doppler ultrasound scanning may be useful to identify areas of increased blood flow
associated with inflammation but is not used routinely because of the limited evidence to
support its utility [25].
Other studies Findings on laparoscopy or transcervical endometrial biopsy can confirm
the clinical diagnosis of PID, but these tests are uncommonly performed.
Laparoscopy Despite its value in confirming a diagnosis of PID, laparoscopy is
not sensitive enough to be considered the diagnostic gold standard. The specificity of
laparoscopy is high, but its sensitivity is as low as 50 percent when compared with
fimbrial histopathology because it does not detect isolated endometritis or mild intratubal inflammation [26]. Additionally, it is an invasive procedure, particularly for a
condition that does not typically warrant surgical intervention, and it is not universally
available in the acute setting.
Laparoscopy can be a useful part of the diagnostic workup for PID when imaging
studies have not been definitively informative in the following situations:
In a patient who has failed outpatient treatment for PID, to look for alternative
causes of the patients symptoms
In a patient whose symptoms are not clearly improving or worsening after
approximately 72 hours of inpatient treatment for PID, which suggests that PID
may not be the correct diagnosis

In addition, some surgeons may proceed directly to laparoscopy in an acutely ill

patient with a high suspicion of a competing diagnosis that would be diagnosed and
intervened on through laparoscopy (eg, appendicitis).
Consent for laparotomy at the same procedure should be obtained in advance for
these patients.
Transcervical endometrial biopsy This can be used to detect endometritis,
which is associated with salpingitis. However, it is not used routinely because the
correlation is not 100 percent, there is a delay associated with processing the biopsy
(which means that the result seldom influences the decision to treat), and there is
inter-individual variation when interpreting the histology due to the patchy nature of
the inflammation, thus limiting consistency.
DIAGNOSIS The presumptive clinical diagnosis of PID is made in sexually active young
women, especially women at high 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.
The sensitivity of this clinical diagnosis is only 65 to 90 percent [6,27,28], but because of
the potential for serious reproductive sequelae if PID treatment is delayed or not given, this
presumptive diagnosis is sufficient to warrant empiric antimicrobial therapy for PID. Even
patients with minimal or subtle findings should be treated since the potential
consequences of withholding therapy are great. (See "Pelvic inflammatory disease:
Treatment", section on 'Indications for treatment'.)
In general, adding more diagnostic criteria increases the specificity, but decreases the
sensitivity of the diagnosis. The following additional findings can be used to support the
clinical diagnosis of PID [4]:
Oral temperature >101F (>38.3C)
Abnormal cervical or vaginal mucopurulent discharge or cervical friability
Presence of abundant numbers of white blood cells (WBCs) on saline microscopy of
vaginal secretions (eg, >15 to 20 WBCs per hpf or more WBCs than epithelial cells)
Documentation of cervical infection with N. gonorrhoeae or C. trachomatis
The CDC also lists an elevated C-reactive protein (CRP) or erythrocyte sedimentation rate
(ESR) as findings that may increase the specificity of the diagnosis of PID. However, these
tests are not particularly specific. In one study, a CRP 60 mg/L or ESR 40 mm/h had a
specificity of only 61 percent for severe PID [29].
Certain findings can suggest against PID, such as the combination of normal cervical
discharge and absence of WBCs on microscopy of vaginal secretions. Also, prominent
gastrointestinal and urinary symptoms can suggest other etiologies of pelvic pain.
(See 'Differential diagnosis' below.)

For women who have undergone additional testing, certain findings can help to confirm the
diagnosis of PID, although their absence does not rule out the possibility of PID:
Pelvic imaging (transvaginal ultrasound, CT, or MRI) findings consistent with PID.
These include thickened, fluid-filled tubes/oviducts with or without free pelvic fluid, or
tubo-ovarian complex. Doppler studies may demonstrate tubal hyperemia suggestive
of pelvic infection.
Laparoscopic abnormalities consistent with PID. These include tubal erythema,
edema, and adhesions; purulent exudate or cul-de-sac fluid; and abnormal fimbriae.
Histologic evidence of endometritis in a biopsy.
Standards for the diagnosis of subclinical PID remain to be established. It is typically
diagnosed retroactively in women who are ultimately found to have tubal factor infertility.
Subclinical PID can also be identified incidentally in women undergoing laparoscopy for
other reasons.
DIFFERENTIAL DIAGNOSIS The differential diagnosis of PID is broad and includes
other pelvic pathology, urinary tract processes, and gastrointestinal tract disorders. The
main differential diagnoses for PID and their suggestive features are summarized in the
Table (table 1). Other diagnoses associated with acute pelvic pain are discussed in further
detail elsewhere. (See "Evaluation of acute pelvic pain in women", section on 'Etiology'.)
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Basics)" and "Patient education: Chlamydia (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
Pelvic inflammatory disease (PID) refers to acute infection of the upper genital tract
structures, including the uterus, fallopian tubes, and/or ovaries. Neisseria
gonorrhoeae and Chlamydia trachomatis are often implicated, although vaginal flora
may also play an important role. Any sexually active female individual is at risk for

PID, but those with multiple

(See 'Introduction' above.)

sexual

partners

are

at

the

highest

risk.

The term PID encompasses a wide spectrum of clinical presentations. Women with
acute symptomatic PID generally complain of recent onset of lower abdominal pain in
association with new vaginal discharge and/or intermenstrual bleeding. Constitutional
symptoms may occur and include fever and chills. Perihepatitis can also occur and
present with marked tenderness in the right upper quadrant. Pelvic organ tenderness
on palpation is the defining exam finding. (See 'Clinical features' above.)
PID should be suspected in any young or sexually active female patient who
presents with pelvic discomfort. The index of suspicion for PID should be high,
especially in adolescents. The goal of the initial evaluation of women with suspected
PID is to establish a presumptive clinical diagnosis of PID, assess for additional
findings that increase the likelihood of that diagnosis, and evaluate for other potential
causes of pelvic pain. Additionally, infections or co-morbidities that can occur in
women at risk for PID should be tested for. (See 'Initial evaluation' above.)
In addition to a history, including sexual history, and physical and pelvic exams, the
following tests should be performed:
Pregnancy test
Microscopy of vaginal discharge (where available)
Nucleic acid amplification tests for C. trachomatis and N. gonorrhoeae
HIV screening
Serologic testing for syphilis
For women who are acutely ill, who do not improve with empiric therapy for PID, or
in whom the diagnosis remains uncertain, imaging is warranted to evaluate for
complications of PID (eg, tubo-ovarian abscess) or alternative diagnoses.
(See 'Additional evaluation for diagnostic uncertainty' above and 'Differential
diagnosis' above.)
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. (See 'Diagnosis' above.)
Because of the potential for serious reproductive sequelae if PID treatment is
delayed or not given, this presumptive diagnosis is sufficient to warrant empiric
antimicrobial therapy for PID. (See "Pelvic inflammatory disease: Treatment", section
on 'Indications for treatment'.)
Other findings, such as fever, mucopurulent discharge or cervical friability, abundant
WBC on saline microscopy of vaginal secretions, and detection of genital infection
with N. gonorrhoeae or C. trachomatis, support the clinical diagnosis of PID. Although
not obtained in all patients, imaging studies with characteristic findings, laparoscopy
abnormalities consistent with PID, and histologic evidence of endometritis on biopsy
can help to confirm the diagnosis. (See 'Diagnosis' above.)

ACKNOWLEDGMENT The editorial staff at UpToDate would like to acknowledge

Charles Livengood, MD, who contributed to an earlier version of this topic review.
Pelvic inflammatory disease: Treatment
Author:
Harold C Wiesenfeld, MD, CM
Section Editor:
Noreen A Hynes, MD, MPH, DTM&H
Deputy Editor:
Allyson Bloom, MD
Contributor Disclosures
All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: Nov 2016. | This topic last updated: Mar 31, 2016.
INTRODUCTION 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 [1]. 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 longterm 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 [1]. (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 [2]. 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'.)
In studies utilizing specialized techniques, anaerobic organisms were frequently recovered
from the upper genital tract in women with acute PID. However, the importance of effective
treatment of anaerobic organisms in women with acute PID is somewhat controversial and
is currently under study (Clinical Trials.gov identifier NCT01160640) [5]. Rarely,
actinomycetes may be isolated in the patient with an intrauterine device (IUD).
AVAILABLE ANTIMICROBIAL AGENTS Multiple antibacterial agents with activity
against the wide variety of implicated pathogens have been studied, including medications
within the beta-lactam, fluoroquinolone, aminoglycoside, lincosamide, and macrolide
classes of drugs [6-8]. Meta-analyses of selected trials have demonstrated overall clinical
and microbiological cure rates of greater than 90 percent for most regimens [6,7].
The vast majority of these studies have included dual therapy arms for coverage of N.
gonorrhoeae, C. trachomatis, and the wide variety of microbes associated with
PID; doxycycline has been the agent of choice for coverage of C. trachomatis in most of
these studies, although azithromycin also has activity against this pathogen. The
combination of clindamycin and gentamicin has moderate in vitro activity against N.
gonorrhoeae and C. trachomatis, while a second generation cephalosporin
(eg, cefoxitin or cefotetan) plus doxycycline have excellent in vitro activity against both
pathogens [3,9]. Ampicillin-sulbactam is a beta-lactam agent with broad spectrum activity,
although there are scant data on its use for the treatment of PID [3].
Fluoroquinolones are no longer recommended in the United States for the treatment of
gonorrhea or associated conditions, such as PID, due to increasing rates of resistance
[10]. (See 'Gonococcal drug resistance' below.)
CLINICAL TRIAL DATA
Defining treatment response Treatment response is based on both short- and longterm outcomes. Clinical cure is defined as "significant" or "complete improvement" in the

signs and/or symptoms of PID. Microbiologic cure is defined as eradication of N.

gonorrhoeae or C. trachomatis, if present at baseline.
Long-term sequelae of PID include infertility, ectopic pregnancy, and chronic pelvic pain.
Limitations of current data sets There are multiple limitations of the clinical trials of
PID treatment.
Clinical efficacy Some studies have not used objective criteria to diagnose PID, raising
concerns as to the whether the appropriate patient population was included [6]. In addition,
others have evaluated subjective improvement in pain scores without blinding of
investigators [6]. Few randomized controlled trials have long-term data on reproductive
outcomes, such as risk of ectopic pregnancy following treatment.
Microbiologic efficacy Although several studies have demonstrated the presence of
anaerobes at initial presentation, there are scant data on their persistence or eradication
after therapy. In fact, excellent clinical cure rates among women with mild to moderate PID
have been documented for several regimens with modest anaerobic coverage
(eg, ceftriaxone plus doxycycline) [5,11].
Assessment of efficacy is also hampered by diagnostic methods that do not distinguish
between relapse versus reinfection. The Pelvic Inflammation Disease Evaluation Clinical
Health trial (ie, PEACH trial), which carefully assessed patients for N. gonorrhoeae and C.
trachomatis infections, demonstrated that 40 percent of the women had evidence of single
or dual infections at baseline; by 30 days after therapeutic invention, approximately 3
percent still had evidence of either infection, representing either reinfection or relapse.
Efficacy of inpatient versus outpatient therapy There has been a persistent trend
toward outpatient treatment of PID with only 15 percent of women now being hospitalized
[12,13]. Clinical trial data support such an approach in patients with mild or moderate PID.
The Pelvic Inflammation Disease Evaluation Clinical Health trial (ie, PEACH trial) randomly
assigned 831 patients with mild or moderate PID to either [14]:
Inpatient therapy with intravenous cefoxitin (2
plus doxycycline (100 mg twice daily for 14 days)

grams

every

hours)

OR
Outpatient therapy with a single intramuscular dose of cefoxitin (2 grams) plus a
single dose of oral probenecid (1 gram) plus oral doxycycline (100 mg twice daily for
14 days) [14].
Eligible women had a history of lower abdominal pain, uterine or adnexal tenderness on
examination, and leukorrhea/mucopurulent cervicitis or documented untreated gonococcal
or chlamydial infection. Patients underwent a standardized interview, and cervical swabs

were obtained for N. gonorrhoeae and C. trachomatis for polymerase chain reaction (PCR)
testing. Vaginal specimens were Gram stained and examined for evidence of bacterial
vaginosis by a reference laboratory. Endometrial biopsies were scored for evidence of
endometritis by two reference pathologists. Long-term follow-up was conducted through
periodic phone calls. Intravenous therapy continued for a minimum of 48 hours; upon
clinical improvement, the patient was switched to doxycycline for a 14-day course.
This clinical trial showed that short-term clinical and microbiologic outcomes and long-term
reproductive outcomes (eg, ectopic pregnancy, chronic pelvic pain) were similar between
arms. Intravenous administration of doxycycline was associated with high rates of
phlebitis.
INDICATIONS FOR HOSPITALIZATION Recommended indications for hospitalization
and parenteral antibiotics include [1]:
Pregnancy
Lack of response or tolerance to oral medications
Nonadherence to therapy
Inability to take oral medications due to nausea and vomiting
Severe clinical illness (high fever, nausea, vomiting, severe abdominal pain)
Complicated PID with pelvic abscess (including tuboovarian abscess)
Possible need for surgical intervention or diagnostic exploration for alternative
etiology (eg, appendicitis)
There are no clinical data to suggest that older age or HIV status should be considered
criteria for hospitalization [3,15].
RECOMMENDED REGIMENS
General approach The therapeutic regimens for PID, discussed below, provide broad
empiric coverage for the wide array of implicated pathogens, although the optimal
treatment regimen remains undefined [14]. Antibiotics selected should have activity
against Neisseria gonorrhoeae and Chlamydia trachomatis, as both play a significant role
in PID. As noted above, meta-analyses have demonstrated that a variety of antibiotics
from multiple classes are all associated with clinical and microbiologic cure rates of greater
than 90 percent. Cost, convenience of administration, safety, formulary availability and
allergy history are all assessed in making antimicrobial selections. The choice of
antimicrobial therapy is also guided by whether the patient will be treated as an inpatient or
outpatient. (See 'Inpatient therapy' below and 'Outpatient therapy' below.)
Gonococcal drug resistance As of 2007, the CDC guidelines state that
fluoroquinolones are no longer recommended as therapy for PID if N. gonorrhoeae is a
proven or suspect pathogen [10].

Role for anaerobic coverage There is no consensus on the degree of anaerobic

coverage that is needed for PID or whether anaerobes need to be targeted at all [3,5].
Anaerobic bacteria are frequently recovered from patients with acute PID; however, there
are no studies to demonstrate that inclusion of anaerobic coverage is superior to antibiotic
regimens with minimal coverage [3]. Furthermore, experts are concerned that the
additional gastrointestinal side effects seen with metronidazole therapy will lead to
nonadherence and inadequately treated PID.
Some experts have suggested that anaerobes should be treated empirically while others
suggest inclusion of anaerobic coverage among select groups of patients, such as those
with severe infection requiring hospitalization and tubo-ovarian abscess [5]. The inpatient
regimens noted below have excellent anaerobic coverage while the outpatient regimens
have only modest coverage. The addition of antibiotics with anaerobic activity
(eg, metronidazole) may be considered among outpatients with:
History of gynecological instrumentation within the preceding two to three weeks.
(See "Management and complications of tubo-ovarian abscess".)
Role for M. genitalium coverage There are no data on the benefits of screening and
treating women with acute PID for M. genitalium, and there is no consensus on whether
women diagnosed with acute PID should be tested for M. genitalium or whether treatment
regimens should include coverage for this organism. Current recommended treatment
regimens are ineffective against M. genitalium, yet clinical response rates are high.
Inpatient therapy Patients with severe PID should be hospitalized and treated with
parenteral therapy. Indications for hospitalization are discussed above. (See 'Indications
for hospitalization' above.)
First-line therapies For patients with severe PID, the CDC recommends either of the
following parenteral regimens, which result in clinical cure of acute disease in >90 percent
of PID cases [1,16-18]:
Cefoxitin (2 g intravenously every 6 hours) or cefotetan (2 g IV every 12 hours)
plus doxycycline (100 mg orally every 12 hours).
Clindamycin (900 mg intravenously every 8 hours) plus gentamicin loading dose
(2 mg/kg of body weight) followed by a maintenance dose (1.5 mg/kg) every 8 hours.
Single daily intravenous dosing of gentamicin may be substituted for three times daily
dosing [1]. (See "Dosing and administration of parenteral aminoglycosides", section
on 'Extended-interval dosing and monitoring'.)
These inpatient regimens provide broad coverage, including streptococci, gram-negative
enteric bacilli (Escherichia coli, Klebsiella spp, and Proteus spp), and anaerobic organisms
(ie, bacterial vaginosis-associated flora) [7,19-21]. We prefer a second generation
cephalosporin plus doxycycline for inpatients with PID due to its overall tolerability.

Antiemetic and antipyretic medications should be offered to those patients who are
symptomatic. Transitioning from parenteral to oral therapy can usually be started after 24
hours of sustained clinical improvement, such as resolution of fever, nausea, vomiting, and
severe abdominal pain, if present [22]. Patients should complete a 14-day course of
treatment with doxycycline (100 mg twice daily). Oral administration of doxycycline is
generally preferred, as soon as vomiting subsides, because of the pain associated with
intravenous drug administration. Importantly, the bioavailability of the oral preparation of
doxycycline is equivalent to parenteral administration.
Patients with a pelvic abscess should also receive oral clindamycin 450 mg every 6 hours
or metronidazole 500 mg every 8 hours for a total of 14 days in addition to doxycycline.
Management of the patient with complicated PID with tubo-ovarian abscess is discussed
separately. (See "Management and complications of tubo-ovarian abscess", section on
'Management'.)
Alternative regimens Limited data are available on the following regimens, which are
considered "alternative" by the CDC:
Ampicillin-sulbactam (3 g intravenous every 6 hours) plus doxycycline (100 mg twice
daily) led to a similar rate of clinical cure as cefoxitin (2 g every 6 hours) plus
doxycycline (100 mg twice daily) among women hospitalized with PID (86 versus 89
percent) [17].
One small randomized trial of patients with mild or moderate PID evaluated the
efficacy of azithromycin (500 mg IV daily for 1 to 2 days followed by 250 mg orally
daily to complete a seven day course) with or without 12 days
of metronidazole compared
with
regimens
containing
a
beta-lactam
and doxycycline [23]. Clinical and microbiological cure rates were greater than 95
percent in all arms.
Outpatient therapy Patients with mild or moderate PID are suitable candidates for
outpatient therapy since clinical outcomes are equivalent with inpatient or outpatient
therapy. (See 'Efficacy of inpatient versus outpatient therapy' above.)
First-line regimens The CDC recommends any of the following outpatient regimens,
with or without metronidazole (500 mg twice a day for 14 days) [1]:
Ceftriaxone (250 mg intramuscularly in a single dose) plus doxycycline (100 mg
orally twice a day for 14 days)
Cefoxitin (2 g intramuscularly in a single dose) concurrently with probenecid (1 g
orally in a single dose) plus doxycycline (100 mg orally twice a day for 14 days)
Other parenteral third-generation cephalosporins, such as cefotaxime (1 gram
intramuscularly in a single dose) or ceftizoxime (1 gram intramuscularly in a single
dose) plus doxycycline (100 mg orally twice a day for 14 days)

Of the cephalosporins listed, ceftriaxone has the overall best activity against gonococcal
infection. We prefer ceftriaxone plus doxycycline in patients with mild to moderate
PID. Metronidazole should be added for patients with Trichomonas vaginalis or in those
women with a recent history of uterine instrumentation.
Alternative agents
The long half-life of azithromycin, its concentration intracellularly, and its activity
against Chlamydia offers the potential for an easier dosing schedule than twicedaily doxycycline. Small clinical trials suggest clinical efficacy although data on
microbiological cures are not available:
A double-blind randomized controlled trial compared the efficacy of a single
intramuscular injection of ceftriaxone followed by either doxycycline (100 mg twice
daily for two weeks) or azithromycin (1 gram once per week for two weeks) in 120
women with mild PID [24]. The azithromycin and doxycycline arms were found to be
equivalent in clinical cure rates. The study limitations include the subjective nature of
the measured outcome, limited microbiologic data and the small sample size.
TREATMENT OF THE PENICILLIN-ALLERGIC PATIENT Treatment considerations
must also take into consideration any history of drug allergy and the risk for gonococcal
infection. Penicillin-allergic patients who have tolerated cephalosporins may be treated
with a cephalosporin-based regimen.
Patients at risk for gonorrhea Patients with PID who require hospitalization can be
treated
with clindamycin and gentamicin,
as
outlined
above.
(See 'Inpatient
therapy' above.)
However, therapeutic options for outpatient management of the penicillin allergic patient at
risk for gonorrhea are limited, particularly among those with a history of severe penicillin
allergy. In patients with mild or moderate PID, it is important to obtain a complete history
regarding the underlying penicillin allergy so a therapeutic regimen may be constructed, as
discussed below.
History of mild allergy A patient with a mild past reaction to a penicillin and who never
reacted to a cephalosporin (or never received one) may be a candidate for treatment with
intramuscular ceftriaxone.
A history of a maculopapular or morbilliform rash, without signs of IgE-mediated allergy
(urticaria, angioedema, respiratory symptoms, hypotension) or desquamation, is
associated with very low risk for a serious allergic reaction to ceftriaxone. Cross-reactivity
between penicillins and third-generation cephalosporins is believed to be uncommon. For
such patients, an initial test dose of ceftriaxone (one-tenth of the full dose, intramuscularly)
can be administered with patient observation for two hours. If no reaction develops, the
remainder of the dose can be given with continued observation for another hour; the

patient should be discharged with doxycycline (100 mg twice daily) for 14 days.
(See "Penicillin-allergic patients: Use of cephalosporins, carbapenems, and
monobactams".)
History of severe allergy Patients with severe or life-threatening penicillin allergies are
not candidates for cephalosporin therapy; options for outpatient therapy are limited.
We suggest the following possible options:
Hospitalize the patient and initiate treatment with clindamycin (900 mg intravenously
every 8 hours) plus gentamicin loading dose (2 mg/kg of body weight) followed by a
maintenance dose (1.5 mg/kg) every 8 hours. Single daily intravenous dosing of
gentamicin may be substituted [1].Following 24 hours of clinical improvement,
treatment may be changed to doxycycline (100 mg orally every 12 hours) to complete
14 days of treatment.
OR
Administer a quinolone-based regimen, eg, levofloxacin (500 mg orally once daily
for 14 days) AND a single dose of azithromycin (2 grams orally). This dosage of
azithromycin is also used in combination with other agents for penicillin allergic
patients with uncomplicated gonococcal infection; however, this high dose of
azithromycin is associated with increased rates of gastrointestinal disturbance. In the
patient with uncomplicated PID, another fluoroquinolone alternative to levofloxacin
is moxifloxacin (400 mg) once daily for 14 days [8]. (See "Treatment of uncomplicated
gonococcal infections", section on 'Penicillin allergic patients'.)
Patients at low risk of gonorrhea As noted above, fluoroquinolones are not
recommended for the treatment of PID because of the risk of gonococcal drug resistance.
However, fluoroquinolones, with metronidazole, may be considered for PID therapy in
circumstances where N. gonorrhoeae is not likely to be a causative agent (eg, the postmenopausal woman who develops PID following uterine instrumentation) or when the
prevalence of fluoroquinolone-resistant N. gonorrhoeae is <5 percent in the locality where
the infection was acquired [10]; resistance data can be obtained from the local department
of public health. Fluoroquinolone resistance is discussed in detail elsewhere.
(See "Treatment of uncomplicated gonococcal infections", section on 'Antibiotic
resistance'.)
Thus, an alternate treatment regimen in these clinical scenarios may include:
Levofloxacin (500 mg orally once daily) or ofloxacin (400 mg orally twice daily) with
or without metronidazole (500 mg orally twice a day); monotherapy
with moxifloxacin (400 mg once daily), which has good anaerobic coverage, is
another option. All regimens are given for 14 days.

Prior to quinolone treatment, cervical specimens should be collected for culture for N.
gonorrhoeae so that the initial treatment regimen can be altered if fluoroquinoloneresistant N. gonorrhoeae are identified. Nucleic acid amplification testing cannot determine
antimicrobial susceptibility. The laboratory should be notified to perform susceptibility
testing on N. gonorrhoeae isolates.
HIV-INFECTED PATIENTS HIV-infected women appear to respond to therapy for PID
as well as uninfected women [15]. Therefore, recommended antibiotic regimens for HIVinfected women with acute PID are similar to those for HIV-uninfected women.
PREGNANT PATIENTS While it is quite rare to have PID during pregnancy, the
infection can occur in the first 12 weeks of gestation before the mucus plug and decidua
seal off the uterus from ascending bacteria [25]. As above, pregnancy is an indication for
hospitalization and parenteral antibiotics for PID. We typically administer a second
generation cephalosporin (eg, intravenous cefoxitin or cefotetan, as in first-line therapies
listed above) and azithromycin 1 gram orally (instead of doxycycline).
DURATION OF THERAPY The optimal duration of therapy is unknown. Most studies
have used 14 days of therapy and this duration has been maintained in the STD
recommendations from the CDC [1,10]. Shorter courses of therapy have not been
explored, mainly related to concerns regarding eradication of C. trachomatis in the setting
of upper tract disease [3].
PATIENT RELATED ISSUES Patient monitoring and counseling are important
components of overall management.
Patient monitoring If outpatient therapy is selected, it is important to see the patient
within 48 to 72 hours to be certain that clinical improvement has occurred (eg, reduction in
abdominal tenderness and reduction in cervical motion tenderness) [26]. If no clinical
improvement has occurred within 72 hours, hospitalization, parenteral therapy, and further
diagnostic evaluation is recommended [1]. (See "Pelvic inflammatory disease: Clinical
manifestations and diagnosis", section on 'Additional evaluation for diagnostic
uncertainty'.)
Medication adherence Compliance with a long course of oral antibiotics can be
problematic [27]. Patients should be educated about the importance of medication
adherence and clinical outcomes.
Counseling and screening Clinicians should counsel patients regarding the route of
acquisition for sexually transmitted infections, the concomitant need for partner treatment,
and future safe sex practices. All patients diagnosed with acute PID should be offered HIV
testing. (See "Screening and diagnostic testing for HIV infection".)
Other important components of the evaluation include:

Assessment of immunity to Hepatitis B virus (eg, through vaccination history or

serologic testing) and vaccination of those who have no evidence of immunity.
(See "Hepatitis B virus vaccination".)
Serologic testing for syphilis. (See "Syphilis: Screening and diagnostic testing".)
Patients who are 9 through 26 years of age should be offered immunization against
human papillomavirus infection, if they have never been vaccinated in the past.
(See "Recommendations for the use of human papillomavirus vaccines".)
Patients diagnosed with acute PID should undergo counseling for safe sex practices. Drug
abuse counseling should be offered to appropriate patients.
Sex partners Male sex partners of women with PID should be examined and treated if
they had sexual contact with the patient during the previous 60 days prior to the patient's
onset of symptoms, regardless of the womans sexually transmitted infection test results.
Evaluation and treatment of the sex partner is essential to decrease the risk of reinfection.
Regimens should include antibiotics with activity against N. gonorrhoeae and C.
trachomatis, such as ceftriaxone (250 mg) intramuscularly plus either azithromycin (1
gram) orally as a single dose or doxycycline (100 mg) orally twice daily for seven days.
INFORMATION FOR PATIENTS UpToDate offers two types of patient education
materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are
written in plain language, at the 5 th to 6th grade reading level, and they answer the four or
five key questions a patient might have about a given condition. These articles are best for
patients who want a general overview and who prefer short, easy-to-read materials.
Beyond the Basics patient education pieces are longer, more sophisticated, and more
detailed. These articles are written at the 10th to 12th grade reading level and are best for
patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to
print or e-mail these topics to your patients. (You can also locate patient education articles
on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
Basics topic (see "Patient education: Pelvic inflammatory disease (The Basics)")
SUMMARY AND RECOMMENDATIONS
Pelvic inflammatory disease (PID) refers to acute infection of the upper genital tract
structures in women, involving any or all of the uterus, oviducts, and/or ovaries. Up to
10 percent of women with untreated gonorrhea and 20 percent of women with
untreated chlamydia infection may go on to develop PID. (See 'Introduction' above.)
Acute PID is caused by cervical microorganisms (including Chlamydia
trachomatis and Neisseria gonorrhoeae) as well as the vaginal microflora, including
enteric gram-negative rods, streptococci, genital mycoplasmas, and Gardnerella
vaginalis. (See 'Pathogens of concern' above.)

Multiple broad-spectrum antibacterial agents have been studied for the treatment of
PID, including beta-lactams, fluoroquinolones, aminoglycosides, lincosamides and
macrolides. Meta-analyses of selected trials have demonstrated overall clinical and
microbiological cure rates of greater than 90 percent for most regimens. Cost,
convenience of administration, safety, allergy history, and drug resistance patterns are
all assessed in making antimicrobial selections. (See 'Available antimicrobial
agents' above.)
Anaerobic coverage is warranted in patients with a history of recent endometrial
instrumentation and women with severe or complicated PID (eg, pelvic abscess).
(See 'Pathogens of concern' above.)
Due to the rising levels
gonorrhoeae isolates, the use
Cephalosporins still maintain
although reports of decreasing
antimicrobial agents' above.)

of fluoroquinolone resistance among Neisseria

of fluoroquinolones is no longer recommended.
excellent activity against Neisseria gonorrhoeae,
susceptibility have been reported. (See 'Available

Indications for hospitalization include: pregnancy, nausea and vomiting, severe

clinical illness (fevers, chills, severe abdominal pain), suspected pelvic abscess, or a
possible
alternative
diagnosis
(eg,
appendicitis).
(See 'Indications
for
hospitalization' above.)
Treatment of pelvic inflammatory disease requires broad antimicrobial coverage
against the likely pathogens, including Neisseria gonorrhoeae, Chlamydia
trachomatis, and the gram-negative and gram-positive organisms that comprise the
cervical and vaginal flora. Additional anaerobic coverage may be important among
patients with severe or complicated PID. There are multiple potential antibiotic
regimens that are suitable for such broad spectrum coverage with proven efficacy in
the treatment of PID.
For inpatient management of severe or complicated PID, we suggest use of a
second generation cephalosporin (eg, cefoxitin 2 g intravenously every 6 hours
or cefotetan 2 g IV every 12 hours) combined with doxycycline (100 mg orally
every 12 hours) (Grade 2B). Another option is clindamycin (900 mg
intravenously every eight hours) plus gentamicin (2 mg/kg loading dose followed
by a 1.5 mg/kg maintenance dose every eight hours). Single daily intravenous
dosing of gentamicin may be substituted for three times daily dosing.
(See 'Inpatient therapy' above.)
Transitioning from parenteral to oral therapy (doxycycline 100 mg twice daily
alone) can usually be started after 24 hours of sustained clinical improvement.
(See 'Inpatient therapy' above.)
For outpatient therapy of mild or moderate PID, we suggest ceftriaxone (250 mg
intramuscularly in a single dose) plus doxycycline (100 mg orally twice a day for
14 days) (Grade 2B). We suggest the addition of metronidazole (500 mg orally
twice a day for 14 days) for those with a history of gynecological instrumentation

in the preceding
therapy' above.)

two

to

three

weeks

(Grade

2C).

(See 'Outpatient

Management of the penicillin allergic patient will depend on the nature of the
penicillin allergy and the risk of gonococcal infection. (See 'Treatment of the penicillinallergic patient' above.)
The optimal duration of therapy is unknown, although most authorities favor 14 days
of treatment. (See 'Duration of therapy' above.)
Patients receiving outpatient therapy should be carefully evaluated for clinical
improvement within 72 hours. (See 'Patient related issues' above.)
Male sex partners of women with PID should be examined and treated if they had
sexual contact with the patient during the previous 60 days prior to the patient's onset
of symptoms to decrease the risk of reinfection. (See 'Sex partners' above.)