Pelvic Inflammatory Disease Empiric Therapy 

Pelvic Inflammatory Disease Empiric Therapy 

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Empiric treatment for pelvic inflammatory disease (PID) should be initiated in sexually active young women and women at risk for sexually transmitted diseases if they are experiencing lower abdominal pain and pelvic tenderness. [1, 2, 3, 4, 5, 6, 7, 8, 9]

In addition, PID empiric therapy is warranted if one or more of the following are present on pelvic examination; cervical motion tenderness, uterine tenderness, or adnexal tenderness.

Empiric therapy should be broad spectrum and should include regiments that are effective against Neisseria gonorrhoeae and Chlamydia trachomatis.

There is no agreement amongst experts on whether treatment of PID should include anaerobic coverage. Outpatient regimens provided below have moderate coverage, while inpatient regimens have excellent coverage. Some experts recommend that all women should be covered for anaerobes, while others recommend that only women with severe disease requiring hospitalization, or those with tubo-ovarian abscesses should be covered. 

Recommended by the CDC. Results in cure in > 90% of patients: 

Cefoxitin 2 grams IV every 6 hours plus doxycycline 100 mg IV or orally every 12 hours or

Cefotetan 2 grams IV every 12 hours plus  doxycycline 100 mg IV or orally every 12 hours or

Clindamycin 900 mg IV every 8 hours plus gentamicin loading dose 2 mg/kg IV, followed by a maintenance dose of 1.5 mg/kg every 8 hours. Single daily dosing of gentamicin (3-5 mg/kg) can be substituted for three times daily dosing.

Alternative regimen per CDC with limited data:

Ampicillin-sulbactam 3 grams IV every 6 hours plus doxycycline 100 mg IV or orally every 12 hours

Note: If patient able to tolerate oral medication, oral doxycycline preferred to IV secondary to discomfort from IV administration. Patients should complete 14 day course of doxycycline (100mg twice daily). If a pelvic abscess is also present, patients should also be treated with oral clindamycin 450mg every 6 hours or metronidazole 500mg every 8 hours for 14 days, in addition to doxycycline. 

As recommended by the CDC:

Ceftriaxone 250 mg intramuscularly in a single dose plus  doxycycline 100 mg orally twice a day for 14 days, with or without metronidazole 500 mg orally twice a day for 14 days or

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 regimens listed above for treatment of mild to moderate PID, ceftriaxone has the best coverage against gonococcal disease and this is the preferred antibiotic in conjunction with doxycycline. Metronidazole should be added for women with trichomonas vaginalis or bacterial vaginosis.


Alternative oral therapy for penicillin- or cephalosporin-allergic patients

Patients with a history of a severe penicillin allergy who cannot tolerate cephalosporins or a known cephalosporin allergy may be prescribed fluoroquinolones (levofloxacin 500 mg orally daily or ofloxacin 400 mg orally twice a day for 14days), with or without metronidazole (500 mg orally twice a day for 14 days). This regimen should only be used for individuals in whom suspicion of N gonorrhoeae is low or resistance in the community is less than 5%.

If N gonorrhoeae is the suspected pathogen, fluoroquinolones are no longer recommended secondary to increased resistance.

If considering a fluoroquinolone, the patient must be cultured for N gonorrhoeae.




Bevan CD, Ridgway GL, Rothermel CD. Efficacy and safety of azithromycin as monotherapy or combined with metronidazole compared with two standard multidrug regimens for the treatment of acute pelvic inflammatory disease. J Int Med Res. 2003 Jan-Feb. 31(1):45-54. [Medline].

Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2002. MMWR Recomm Rep. 2002 May 10. 51(RR-6):1-78. [Medline].

Centers for Disease Control and Prevention. Update to CDC’s sexually transmitted diseases treatment guidelines, 2006: fluoroquinolones no longer recommended for treatment of gonococcal infections. MMWR Morb Mortal Wkly Rep. 2007 Apr 13. 56(14):332-6. [Medline].

Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep. 2010 Dec 17. 59:1-110. [Medline].

U.S. Preventive Services Task Force. Screening for chlamydial infection: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2007 Jul 17. 147(2):128-34. [Medline].

Ness RB, Soper DE, Holley RL, et al. Effectiveness of inpatient and outpatient treatment strategies for women with pelvic inflammatory disease: results from the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) Randomized Trial. Am J Obstet Gynecol. 2002 May. 186(5):929-37. [Medline].

Savaris RF, Teixeira LM, Torres TG, et al. Comparing ceftriaxone plus azithromycin or doxycycline for pelvic inflammatory disease: a randomized controlled trial. Obstet Gynecol. 2007 Jul. 110(1):53-60. [Medline].

Walker CK, Wiesenfeld HC. Antibiotic therapy for acute pelvic inflammatory disease: the 2006 Centers for Disease Control and Prevention sexually transmitted diseases treatment guidelines. Clin Infect Dis. 2007 Apr 1. 44 Suppl 3:S111-22. [Medline].

[Guideline] Centers for Disease Control and Prevention. Update to CDC’s Sexually transmitted diseases treatment guidelines, 2010: oral cephalosporins no loner a recommended treatment for gonococcal infections. MMR Morb Mortal Wkly Rep. Aug/2012. 61:91-95. [Medline].

Ritu Kumar, MD Resident, Department of Emergency Medicine, Hospital of the University of Pennsylvania

Ritu Kumar, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Student Association/Foundation, Society for Academic Emergency Medicine, Emergency Medicine Residents’ Association

Disclosure: Nothing to disclose.

Jasmeet Anand, PharmD, RPh Adjunct Instructor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Nicole W Karjane, MD Associate Professor, Department of Obstetrics and Gynecology, Virginia Commonwealth University Medical Center

Nicole W Karjane, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, Association of Professors of Gynecology and Obstetrics, North American Society for Pediatric and Adolescent Gynecology

Disclosure: Received income in an amount equal to or greater than $250 from: Merck<br/>Served as Nexplanon trainer for: Merck.

Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center; Master of the American College of Physicians; Fellow, Infectious Diseases Society of America; Fellow of the Royal College of Physicians, London

Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Medical Association, Association of Professors of Medicine, Infectious Diseases Society of America, Oklahoma State Medical Association, Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

Pelvic Inflammatory Disease Empiric Therapy 

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