Treatment Of PID

Successful treatment of PID has three parts. The first is multiple antibiotic treatment to kill the infection. The second is the treatment of the woman's partner to prevent the woman from being re-infected. The third is bed rest to help the pelvic organs heal. All three parts must be combined for treatment to be successful.

MULTIPLE ANTIBIOTICS: The idea with antibiotic treatment is to make sure that the bacteria causing PID are completely eradicated, so more damage does not occur. We don't know why, but most pelvic infections involve many bacteria. For example, the reproductive organs become infected with many different bacteria, even if only one bacterium initially started the infection. This is called polymicrobial infection. For this reason, one antibiotic alone is never recommended for the treatment of PID. Both the Canadian and the U.S. guidelines for the treatment of PID emphasize that multiple antibiotics are essential to insure that all bacteria are eradicated.

Antibiotics for PID can be given orally (by mouth) or intravenously (through a vein, usually this is done in the hospital, but sometimes it can be done on an outpatient basis). Definitive research has not been done, but most experts believe that IV (intravenous) antibiotics are superior because they have better penetration into infected tissues (oral antibiotics must be absorbed through the stomach first), and also because some powerful antibiotics used to treat PID, such as aminoglycosides, cannot be given by mouth. The U.S. Centers for Disease Control states that oral antibiotics may be less effective than IV antibiotics. Both the Canadian and the U.S. guidelines for the treatment of PID recommend IV antibiotics in many cases.

If a woman is given oral antibiotics, the guidelines recommend an injection of ceftriaxone (or a similar cephalosporin antibiotic) plus ten to 14 days of doxycycline (this is effective against many bacteria, including chlamydia). Some experts also recommend the addition of the antibiotic metronidazole (brand name Flagyl) to kill anaerobic bacteria. Anaerobic bacteria are bacteria which do not require oxygen to survive. These bacteria are often found in pelvic infection, especially if the infection has gone on for a long time, if an abscess is involved, or if the woman has bacterial vaginosis. The new Canadian guidelines for the treatment of PID recommend that the practitioner consider adding Flagyl if an anaerobic infection is suspected. Anaerobic infections are especially likely if the woman has had repeated bouts of PID, is an older woman, or has had chronic infection. Also, if a woman is given oral antibiotics, both the Canadian and U.S. guidelines for the treatment of PID recommend that the woman be re-examined within 48 to 72 hours, and if she has not improved by then, hospitalization and evaluation by a specialist are recommended.

If a woman is given IV antibiotics, there are two recommended options: doxycycline with cefoxitin, or clindamycin with gentamicin.

The Canadian guidelines emphasize the first option as the preferred option and the second as the alternative, but the U.S. guidelines consider both to be equal choices. Both of these IV combinations will kill a wide range of PID-causing bacteria, but neither will kill all of the bacteria that might cause PID. The doxycycline/cefoxitin option is especially effective against chlamydia and a broad range of other bacteria, but it is not the best choice if an anaerobic infection is present. The clindamycin/gentamicin regimen is recommended if anaerobic bacteria or gram-negative bacteria are present. It is important to note that the clindamycin/gentamicin should be used if an abscess is present. Clindamycin is more effective than other antibiotics at penetrating pus, and it is also very effective at killing anaerobic bacteria, which are usually present within abscesses.

All IV antibiotics have to be continued for at least four days AND at least two days after the woman has recovered. For example, if a woman did not improve until the tenth day, she would need at least twelve days of IV antibiotics. Failure to continue antibiotic treatment for long enough can result in continuing infection and damage to the reproductive organs.

Once a woman has been discharged from hospital, IV antibiotics must be followed by oral antibiotics so that the combined total of antibiotic treatment is at least ten to 14 days. Both of the IV antibiotic combinations should be followed by oral doxycycline, to insure that chlamydia is eradicated, but other antibiotics may also be added.

Although these antibiotics are recommended, the recommendations may not always be followed in practice. For example, research in England and the United States shows that most prescriptions given to women with PID do not follow the Center for Disease Control guidelines, and that most prescriptions are not appropriate and would not eradicate most pelvic infections. Similar research has not been done in Canada.