How do I treat PID?

A low threshold for starting empirical antibiotics for PID is recommended, due to the lack of sensitive or specific signs and symptoms, the severity of the complications, and the need to start treatment as early as possible.

Empirical treatment should be offered to any sexually active woman with new onset lower abdominal pain with bimanual tenderness in whom no other cause has been identified. Ideally swabs should be taken before antibiotics are commenced but treatment should not be delayed to wait for test results or a sexual health clinic appointment as this could increase the risk of complications.

Identify high risk patients requiring admission

Most patients can be effectively managed as outpatients. Inpatient admission for observation, intravenous antibiotics, further investigation and potential surgical review should be considered in the following cases:

• Patients who are systemically unwell or septic
• Patients who are unable to tolerate oral antibiotics
• Lack of response to oral antibiotics
• Suspected tubo-ovarian abscess
• A surgical emergency cannot be excluded
• Pregnant women. PID is associated with an increased risk of maternal and foetal morbidity and pre-term delivery

Antibiotics

Outpatient regime*

First-line treatment for mild to moderate PID is a stat dose of intramuscular ceftriaxone 1g (single dose) followed by oral doxycycline 100mg BD and oral metronidazole 400mg BD for 14 days.

Inpatient regime*

If intravenous therapy is needed the recommended first-line treatment is ceftriaxone 2g OD and doxycycline 100mg BD.

*Check with local guidelines as common causative organisms and sensitivities may vary.

Analgesia

Provide regular analgesia and anti-emetics as required.

Contact tracing

Current partners should be offered a sexual health screen.

Advise contact tracing for sexual partners within six months of symptom onset.

Sexual health

Advise sexual abstinence until the treatment is complete (or use condoms if will not abstain).

An IUD can remain in situ initially, but if symptoms have not improved by 72 hours after starting antibiotics, then it should be removed. Emergency contraception may be required to protect against pregnancy.

Other considerations

Ask advice from a specialist if the patient is HIV positive. In mild to moderate cases, the empirical antibiotic is usually unchanged.

Patient information leaflets

Patient information leaflets are available from websites for the NHS, BASHH (British Association of Sexual Health and HIV) and RCOG (Royal College of Obstetricians and Gynaecologists).

Follow up

Safety net patients prior to discharge. Consider arranging follow-up in the next 72hrs to ensure patients are improving. If a swab returns positive, repeat swabs are often necessary to ensure resolution.⁷