Ceftriaxone, 250 mg IM in a single dose, or, if not an option Cefexime, 400 mg in a single dose
Azithromycin, 1 g orally (single dose), or Doxycycline, 100 mg orally twice daily for 7 days
Adapted from Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2010. Workowski KA, Berman S; Centers for Disease Control and Prevention (CDC). MMWR Recomm Rep. 2010 Dec 17;59(RR-12):1–110. Erratum in: MMWR Recomm Rep. 2011 Jan 14;60(1):18. Dosage error in article text.
PID is caused by micro-organisms colonizing the endocervix and ascending to the endometrium and fallopian tubes. It is a clinical diagnosis implying that the patient has upper genital tract infection and inﬂammation. The inﬂammation may be present at any point along a continuum that includes endometritis, salpingitis, and peritonitis (Fig. 18.1).
PID is commonly caused by the sexually transmitted micro-organisms N. gonorrhoeae and
C. trachomatis (31–33). Recent evidence suggests that Mycoplasma genitalium can cause PID and presents with mild clinical symptoms similar to chlamydial PID (34). Endogenous microorganisms found in the vagina, particularly the BV micro-organisms, are often isolated from the upper genital tract of women with PID. The BV micro-organisms include anaerobic bacteria such as Prevotella and peptostreptococci as well as G. vaginalis. BV often occurs in women with PID, and the resultant complex alteration of vaginal ﬂora may facilitate the ascending spread of pathogenic bacteria by enzymatically altering the cervical mucus barrier (35). Less frequently, respiratory pathogens such as Haemophilus inﬂuenzae, group A streptococci, and pneumococci can colonize the lower genital tract and cause PID.
Figure 18.1 Micro-organisms originating in the endocervix ascend into the endometrium, fallopian tubes, and peritoneum, causing pelvic inﬂammatory disease (endometritis, salpingitis, peritonitis). (From Soper DE. Upper genital tract infections. In: Copeland LJ, ed. Textbook of gynecology. Philadelphia, PA: Saunders, 1993:521, with permission.)
Diagnosis Traditionally, the diagnosis of PID is based on a triad of symptoms and signs, including pelvic pain, cervical motion and adnexal tenderness, and the presence of fever. It is recognized that there is wide variation in many symptoms and signs among women with this condition, which makes the diagnosis of acute PID difficult. Many women with PID exhibit subtle or mild symptoms that are not readily recognized as PID. Consequently, delay in diagnosis and therapy probably contributes to the inﬂammatory sequelae in the upper reproductive tract (36).
In the diagnosis of PID, the goal is to establish guidelines that are sufficiently sensitive to avoid missing mild cases but sufficiently specific to avoid giving antibiotic therapy to women who are not infected. Genitourinary tract symptoms may indicate PID; therefore, the diagnosis of PID should be considered in women with any genitourinary symptoms, including, but not limited to, lower abdominal pain, excessive vaginal discharge, menorrhagia, metrorrhagia, fever, chills, and urinary symptoms (37). Some women may develop PID without having any symptoms.