By Christopher Oseh, MBBS
Dr. Peter gave his patient a puzzled look when she returned to his clinic because of the same complaint—persistent vaginal discharge and lower abdominal pain. “So you still have the same symptoms despite completing the antibiotics I prescribed at your last visit,” Dr. Peter reiterated because he thought the antibiotics should have worked. The patient later confessed she had taken lots of antibiotics before presenting to the hospital. Dr. Peter felt a little constrained because he needed to combine the right antibiotics to successfully treat suspected resistant pelvic inflammatory disease (PID) in this patient.
Dr. Peter’s plight is prevalent among doctors in resource-poor countries where self-medication practices increase the risk of antibiotics resistance to the causative organisms. Health professionals, especially doctors who are not updated regularly on current treatment guidelines for resistant cases of infectious diseases, may have difficulties treating infectious diseases like PID because of the rapid emergence of antibiotics resistance. Pelvic inflammatory disease is one of the common gynaecological infections responsible for hospital presentations and admissions in sub-Saharan Africa. Therefore, keeping up-to-date with recent management guidelines is essential.
In this article, you will learn current PID management practices you can apply in your clinical practice.
What is pelvic inflammatory disease?
Pelvic inflammatory disease is an ascending infection from the female lower genital tract (vulva and vagina) into the upper genital tract (uterus, fallopian tubes, and ovaries). Neisseria gonorrhoeae and chlamydia trachomatis, cause PID in 85% of cases, while other organisms like anaerobes account for 15% of cases.
Pelvic inflammatory disease symptoms
Pelvic inflammatory disease is more prevalent among females with multiple sexual partners. It is a differential diagnosis when a female patient presents with the following complaints:
- Severe lower abdominal pain
- Nausea and vomiting
- Persistent high fever
- Foul-smelling vaginal discharge
Pelvic inflammatory disease diagnosis
Doctors and other allied health care professionals should suspect PID in females with recurrent unexplained fever and lower abdominal pain. Untreated PID may result in multiple pockets of abscesses in the reproductive tract leading to bacterial invasion and increasing the risk of complications such as infertility, tubo-ovarian abscess, and ectopic pregnancy.
Pelvic examination helps clinicians properly diagnose a pelvic inflammatory disease to begin early treatment in suspected cases. A pelvic examination that reveals cervical discharge, tenderness in the cervix, and adnexa suggests a PID. PID is a clinical diagnosis, so you should start using oral antibiotics when a patient has both the highlighted classic symptoms and pelvic examination findings.
Perform the following investigations to rule out PID complications and confirm the diagnosis:
- Pelvic ultrasound scan: This scan report visualizes the internal female reproductive tract and identifies pus collections in the adnexa.
- Pregnancy test: This helps to exclude ectopic pregnancy, which is a firm differential diagnosis.
- Blood test: Neisseria gonorrhoeae and chlamydia trachomatis are sexually transmitted organisms, so blood tests are done to identify if the cause of the PID is because of these organisms and determine the degree of infection.
- Endocervical/high vaginal swab for microscopy, culture, and sensitivity. This standard test helps to isolate the causative organism after laboratory culture for 2-3 days.
The antibiotics sensitivity pattern determines the right combination of drugs to administer to clear the microorganism.
What is the best treatment for pelvic inflammatory disease?
The Centers for Disease Control and Prevention released updated guidelines in July 2021 for the treatment of PID. The guidelines encourage early treatment of PID cases when there is a high index of suspicion and hospital admission for:
- Tubo-ovarian abscess
- Pregnancy
- Severe illness, nausea, and vomiting, or oral temperature >38.5°C
- Acutely ill patients who cannot tolerate outpatient therapy or oral drugs.
- No clinical response to oral antimicrobial therapy
Here are the recommended antibiotics (modified for resource-limited settings) for PID treatment:
Parenteral drugs for severe cases
First Line
- Ceftriaxone, 1 g IV every 24 hours PLUS
- Doxycycline, 100 mg PO/IV every 12 hours
- Metronidazole, 500 mg IV every 12 hours
Second Line
- Cefotetan, 2 g IV every 12 hours
PLUS - Doxycycline, 100 mg PO or IV every 12 hours
3rd Line
- Cefoxitin, 2 g IV every 6 hours
PLUS - Doxycycline, 100 mg PO or IV every 12 hours
Alternative parenteral treatment regimens
- Ampicillin-sulbactam, 3 g IV every 6 hours
PLUS - Doxycycline, 100 mg PO or IV every 12 hours
Recommended intramuscular or oral regimens
- Ceftriaxone, 500 mg IM in a single dose (for persons weighing ≥150 kg, administer 1 g of ceftriaxone)
PLUS - Doxycycline, 100 mg PO BID for 14 days with metronidazole at 500 mg PO BID for 14 days.
OR - Other parenteral third-generation cephalosporins (e.g., ceftizoxime, cefotaxime)
PLUS - Doxycycline, 100 mg PO BID for 14 days with metronidazole at 500 mg PO BID for 14 days.
Doctors must add metronidazole to any chosen regimen to eradicate anaerobic bacteria implicated in PID. A research study found that drug regimens with metronidazole had a higher clearance of anaerobes compared to those without.
Final Thoughts
PID is a female genital tract infection that requires early treatment to reduce complications. As a health professional, you should suspect PID in young females with recurrent lower abdominal pain and foul-smelling vaginal discharge. A combination of clinical history and pelvic examination findings is essential for the accurate diagnosis of PID.
The current CDC treatment guidelines can help health professionals in resource-limited settings combine the right drugs for effective treatment of resistant PID infection. Feel free to share this information with your colleagues.
Dr. Christopher Oseh is an experienced primary care physician, health blogger, content marketing professional, and self-published author. He specializes in creating content for health care providers and health technology companies.
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