Pelvic Inflammatory Disease (PID)

Description

General measures

Medicine treatment

Referral

---

ICD-10 code: N70.0-1/N70.9/N71.0-1/N71.9/N72/N73.0-6/N73.8-9

DESCRIPTION

Pelvic inflammatory disease (PID) includes salpingitis with or without oophoritis. As precise clinical localisation is often difficult, PID denotes a spectrum of conditions resulting from infection of the upper genital tract. Sequelae include:

• recurrent infections if inadequately treated,
• infertility,
• increased probability of ectopic pregnancy, and
• chronic pelvic pain.

Stage	Manifestations
Stage I	- cervical motion tenderness and/or uterine tenderness and/or adnexal tenderness
Stage II	- as stage I, plus pelvic peritonitis
Stage III	- as stage II, plus - tubo-ovarian complex or abscess
Stage IV	- generalised peritonitis - ruptured tubo-ovarian complex - septicaemia

GENERAL MEASURES

• Hospitalise all patients with stage II–IV PID for parenteral antibiotic therapy.
• Frequent monitoring of general abdominal and pelvic signs is essential.
• Admission for parenteral therapy, observation, further investigation and/or possible surgical intervention should also be considered in the following situations:
  • a surgical emergency cannot be excluded
  • lack of response to oral therapy
  • clinically severe disease
  • presence of a tubo-ovarian abscess
  • intolerance to oral therapy
  • pregnancy
• In stage III, surgery is indicated if:
  • the diagnosis is uncertain,
  • there is no adequate response after 48 hours of appropriate therapy,
  • the patient deteriorates on treatment, or
  • there is a large or symptomatic pelvic mass after 6 weeks.

Further Investigation

All sexually active patients should be offered:

• a pregnancy test: an ectopic pregnancy forms part of the differential diagnosis.
• screening for sexually transmitted infections including HIV.

---

 Note:
Remove IUCD if present, and provide alternative contraception.

---

MEDICINE TREATMENT

Stage I

• Azithromycin, oral, 1 g as a single dose

LoE:IIb^xii

AND

• Ceftriaxone, IM, 250 mg as a single dose.
  • Dissolve ceftriaxone, IM, 250 mg in 0.9 mL lidocaine 1% without adrenaline (epinephrine).

LoE:IVb^xiii

AND

• Metronidazole, oral, 400 mg 12 hourly for 7 days.

LoE:IIIb^xiv

Severe penicillin allergy:

ICD-10 code: (Z88.0)

• Azithromycin, oral, 2 g as a single dose.

LoE:Ib^xv

AND

• Metronidazole, oral, 400 mg 12 hourly for 7 days.

Stage II–IV

• Ceftriaxone, IV, 1 g daily.

AND

• Metronidazole, IV, 500 mg 8 hourly.

Continue intravenous therapy until there is definite clinical improvement (within 24-48 hours). Thereafter, change IV therapy to:

• Amoxicillin/clavulanic acid, oral, 875/125 mg 12 hourly to complete 10 days of antibiotic therapy.

LoE:IIIb^xvi 

---

Note:
The addition of metronidazole to amoxicillin/clavulanic acid is unnecessary as amoxicillin/clavulanic acid has adequate anaerobic cover.

---

Severe penicillin allergy:

ICD-10 code: (Z88.0)

• Clindamycin, IV, 600 mg 8 hourly.

AND

• Gentamicin, IV, 6 mg/kg daily (see Prescribing Information for Specific Medicines for guidance on prescribing).

AND

• Azithromycin, oral, 1 g, as a single dose.

LoE:IIIb^xvii

Continue intravenous therapy until there is definite clinical improvement (within 24-48 hours). Thereafter, change to:

• Clindamycin, oral, 450 mg 8 hourly.

AND

• Ciprofloxacin, oral, 500 mg 12 hourly to complete 10 days of antibiotic therapy.

---

Note:
The addition of metronidazole to clindamycin is unnecessary as clindamycin has adequate anaerobic cover.

---

REFERRAL

• Stages III and IV should be managed in consultation with a gynaecologist.
• For surgical intervention – See indications above.

Click here for the pdf 

---

Standard Treatment Guidelines and Essential Medicines List for South Africa Adult Hospital _Chapter 5: Gynaecology; Version 1.0, 2020-4_June 2024