Clinical Expert Series

Pelvic Inflammatory Disease

David E. Soper, MD

Pelvic inflammatory disease (PID) is an infection-caused inflammatory continuum from the

cervix to the peritoneal cavity. Most importantly, it is associated with fallopian tube inflamma-
tion, which can lead to infertility, ectopic pregnancy, and chronic pelvic pain. The microbial
etiology is linked to sexually transmitted microorganisms, including Chlamydia trachomatis,
Neisseria gonorrheae, Mycoplasma genitalium, and bacterial vaginosis-associated microorgan-
isms, predominantly anaerobes. Pelvic pain and fever are commonly absent in women with
confirmed PID. Clinicians should consider milder symptoms such as abnormal vaginal discharge,
metrorrhagia, postcoital bleeding, and urinary frequency as potential symptoms associated with
the disease, particularly in women at risk of sexually transmitted infection. The diagnosis of PID
is based on the findings of lower genital tract inflammation associated with pelvic organ
tenderness. The outpatient treatment of mild-to-moderate PID should include tolerated
antibiotic regimens with activity against the commonly isolated microorganisms associated with
PID and usually consists of an extended spectrum cephalosporin in conjunction with either
doxycycline or azithromycin. Clinically severe PID should prompt hospitalization and imaging to
rule out a tuboovarian abscess. Parenteral broad-spectrum antibiotic therapy with activity
against a polymicrobial flora, particularly gram-negative aerobes and anaerobes, should be
implemented. Screening for and treatment of Chlamydia infection can prevent PID.
(Obstet Gynecol 2010;116:419–28)

P elvic inflammatory disease (PID) is characterized

by an infection-caused inflammatory continuum
from the cervix to the peritoneal cavity (endocervici-
tis, endometritis, salpingitis, peritonitis) (Fig. 1).1 This
is an important disease for women because it can be
associated with significant sequelae, including tubal
factor infertility, ectopic pregnancy, and chronic pel-
vic pain. Women developing PID are also at in-
creased risk of recurrent infection. Finally, acute PID
may lead to tuboovarian abscess formation, which
can be life threatening if rupture occurs.
Pelvic inflammatory disease is diagnosed in more
than 800,000 women annually in the United States.
Ninety percent of women with PID are treated as
outpatients. Most of these women are less than 25
years old with sexually active adolescents being at the
highest risk.2 The annual cost of this condition now
approaches US $2 billion, with 70% of these costs
attributed to the care of women with acute PID rather
than diagnosis and treatment of sequelae.3 Unfortu-
nately, these estimates fail to take into consideration
the number of women with “silent salpingitis,” an
entity that remains asymptomatic or is associated with
atypical symptoms eluding diagnosis.4

From the Department of Obstetrics and Gynecology, Medical University of South

Carolina, Charleston, South Carolina.
Continuing medical education for this article is available at http://links.lww.com/
AOG/A190.
Corresponding author: David E. Soper, MD, Medical University of South Carolina,
Department of Obstetrics and Gynecology, 96 Jonathan Lucas Street, Suite 634,
P.O. Box 250619, Charleston, SC 29425; e-mail: soperde@musc.edu.
Financial Disclosure
The author did not report any potential conflicts of interest.
© 2010 by The American College of Obstetricians and Gynecologists. Published
by Lippincott Williams & Wilkins.
ISSN: 0029-7844/10
PATHOPHYSIOLOGY
The mucosal innate immune system of the female
reproductive tract is uniquely adapted to facilitate the
specialized physiologic functions that include menstrua-
tion and fertilization while eliminating threatening sex-
ually transmitted and environmental pathogens. The
vagina and cervix harbor a variety of commensal bac-
teria in their normal state as well as potential pathogens
when bacterial vaginosis is present. Despite this constant
exposure to microbes, infections are relatively uncom-

VOL. 116, NO. 2, PART 1, AUGUST 2010 OBSTETRICS & GYNECOLOGY 419

Fig. 1. Microorganisms from the lower genital tract ascend
into the endometrium, fallopian tubes, and peritoneum to
cause endometritis-salpingitis-peritonitis (pelvic inflammatory
disease). The arrows indicate the “flow” of microorganisms
from the lower genital tract to the upper genital tract. This is
noted as an ascending infection in the text. Reprinted from:
Soper DE. Upper genital infections. In: Copeland LJ, ed.
Texbook of gynecology. Philadelphia (PA): WB Saunders,
1993:521. Copyright © 1993 Elsevier.
Soper. Pelvic Inflammatory Disease. Obstet Gynecol 2010.
mon, suggesting effective containment or efficient elim-
ination of pathogens.5
The sexually transmitted microorganisms Neisseria
gonorrhoeae and Chlamydia trachomatis have been isolated
from the cervix, endometrium, and fallopian tube of
women with histologically confirmed endometritis and
visually confirmed salpingitis. They are universally ac-
cepted as etiologic agents of PID.6,7 Bacterial vaginosis is
present in up to two thirds of women with PID.8
Bacterial vaginosis is a complex alteration of the vaginal
microflora in which the normal lactobacilli dominant
vaginal flora are replaced with an anaerobic dominant
microflora in association with increasing concentrations
of Gardnerella vaginalis and genital mycoplasmas. The
microbial milieu of bacterial vaginosis is associated with
the elaboration of a variety of mucolytic proteinases that
appear to degrade the mucous plug and the natural
occurring antimicrobials, eg, secretory leukocyte pro-
tease inhibitor, that reside on the genital tract mu-
cosa.9,10 This potentiates the development of cervical
inflammation and may facilitate ascending infection by
cervical and vaginal microorganisms, thus resulting in
endometritis and salpingitis.11 “Bacterial vaginosis mi-
croorganisms,” particularly anaerobic gram-negative
rods, are associated with upper genital tract inflamma-
tion.12 Bacterial vaginosis, therefore, not only facilitates
ascending spread of vaginal microorganisms by interfer-
ing with the host’s defenses but also provides an inocu-
lum of potentially pathogenic microorganisms. The mi-
crobial etiology of PID can be referred to as
420 Soper Pelvic Inflammatory Disease
polymicrobial.13,14 Anaerobic and facultative aerobic
bacteria with and without N gonorrhoeae and C trachomatis
have been isolated from the upper genital tract in up to
70% of women with PID. Rarely, respiratory pathogens,
eg, Haemophilus influenzae and Streptococcus pneumoniae,
can be isolated from the fallopian tubes of women with
salpingitis.
There has been a recent resurgence of interest in
the sexually transmitted pathogen, Mycoplasma geni-
talium, as a possible cause of PID. Haggerty and col-
leagues15 reported the detection of M genitalium from the
endocervix or endometrium or both in 14% of women
with non-gonococcal, non-chlamydial PID, and the mi-
croorganism has been isolated from the fallopian tube of
a patient with visually confirmed salpingitis.16 M genitali-
um–associated PID appears to present with mild clinical
symptoms similar to chlamydial PID.17
There is little to no long-term morbidity associated
with cervcitis or endometritis without the concurrent
association of salpingitis.18 Once infection-induced in-
flammation reaches the fallopian tube, epithelial degen-
eration and deciliation of ciliated cells occurs along the
fallopian tube mucosa in association with a submucosal
inflammatory cell infiltrate.19 There is an associated
edema of the fallopian tube that augments the intralu-
minal agglutination that occurs with endosalpingitis and
leads to clubbing of the involved fallopian tube(s). This
leads to a dysfunctional, partially or totally obstructed
fallopian tube causing infertility or ectopic pregnancy.
Peritonitis is characterized by a fibrinoid exudate on the
serosal surfaces of the uterus, tubes, and ovaries leading
to an agglutination of the tubes, ovaries, bowel, and
omentum to the pelvic structures and to each other
(Fig. 2).20 This agglutination matures to both filmy
and thick pelvic adhesive disease, which is a well-
known cause of pelvic pain.
DIAGNOSIS
The clinician needs to consider PID in the differential
diagnosis of women presenting to their offices or
emergency departments. The diagnosis is dependent
on the elements of patient evaluation: history, physi-
cal examination, laboratory studies, and imaging.
If women with the clinical diagnosis of PID were
to undergo routine laparoscopy, visual evidence of
acute tubal inflammation (erythema, edema, and pu-
rulent exudate) would be confirmed approximately
65% of the time.21 Therefore, the clinical diagnosis of
PID may represent women with visually confirmed
acute salpingitis. However, the clinical diagnosis of
PID may also represent women with cervicitis and
endometritis without salpingitis or with cervicitis
alone.22,23 Chlamydia trachomatis, N. gonorrhoeae, bacte-
OBSTETRICS & GYNECOLOGY

Fig. 2. Laparoscopic visualization of acute salpingitis with an
associated peritoneal exudate. Reprinted from: Soper DE.
Diagnosis and laparoscopic grading of acute salpingitis. Am J
Obstet Gynecol 1991;164:1370–6. Copyright © 1991 Elsevier.
Soper. Pelvic Inflammatory Disease. Obstet Gynecol 2010.
rial vaginosis, and trichomonas vaginitis are associ-
ated with histologic evidence of endometritis in
women without the clinical manifestations of PID.22
These realities affect the way we must think about the
diagnosis of PID. The symptoms and signs of PID are
essentially indistinguishable among women with
acute salpingitis, those with endometritis without
acute salpingitis, and those with cervicitis but neither
endometritis nor salpingitis.23–25 Put another way,
historical variables and clinical findings are not statis-
tically significant predictors of laparoscopically con-
firmed acute salpingitis.26 Despite this, certain patient
complaints (Box 1), when associated with signs of
genital tract inflammation, do define a group of
Box 1. Symptoms in Women With Clinically
Suspected Pelvic Inflammatory Disease
Abdominal pain
Abnormal discharge
Intermenstrual bleeding
Postcoital bleeding
Fever
Urinary frequency
Low back pain
Nausea/vomiting
Data from references 24 and 27.
VOL. 116, NO. 2, PART 1, AUGUST 2010
women who benefit from antimicrobial therapy for
the syndromic diagnosis of PID.
Many clinicians still consider the acute onset of
moderate-to-severe lower abdominal pain associated
with tenderness and fever as the sine qua non for a
diagnosis of acute PID. In fact, less than one third of
women with PID will have an elevated temperature
when evaluated.23,27 In addition, women may charac-
terize their lower abdominal pain as mild, so mild in
fact, that it is often overshadowed by other lower
genital tract symptoms such as abnormal vaginal
discharge, intermenstrual bleeding, metrorrhagia,
postcoital bleeding, low back pain, or urinary fre-
quency as a chief complaint. For this reason, clini-
cians need to broaden their differential diagnosis in
women complaining of these symptoms and con-
sider the diagnosis of PID. An assessment of risk for
a sexually transmitted infection (STI) enhances the
specificity of the above presenting symptoms as
they may relate to a diagnosis of PID.28 However,
women without such risk factors should still have
the diagnosis considered, given that many will not
be accurate in believing that they reside in a
mutually monogamous sexual relationship.29
Abdominal tenderness may not be present in
many women with PID, particularly if peritonitis is
not present or the patient has endometritis without
salpingitis. A bimanual pelvic examination may re-
veal pelvic organ tenderness, uterine tenderness in the
case of endometritis, and adnexal tenderness in the
case of salpingitis. Cervical motion tenderness is
another common finding in women with PID. The
Centers for Disease Control and Prevention recom-
mends empiric treatment for PID in sexually active
young women (25 years old or younger) and other
women at risk of STI (multiple sex partners or history
of STI) if they are experiencing pelvic or lower
abdominal pain, if no cause for the illness other than
PID can be identified, and if one or more of the
following is appreciated on bimanual pelvic examina-
tion: cervical motion tenderness, uterine tenderness,
or adnexal tenderness. The limitation of this approach
is that it fails to discriminate between the differential
diagnoses of acute pelvic pain in reproductive-aged
women. For this reason, the lower genital tract needs
to be assessed for signs of inflammation.
The diagnosis of PID can be based on the recog-
nition of a continuum of ascending inflammation.
Microscopy of the vaginal secretions should be per-
formed looking for leukorrhea (more than 1 leukocyte
per epithelial cell), and the cervix should be inspected
for mucopus (green or yellow exudate) and friability
(sustained endocervical bleeding after the gentle pas-
Soper Pelvic Inflammatory Disease 421
sage of a cotton swab through the cervical os).30 In
addition, evaluation for bacterial vaginosis (vaginal
pH, clue cells, and whiff test) and trichomonas vagi-
nitis is in order. Finally, nucleic acid amplification
testing for N. gonorrhoeae and C. trachomatis should be
performed. If the cervix is normal and no white blood
cells are noted during microscopy of the vaginal
secretions, an alternative diagnosis should be investi-
gated since this reliably excludes (negative predictive
value 94.5%) upper genital tract infection.31
Clinicians should maintain a low threshold for
the diagnosis of PID. The diagnosis should be consid-
ered in sexually active women with or without lower
abdominal pain and symptoms noted in Box 1. A
physical examination should be performed assessing
the abdomen for tenderness. A pH of the vaginal
secretions should be performed along with a whiff test
to assess for the presence of bacterial vaginosis.
Microscopy of the vaginal secretions (wet mount)
should be examined for the presence of leukocytes as
well as clue cells and trichomonads (Fig. 3). The
cervical canal should be examined for the presence of
yellow or green mucopus and friability and testing for
C. trachomatis and N. gonorrhoeae should be performed.
A bimanual pelvic examination should be performed
to assess for pelvic organ tenderness and for evidence
Fig. 3. Microscopy of a wet mount of the vaginal secretions
from women with PID will commonly show the presence of
leucorrhea (more than 1 leukocyte per epithelial cell) and
clue cells suggesting the concurrent diagnosis of bacterial
vaginosis (400⫻ magnification). Reprinted from: Soper DE.
Urinary tract infections and infections of the female pelvis;
Cervicitis and endometritis. In: Mandell GL, ed. Atlas of
Infectious Diseases. Philadelphia (PA): Churchill Living-
stone, 1997:8.9.
Soper. Pelvic Inflammatory Disease. Obstet Gynecol 2010.
422 Soper Pelvic Inflammatory Disease
of a pelvic mass, which might suggest the presence of
a tuboovarian abscess.
Laboratory testing adds little to the diagnosis of
PID. The peripheral white blood cell count is com-
monly normal in women with PID. While the eryth-
rocyte sedimentation rate (ESR) or C-reactive protein
is commonly elevated in women with confirmed
salpingitis, the results of these tests are not rapidly
available in most laboratories. A more thorough
evaluation, including a complete blood count and
erythrocyte sedimentation rate, is recommended for
the woman with clinically severe PID.26,32 Women
with a clinical diagnosis of PID should be screened for
human immunodeficiency virus (HIV).
Imaging is most helpful when ruling out compet-
ing differential diagnoses such as the use of pelvic
ultrasonography to rule out symptomatic ovarian
cysts and computed tomography to rule out appendi-
citis.33,34 Pelvic ultrasonography has limited sensitivity
for the diagnosis of PID, but the specific finding of
thickened fluid-filled tubes by ultrasonography sup-
ports the diagnosis of upper genital tract inflamma-
tion. Pelvic ultrasonography should be ordered in
patients requiring hospitalization or those with a
pelvic mass noted on bimanual pelvic examination to
further characterize what is likely to be a tuboovarian
abscess.35
TREATMENT
Women with evidence of lower genital tract infection/
inflammation and no pelvic organ tenderness can be
treated for an uncomplicated lower genital tract infec-
tion or cervicitis (Box 2).28,36 Although a significant
proportion of these women will have histologic evi-
Box 2. Outpatient Antibiotic Regimen for
Cervicitis
Azithromycin 1 g orally in a single dose
OR
Doxycycline 100 mg orally twice daily for 7 days
PLUS*
Ceftriaxone 125 mg intramuscularly or cefixime 400 mg
orally in a single dose
PLUS
Metronidazole 500 mg twice daily for 7 days if bacterial
vaginosis is present
* Empiric treatment for gonorrhea is appropriate if the patient
population prevalence is 5% or higher.
Data from references 28 and 36.
OBSTETRICS & GYNECOLOGY
dence of endometritis, Eckert et al36 have shown that
a short course oral antibiotic regimen (single dose
cefexime 400 mg, single-dose azithromycin 1 g, and
metronidazole 500 mg twice daily for 7 days) was
effective treatment resulting in the resolution of his-
tologic endometritis in 89% of women (Box 2).
For those with lower genital tract inflammation
and pelvic organ tenderness, treatment for the syn-
dromic diagnosis of PID is in order. Treatment of PID
should provide high rates of clinical and microbio-
logic cure for infection with N. gonorrhoeae, C. tracho-
matis, and the polymicrobial flora found associated
with bacterial vaginosis.14,28,37 In addition, coverage
for M. genitalium should be considered.38
Several quinolone antibiotics (ciprofloxacin, ofloxa-
cin, moxifloxacin) have been studied as monotherapy
and shown to be effective in the treatment of acute
PID.7,39 – 41 However, ciprofloxacin appeared less effec-
tive in clearing bacterial vaginosis–associated microor-
ganisms from the endometrium despite the patients’
clinical cure.39 In addition, fluoroquinolone-resistant N.
gonorrhoeae is now widespread in the United States. As a
consequence, this class of antibiotics is no longer recom-
mended for the treatment of gonorrhea in the United
States and therefore cannot be considered a primary
option for the treatment of PID.42,43
Current treatment recommendations for the out-
patient therapy of PID suggest the addition of oral
metronidazole to doxycycline after a single parenteral
dose of an extended-spectrum cephalosporin to ex-
pand coverage of anaerobic bacteria, particularly if
bacterial vaginosis is noted. However, the combina-
tion of doxycycline and metronidazole has consis-
tently been associated with low clinical and microbi-
ologic cure rates (approximately 75%) for PID. In
addition, it appears that the highest rates of adverse
effects and study discontinuation in several random-
ized clinical trials occur in those arms utilizing met-
ronidazole, suggesting that poor tolerability limits
adherence.44 It appears that the combination of doxy-
cycline and metronidazole is a suboptimal choice for
the treatment of PID.43
Azithromycin provides excellent coverage of
Chlamydia and moderate-to-good coverage for a range
of aerobic and anaerobic bacteria, including gram-
negative anaerobes.45,46 It is also at least 100-fold more
active in vitro against M. genitalium than any of the
fluorquinolones or tetracyclines.47,48 This antimicro-
bial is also attractive because of its once-a-day dosing
and its tolerability, particularly in adolescents. More-
over, in a macaque animal model, azithromycin was
found to be more effective than doxycycline in the
VOL. 116, NO. 2, PART 1, AUGUST 2010
microbiologic cure of C. trachomatis infection and in
reducing the immunopathologic upper reproductive
tract damage of acute salpingitis.49 In three clinical
trials of azithryomycin alone or azithromycin plus
metronidazole, clinical cure rates were 94% or gre-
ater.50 –52 However, N. gonorrhoeae resistance to azithro-
mycin has been reported and the higher 2-g dose
recommended to treat this pathogen is associated with
significant gastrointestinal side effects. Despite these
concerns, multidose regimens of azithromycin mono-
therapy reliably eradicated N. gonorrhoeae when iso-
lated in women with PID in the studies cited.
As noted above, women with PID will respond to
a number of antimicrobial regimens. However, these
regimens do not always cover the broad spectrum of
microorganisms recovered from the upper genital
tract of these infected women. Investigators have
demonstrated the persistence of microorganisms, in-
cluding anaerobes, C. trachomatis, and M. genitalium in
the endometrium of women who have had a clinical
response to therapy. There is significant concern
about their persistence leading to persistence of en-
dometritis and their potential ability to cause relapse
or chronic fallopian tube infection. Optimal treatment
regimens should consider these findings.38,39,53
Most women with PID have clinically mild or
moderate cases. The Pelvic Inflammatory Disease
Evaluation and Clinical Health (PEACH) Random-
ized Trial study provides us with the best guidance
regarding an antibiotic regimen useful in treating
women with mild-to-moderate PID. In this large
(n⫽808), prospective, randomized trial, a single intra-
muscular dose of cefoxitin administered with probe-
necid and followed with 14 days of doxycycline
resulted in a similar short term cure rate (both greater
than 98%) in outpatients when compared with multi-
ple parenteral doses of cefoxitin and oral doxycycline
in inpatients.54 There was also no difference in the
long-term outcomes of fertility and ectopic pregnan-
cies between the two groups. Almost 60% of women
in the PEACH Randomized Trial had concurrent
bacterial vaginosis, but no woman received concur-
rent metronidazole as therapy. This suggests that a
single dose of cefoxitin, which has good activity
against gram-negative anaerobes, and multiple doses
of doxycycline, despite suboptimal activity against
anaerobic bacteria, are sufficient for clinical cure and
apparently do not adversely affect long-term outcome
comparatively.
Women with mild-to-moderate PID can be
treated as outpatients. It appears that a single dose of
cefoxitin administered with probenicid and followed
with a 14 day course of doxycycline provides excel-
Soper Pelvic Inflammatory Disease 423
lent cure rates. Azithromycin, for the reasons enumer-
ated above, is an acceptable and possibly superior
alternative to doxycycline. Caution should be exer-
cised when using this agent as monotherapy for PID
because of its suboptimal coverage of N. gonorrhoeae
(Box 3). Topical therapy for concurrent bacterial
vaginosis should avoid the poor tolerability of oral
metronidazole regimens.55
Women with severe PID or the criteria noted in
Box 4 or both should be considered for hospitaliza-
tion and inpatient parenteral therapy. Patients with
severe PID are more likely to have gonococcal or
non-chlamydial polymicrobial PID. Given that up to
one third of women hospitalized with severe PID will
have evidence of tuboovarian abscess, imaging with
pelvic ultrasonography or computed tomography is
recommended.56 Although 75% of women with tubo-
ovarian abscess will respond to antibiotic therapy
alone, some will fail to respond and require surgical
drainage. The need for surgical intervention is related
to the size of the tuboovarian abscess with 60% of
those women with abscesses 10 cm or greater in
diameter, 30% of those measuring 7 to 9 cm, and only
15% of those 4 to 6 cm in diameter needing surgery.57
Those patients failing to respond to antibiotic treat-
ment within 48 to 72 hours as characterized by
persistent fever, an increasing size of tuboovarian
abscess, and a persistent or increasing leukocytosis,
should be considered for surgical drainage. Drainage
of tuboovarian abscess can be effected by laparotomy,
laparoscopy, or image guided percutaneous routes.
Proper antimicrobial therapy of pelvic abscesses
includes antibiotic regimens with activity against an-
aerobic bacteria in addition to an ability to penetrate
abscess cavities while remaining stable in an acidic,
Box 3. Outpatient Antibiotic Regimen for
Treatment of Mild-to-Moderate Pelvic
Inflammtory Disease*
Cefoxitin 2 g intramuscularly in a single dose and
probenicid, 1 g orally administered concurrently in a
single dose
PLUS
Doxycycline 100 mg orally twice daily for 14 days
OR
Azithromycin 500 mg orally followed by 250 mg orally
daily for a total of 7 days
* Topical metronidazole or clindamycin may be used to treat
concurrent bacterial vaginosis.55
Data from references 51 and 54.
424 Soper Pelvic Inflammatory Disease
Box 4. Criteria for Hospitalization in Women
With Pelvic Inflammatory Disease
Surgical emergencies (eg appendicitis) cannot be ex-
cluded
Patient is pregnant
Patient does not respond clinically to oral antibiotic
therapy
Patient is unable to follow or tolerate an outpatient oral
regimen
Patient has severe illness, nausea and vomiting or high
fever
Patient has a tuboovarian abscess
Data from reference 28.
hypoxic abscess environment. In addition, Escherichia
coli is a common isolate from those patients with
ruptured tuboovarian abscess, and is a well-recog-
nized cause of gram-negative sepsis, making coverage
of this microorganism critical. Although regimens
containing an aminoglycoside have been used effec-
tively in women with pelvic abscesses, this class of
antibiotic have their activity significantly reduced at
low pH, at low oxygen tension, and in the presence of
drug-binding purulent debris.58 McNeeley et al59
showed that the combination of clindamycin and
gentamicin was associated with a significantly lower
response rate (47%) than the combination of clinda-
mycin/ampicillin/gentamicin (87.5%) when used to
treat patients with tuboovarian abscess. For these
reasons, an extended spectrum cephalosporin, eg,
ceftriaxone may be a better choice to combine with
either clindamycin or metronidazole in treating
women with severe PID with or without a tuboovar-
ian abscess. In addition, extended spectrum cephalo-
sporins have a much higher serum level to minimum
inhibitory concentration ratio than the aminoglyco-
sides. Clindamycin is actively transported into poly-
morphonuclear leukocytes and macrophages and is
present in relatively high concentrations, compared
with peak serum levels, in experimental abscesses.60
Antimicrobial regimens recommended for the treat-
ment of severe PID and tuboovarian abscess are listed
in Box 5. Patients should be discharged on a broad-
spectrum oral antimicrobial regimen to complete a
14-day course. Recommended oral regimens for dis-
charge include amoxicillin/clavulanate (875 mg twice
daily) or the combination of trimethoprim/sulfame-
thoxazole (160/800 mg twice daily) and metronida-
zole (500 mg twice daily) due to excellent polymicro-
bial coverage.
OBSTETRICS & GYNECOLOGY
 days after the onset of abdominal pain.64 Infertility
Box 5. Inpatient Parenteral Antibiotic Regimens was also more common in women with increasing
for Treatment of Severe Pelvic Inflammatory severity of acute salpingitis when laparoscopically
Disease and Tuboovarian Abscess graded.65 Finally, infertility increased with additional
Recommended Regimen episodes of PID18 (Table 1).
As expected, women with visually confirmed sal-
Clindamycin 900 mg intravenously every 8 hours
pingitis also have a sevenfold increased risk of ectopic
PLUS pregnancy when compared with women in a control
Ceftriaxone 1g intravenously every 12 hours group.18 Predictably, their risk for ectopic pregnancy
[Substitute gentamicin for ceftriaxone in patients with increases with the number of episodes of PID and with
␤-lactam allergy: gentamicin loading dose 2 mg/kg the severity of the laparoscopic grade of disease.66
intravenously or intramuscularly followed by mainte-
nance dose (1.5 mg/kg) every 8 hours. Single daily Women with either laparoscopically or clinically
dosing may be substituted.] diagnosed PID are at higher risk of chronic pelvic
pain, defined as menstrual or nonmenstrual pain of at
Alternative Regimens least 6 months’ duration. Furthermore, the risk for
Cefoxitin 2 g intravenously every 6 hours debilitating pain applies to women with mild-to-
OR severe PID and those treated as inpatients or outpa-
Cefotetan 2 g intravenously every 12 hours tients. Chronic pelvic pain is found in from 18% to
PLUS
75% of women with PID compared with only 5% to
25% of unaffected women.67
Doxycycline 100 mg orally or intravenously* every 12
hours
PREVENTION
OR
Methods for preventing transmission of STI are well
Ampicillin/sulbactam 3 g intravenously every 6 hours
known. They include abstinence and reduction of the
PLUS
number of sex partners and the consistent, correct use
Doxycycline 100 mg orally or intravenously* every 12 of condoms. There is general agreement that efforts to
hours
prevent PID must also address the earliest parts of this
* May be initiated when patient is able to tolerate oral therapy to
causal chain—that is, they must emphasize the primary
avoid phlebitis associated with parenteral doxycycline. prevention or early detection of infections of the
lower genital tract.68 Scholes et al69 showed that a
strategy of identifying, testing, and treating women at
Ruptured tuboovarian abscess should be consid- increased risk of cervical chlamydial infection can
ered in patients with PID presenting with an acute reduce the incidence of PID. Although not proven, it
abdomen and signs of septic shock. Tuboovarian
abscesses in patients undergoing medical manage-
ment of PID may rupture and require emergent Table 1. Infertility and Ectopic Pregnancy in
surgical therapy. Surgical exploration with extirpa- Women With Pelvic Inflammatory
tion of the involved adnexa and drainage of puru- Disease by Age, Episode, and
lent loculations is life saving. Hysterectomy is usu- Laparoscopic Grade of Disease
ally not necessary.61,62 Ectopic
Infertility Pregnancy
SEQUELAE Age Age
The sequelae associated with acute salpingitis are Number of Age Less Greater Age Less Greater
tubal factor infertility, ectopic pregnancy, chronic Episodes Than 25 y Than 25 y Than 25 y Than 25 y
pelvic pain, and an increased risk of recurrent infec- One 8 9 4 9
tion. When compared with healthy women in a Mild* ⬍1 – 2 —
control group or with women with a clinical diagnosis Moderate* 6 6 6 —
of PID but negative laparoscopic findings, women Severe* 20 25 13 —
with laparoscopically confirmed acute salpingitis were Two 18 26 8 —
Three or more 38 75 14 —
more likely to be infertile, to develop an ectopic Total 11 12 —
pregnancy, and to report chronic abdominal pain.63
Data are %.
Infertility was 2.6 times more common in those Data from references 65 and 66.
women who delayed seeking healthcare 3 or more * Laparoscopic grade of pelvic inflammatory disease.

VOL. 116, NO. 2, PART 1, AUGUST 2010 Soper Pelvic Inflammatory Disease 425
likewise follows that treatment of incident infections
associated with endometritis (N. gonorrhoeae, bacterial
vaginosis, trichomonas vaginitis) would also contrib-
ute to prevention. The U.S. Preventative Services
Task Force recommends screening for Chlamydia in
sexually active women 25 years of age and younger as
well as high-risk (multiple sex partners or a history of
prior sexually transmitted disease or both) women
over 25. Finally, sex partners of women with PID
should be examined and treated for gonococcal and
chlamydial infection regardless of the pathogens de-
tected in the patient with PID. These male sex
partners are commonly asymptomatic but still have a
strong likelihood of being infected.
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