This document discusses the guidelines, clinical criteria, management, and treatment of acute pelvic inflammatory disease (PID). The goals of PID treatment are to treat infection, minimize tubal damage, prevent adhesions, and reduce risks of complications. Treatment involves antimicrobial therapy to cover gonococcal, chlamydial, aerobic, and anaerobic infections. Management may be outpatient or inpatient depending on severity of infection. Surgical intervention can be used in some cases to drain abscesses. Follow up is important to ensure adequate response to therapy and reduce risk of chronic PID or infertility.

1. Aswathi Raveendran U.V

2. Acute PID
Goals of treatment:
 Treat infection
 Minimize tubal damage
 Prevent adhesions
 Reduce the risk of complications , sequelae and chronic
PID

3. CDC Guidelines
 Minimum Criteria
 Lower abdominal pain
 Adnexal tenderness
 Cervical motion tenderness

4.  Additional Criteria
 Oral temperature > 38o C
 Vaginal/ cervical discharge – mucopurulent
 Vaginal discharge – WBCs on microscopy
 Elevated ESR
 Elevated CRP
 Laboratory documentation of cervical infection with
N.gonorrhoeae or C.trachomatis

5.  Definitive Criteria
 Endometrial biopsy :
 Histopathological evidence of endometritis
 Trans Vaginal Ultra sonogram / MRI
 Thickened tubes
 Fluid filled tubes
 Tubo ovarian mass
 Laparoscopy
 Changes consistent with PID:
 Dilated hyperemic tubes
 Pyosalpinx
 Tubo-ovarian mass

6. Clinical criteria for initiating
therapy
In young women
Women at risk of STI
Minimum criteria present
No other cause for illness identified
Start Empiric treatment

7. Management Of Acute PID
 Assessment of need for hospitalization
 Antimicrobial therapy
 Treatment of partners
 Counseling
 Assessment of response to therapy
 Surgical intervention
 Follow up for sequelae

8. Outpatient
One or more of
minimum
criteria present
No severe
infection
Inpatient
Moderate to
Severe
infection
Inadequate
response to OP
treatment

9. Drugs and DosagesDRUG DOSE DURATION
CEFTRIAXONE 250mg IM single dose (or)
CEFOXITIN 2g IM single dose
(+ PROBENECID)
(or)
Other THIRD –
GENERATION
CEPHALOSPORIN
IM single dose
With
DOXYCYCLINE
100 mg oral BD 14 days
With or without
METRONIDAZOLE
400mg twice daily 14 days

10.  Drugs should cover gonococcal , chlamydial, aerobic
and anaerobic infections
 Re assess after 48-72 hours
 In adequate response – hospital admission

11. Indications for Admission to
hospital
 Surgical emergencies cannot be ruled out
 No response to OP oral treatment
 Presence of Tubo-ovarian abscess
 Clinically severe disease with nausea, vomiting and
high fever
 PID in pregnancy

12. Inpatient Management of PID
 Rest
 IV Fluids
 Dehydration
 Vomiting
 Electrolyte imbalance
 Analgesics
 Antibiotics at the earliest

13. DRUG DOSE DURATION
REGIMEN A
CEFOTETAN 2g IV every 12hrs (or) Upto 24 hours after
patient becomes
afebrile
CEFOXITIN 2g IV every 6 hrs
+
DOXYCYCLINE
100mg oral/ IV every 12hr Continue oral BD *
14days
REGIMEN B
CLINDAMYCIN 900mg IV every 8hrs 24 hrs after patient
become afebrile,
450mg oral QID *
14days
+ GENTAMICIN 2mg/kg IV or IM loading
dose
1.5mg/kg every 8 hr
maintenance dose
Or single daily dose

14. Alternative Regimens
DRUG DOSE
OFLOXACIN 400mg IV every 12hrs (or)
LEVOFLOXACIN 500mg Iv OD
With/ without
METRONIDAZOLE
AMPICILLIN/ SULBACTAM
500mg IV every 8 hrs (or)
3g IV every 6hr
Plus DOXYCYCLINE 100mg oral / IV every 12hrs

15.  Azithromycin 500mg IV 6th hourly x 2 days , followed
by oral therapy -for Chlamydia
 Placentrex
 Aqueous extract of fresh placenta
 2ml IM daily/ alternate days
 10 injections
 Anti inflammatory / tissue regeneration/ wound healing
/significant immunotropic action

16. Actinomyces PID
 Anaerobic gm positive organism
 Associated with IUCD – 7% higher incidence
 Fever , abdominal pain, bleeding , discharge
 Penicillin 2,50,000units/kg IV daily x 4 doses for 2-6
weeks
 Followed by oral penicillin 100mg/kg daily x 3- 12
months
 Tetracycline/ Erythromycin/Clindamycin/
Chloramphenicol

17. Surgical Interventions
 Ultrasound guided aspiration
 Pelvic abscess – 70% success
 Subdiaphragmatic collection
 May cause rupture/ pelvic vein thrombosis/ C/c
infection
 Posterior colpotomy
 Incision on posterior vaginal fornix to drain pelvic
abscess

18. Minimal Invasive Surgery
Laparoscopic aspiration/drainage/adhesiolysis
 Tubo-ovarian abscess
 Size of abscess > 10cm
 Failure to respond to antibiotics in 48 -72 hrs
 Abscess ruptures
 Pyo peritoneum
 Pelvic abscess
 Complications : recurrence / chronic PID / tubal
blockage / chronic pelvic pain

19.  Dilatation and evacuation:
 Post abortal sepsis
 Laparotomy
 Rupture of tubo-ovarian abscess
 Multiple intra abdominal collections
 Salpingo – oophorectomy
 Tubo-ovarian mass / abscess

20. Management of sexual partners
 Contact partners within 6 months of ondet of disease
 Screen for gonococcal/ chlamydial infections
 If screening not possible start empirical treatment
 Avoid intercourse till the partner completes treatment

21. Counselling
 Practice safe sex , prevent re infection & sequelae
 Early treatment reduces the risk not eliminate
 Barrier contraception
 Recurrence increases risk of infertility
 Treatment of sexual partner

22. Follow up
 After 6 – 8 weeks
 Ensure adequate response to therapy
 Compliance
 Counselling

23. Management of Chronic PID
 Surgical treatment
 Depends on
 Age
 Parity
 Symptoms and pelvic pathology

24.  Laparoscopy
 Adhesiolysis - by laser or electro cautery
 Salpingo - oophorectomy
 Laparotomy
 Adhesiolysis
 Salpingo-oophorectomy
 Hysterectomy with BSO
 Tuboplasty
 Tubal lumen blocked
 Hysteroscopic falloposcopy assess extent of damage
 Laparoscopic salpingoscopy

25. Prognosis
 Boer – Meisel system of prognostic evaluation
 Extent of adhesions
 Nature of adhesions : flimsy/ dense
 Size of hydrosalpinx
 Macroscopic condition of hydrosalpinx
 Thickness of tubal wall

26. End Results
 Decreased mortality rates
 Considerable Morbidity persists :
 Chronic pelvic pain
 Menorrhagia
 Ectopic pregnancy
 Infertility
 Back ache, dyspareunia, vaginal discharge

27. 15%
• Fail to respond to chemo therapy
20%
• At least one recurrence
• Chronic pelvic pain
15%
• Infertility
8%
• Of those who conceive have ectopic pregnancy

28. Prophylaxis
Hospital
delivery
Trained
dais
Reduce
puerperal
infection
Contraception
Barrier
method
Minipills /
OCPs
Sex education Risk of STD
Femshield
use