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Pelvic inflammatory disease - Management
How should I manage someone with suspected PID?

  • Women with suspected mild or moderate pelvic inflammatory disease (PID) may be treated in primary care if an ectopic pregnancy can be ruled out.
  • Test for other sexually transmitted infections and other genital infections.
    • Refer the woman and her sexual partner(s) to a genito-urinary medicine or sexual health clinic to facilitate screening for infections (and contact tracing). Ideally the woman should be screened for other sexually transmitted diseases before commencing antibiotics so that a diagnosis can be made and is not compromised. However starting antibiotics is a priority if PID is suspected and should not be delayed whilst awaiting an appointment.
  • Provide pain relief with ibuprofen or paracetamol. If the response to either drug is insufficient consider:
    • Combining/alternating paracetamol and ibuprofen, or
    • Adding codeine to paracetamol or ibuprofen.
  • Start empirical antibiotics as soon as a presumptive diagnosis of PID is made clinically. Do not wait for swab results.
    • If the risk of gonococcal infection is low prescribe any of the following:
      • Ofloxacin 400 mg orally twice daily plus oral metronidazole 400 mg twice daily, both for 14 days.
      • Ceftriaxone 250 mg as a single intramuscular dose, plus oral doxycycline 100 mg twice daily and oral metronidazole 400 mg twice daily, both for 14 days.
      • Ceftriaxone 250 mg as a single intramuscular dose, followed by oral azithromycin 1 g per week for 2 weeks (but there is less evidence to support this regimen).
      • Oral cefixime 400 mg as a single dose (off-label use) can be used as an alternative to ceftriaxone 250 mg in the above regimens.
    • If the risk of gonococcal infection is high (the woman's partner has gonorrhoea, her symptoms and signs are clinically severe, or she has had sexual contact whilst abroad) prescribe either of the following:
      • Ceftriaxone 250 mg as a single intramuscular dose, plus oral doxycycline 100 mg twice daily and oral metronidazole 400 mg twice daily, both for 14 days.
      • Cefixime 400 mg as a single oral dose (off-label use), plus oral doxycycline 100 mg twice daily and oral metronidazole 400 mg twice daily, both for 14 days.
      • Regimens containing ofloxacin or azithromycin are not recommended.
    • A regimen of metronidazole and doxycycline (without intramuscular ceftriaxone) is not recommended.
    • See Prescribing information.
  • If there is a risk of a very early pregnancy (too early for a pregnancy test to be positive):
    • Offer paracetamol first line for analgesia. Ibuprofen is an alternative if paracetamol is ineffective but should only be used before 30 weeks gestation.
    • The risk of giving any of the recommended antibiotic regimens at this stage of pregnancy is low. If drug toxicity did occur at this stage of pregnancy, it would result in failed implantation. For a more detailed discussion of potential risks, see Basis for recommendation.
    • Admit women with a positive pregnancy test urgently.
  • Treat women who are infected with HIV the same treatment as women who are not infected. PID should be managed in conjunction with their HIV physician.

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