In addition to these evidence-based recommendations, the guideline development group also identifies points of best clinical practice in the original guideline document.
Classification of evidence levels (1++ to 4) and grades of recommendations (A-D) are defined at the end of the "Major Recommendations" field.
Making a Diagnosis of Acute Pelvic Inflammatory Disease (PID)
B - A low threshold for empiric treatment of PID is recommended because of the lack of definitive clinical diagnostic criteria and because the potential consequences of not treating of PID are significant. In clinically severe cases, referral to hospital for treatment and further investigation is advisable.
The following clinical features are suggestive of a diagnosis of PID:
- Bilateral lower abdominal tenderness (sometimes radiating to the legs)
- Abnormal vaginal or cervical discharge
- Fever (greater than 38°C)
- Abnormal vaginal bleeding (intermenstrual, postcoital or 'breakthrough')
- Deep dyspareunia
- Cervical motion tenderness on bimanual vaginal examination
- Adnexal tenderness on bimanual vaginal examination (with or without a palpable mass)
B - Women with suspected PID should be tested for gonorrhoea and chlamydia.
Testing for gonorrhoea should be with an endocervical specimen and tested via culture (direct inoculation on to a culture plate or transport of swab to laboratory within 24 hours) or using a nucleic acid amplification test (NAAT). If gonorrhoea is detected using a NAAT, an additional endocervical swab should be taken for gonococcal culture to allow the reporting of antibiotic sensitivities and revision of therapy if required (women at high risk of gonorrhoea should have an endocervical swab for gonococcal culture taken at their first examination; for example, where the woman's partner has gonorrhoea, clinically severe disease, sexual contact abroad). [Evidence level 2+]
Testing for chlamydia should also be from the endocervix, preferably using a NAAT (such as polymerase chain reaction, strand displacement amplification). [Evidence level 2+]
Taking an additional sample from the urethra can increase the diagnostic yield for gonorrhoea and chlamydia but is only recommended if the more sensitive NAAT is not available. A first catch urine or self-taken vulvovaginal swab sample provides an alternative sample for some NAATs. [Evidence level 2+]
How Should PID Be Managed in the Outpatient Setting?
B - Outpatient antibiotic treatment should be commenced as soon as the diagnosis is suspected.
B - Outpatient antibiotic treatment should be based on one of the following regimens:
- Oral ofloxacin 400 mg twice daily plus oral metronidazole 400 mg twice daily for 14 days
- Intramuscular ceftriaxone 250 mg single dose*, followed by oral doxycycline 100 mg twice daily plus metronidazole 400 mg twice daily for 14 days.
*Cefoxitin has a better evidence base for the treatment of PID than ceftriaxone but is not easily available in the UK. Ceftriaxone is therefore recommended.
Broad-spectrum antibiotic therapy is generally required to cover Neisseria gonorrhoeae, Chlamydia trachomatis and anaerobic infection. Ofloxacin should be avoided in women who are at high risk of gonococcal PID because of increasing quinolone resistance in the UK. Those women at high risk of acquiring gonorrhoea include those whose partner has gonorrhoea, in clinically severe disease or if there is a history of sexual contact abroad. [Evidence level 1-]
Metronidazole may be discontinued in those women with mild or moderate PID who are unable to tolerate it, since its addition provides uncertain additional efficacy in this patient group. [Evidence level 1]
What Hospital Treatment Should Be Given and When Should It Be Recommended?
Admission to hospital would be appropriate in the following circumstances:
- Surgical emergency cannot be excluded
- Clinically severe disease
- Tubo-ovarian abscess
- PID in pregnancy
- Lack of response to oral therapy
- Intolerance to oral therapy
B - Inpatient antibiotic treatment should be based on intravenous therapy which should be continued until 24 hours after clinical improvement and followed by oral therapy.
Recommended regimens are:
- Ceftriaxone 2 g by intravenous infusion daily plus intravenous doxycycline 100 mg twice daily (oral doxycycline may be used if tolerated), followed by oral doxycycline 100 mg twice daily plus oral metronidazole 400 mg twice daily for a total of 14 days.
- Intravenous clindamycin 900 mg three times daily plus intravenous gentamicin*, followed by either
- Oral clindamycin 450 mg four times daily to complete 14 days
- Oral doxycycline 100 mg twice daily plus oral metronidazole 400 mg twice daily to complete 14 days
- Intravenous ofloxacin 400 mg twice daily plus intravenous metronidazole 500 mg three times daily for 14 days
*Gentamicin should be given as a 2 mg/kg loading dose followed by 1.5 mg/kg three times daily (or a single daily dose of 7 mg/kg may be substituted).
Treatment in a Woman with an Intrauterine Contraceptive Device
B - Consideration should be given to removing an intrauterine contraceptive device (IUD) in women presenting with PID, especially if symptoms have not resolved within 72 hours.
Other Modes of Treatment
B - Surgical treatment should be considered in severe cases or where there is clear evidence of a pelvic abscess.
Management of Sexual Partner(s) of Women with PID
B - When a sexually transmitted infection is either proven or likely to be the cause of PID, the current sexual partner(s) should be contacted and offered health advice and screening for gonorrhoea and chlamydia.
Other recent sexual partners may also be offered screening. Tracing of sexual partners within a 6-month period of the onset of symptoms is recommended but this time period may be influenced by the sexual history. The risk of detecting sexually transmitted infections (STIs) in the partners of women with PID is high. Women should be advised to avoid intercourse until they and their partner have completed the treatment course. Gonorrhoea diagnosed in their sexual partner should be treated appropriately and concurrently with the index woman. Concurrent empirical treatment for chlamydia is recommended for all sexual partners, owing to the variable sensitivity of currently available diagnostic tests. If adequate screening for gonorrhoea and chlamydia in the sexual partner(s) is not possible, empirical therapy for both gonorrhoea and chlamydia should be given. Currently recommended regimens are available at www.bashh.org . Tracing of sexual partners is not required where a non-sexually transmitted pathogen has been clearly identified as the cause of infection. [Evidence level 3]
Review of Women with PID
C - In the outpatient setting, review at 72 hours is recommended, particularly for those with a moderate or severe clinical presentation.
Failure to improve clinically suggests the need for further investigation, to exclude competing diagnoses, and may require admission for parenteral therapy and/or surgical intervention.
Further review 4–6 weeks after therapy may be useful to ensure:
- Adequate clinical response to treatment
- Compliance with oral antibiotics
- Screening and treatment of sexual contacts
- Awareness of the significance of PID and its sequelae
- That a repeat pregnancy test is negative, if clinically indicated
Repeat testing for gonorrhoea after treatment is recommended in those initially found to be infected unless sensitivity testing of the isolate confirms sensitivity to the prescribed antibiotic. [Evidence level 4]
Repeat testing for chlamydia and gonorrhoea is appropriate in those in whom persisting symptoms, compliance with antibiotics and/or tracing of sexual contacts indicate the possibility of persisting or recurrent infection. [Evidence level 4]
A repeat chlamydia and gonorrhoea test is not otherwise required. [Evidence level 4]
Women Who Are Infected with Human Immunodeficiency Virus (HIV)
B - Women with PID who are also infected with HIV should be treated with the same antibiotic regimens as women who are HIV negative.
Contraception Options and PID
C - Women on hormonal contraception presenting with breakthrough bleeding should be screened for genital tract infection, especially Chlamydia trachomatis.
All women diagnosed with PID should be provided with information about future contraceptive options and should be assisted in making an informed choice.
Classification of Evidence Levels
1++ High-quality meta-analyses, systematic reviews of randomised controlled trials or randomised controlled trials with a very low risk of bias
1+ Well-conducted meta-analyses, systematic reviews of randomised controlled trials or randomised controlled trials with a low risk of bias
1- Meta-analyses, systematic reviews of randomised controlled trials or randomised controlled trials with a high risk of bias
2++ High-quality systematic reviews of case–control or cohort studies or high-quality case–control or cohort studies with a very low risk of confounding, bias or chance and a high probability that the relationship is causal
2+ Well-conducted case–control or cohort studies with a low risk of confounding, bias or chance and a moderate probability that the relationship is causal
2- Case–control or cohort studies with a high risk of confounding, bias or chance and a significant risk that the relationship is not causal
3 Non-analytical studies; e.g., case reports, case series
4 Expert opinion
Grades of Recommendations
A - At least one meta-analysis, systematic review or randomised controlled trial rated as 1++, and directly applicable to the target population; or
A systematic review of randomised controlled trials or a body of evidence consisting principally of studies rated as 1+, directly applicable to the target population and demonstrating overall consistency of results.
B - A body of evidence including studies rated as 2++ directly applicable to the target population, and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
C - A body of evidence including studies rated as 2+ directly applicable to the target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
D - Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
Good Practice Point - Recommended best practice based on the clinical experience of the guideline development group