PID: Treatment

	Recomended	Alternatives
NAG 2014
IV Therapy (for moderate to severe disease):	Cefuroxime 1.5gm IV q8h OR Ceftriaxone 2gm IV q24h PLUS Doxycycline 100mg PO q12h PLUS Metronidazole 500mg IV/PO q8h Duration of treatment is 14 days	Ampicillin/Sulbactam 3gm IV q6h PLUS Doxycycline100mg PO q12h
Outpatient therapy (for mild disease)	Ceftriaxone 250mg IM in a single dose OR Cefotaxime 1gm IM in a single dose PLUS Doxycycline 100 mg PO q12h for 14 days	Ceftriaxone 250mg IM in a single dose OR Cefotaxime 1gm IM in a single dose PLUS Azithromycin (1gm once per week for 2 weeks)
CDC STD Treatment Guideline 2015
IV Therapy	Clindamycin 900 mg IV every 8 hours PLUS Gentamicin loading dose IV or IM (2 mg/kg), followed by a maintenance dose (1.5 mg/kg) every 8 hours. Single daily dosing (3–5 mg/kg) can be substituted	Ampicillin/Sulbactam 3 g IV every 6 hours PLUS Doxycycline 100 mg orally or IV every 12 hours
IM/Oral Therapy	Ceftriaxone 250 mg IM in a single dose PLUS Doxycycline 100 mg orally twice a day for 14 days WITH* or WITHOUT Metronidazole 500 mg orally twice a day for 14 days Other parenteral third-generation cephalosporin (e.g., ceftizoxime or cefotaxime) PLUS Doxycycline 100 mg orally twice a day for 14 days WITH* or WITHOUT Metronidazole 500 mg orally twice a day for 14 days	Azithromycin (500 mg IV daily for 1–2 doses, followed by 250 mg orally daily for 12–14 days (as monotherapy) OR In combination with metronidazole (12 days) Azithromycin 1 g orally once a week for 2 weeks in combination with ceftriaxone 250 mg IM single dose

Rationale for IV

• doxycycline should be administered orally when possible (due to pain). Oral and IV administration of doxycycline provide similar bioavailability.
• Although use of a single daily dose of gentamicin has not been evaluated for the treatment of PID, it is efficacious in analogous situations
• For the clindamycin/gentamicin regimen,  oral therapy with clindamycin (450 mg orally four times daily) or doxycycline (100 mg twice daily) can be used to complete the 14 days of therapy. 
• However, when tubo-ovarian abscess is present, clindamycin (450 mg orally four times daily) or metronidazole (500 mg twice daily) should be used to complete at least 14 days of therapy with doxycycline to provide more effective anaerobic coverage than doxycycline alone.
• Ampicillin/sulbactam plus doxycycline has been investigated in at least one clinical trial and has broad-spectrum coverage.  Ampicillin/sulbactam plus doxycycline is effective against C. trachomatis, N. gonorrhoeae, and anaerobes in women with tubo-ovarian abscess.
• Another trial demonstrated high short-term clinical cure rates with azithromycin, either as monotherapy for 1 week (500 mg IV daily for 1 or 2 doses followed by 250 mg orally for 5–6 days) or combined with a 12-day course of metronidazole

Rationale for IM/Oral

• these regimens are similar to those treated with intravenous therapy
• Patients who do not respond to oral therapy within 72 hours should be reevaluated to confirm the diagnosis and should be administered parenteral therapy on either an outpatient or inpatient basis
• No data have been published regarding the use of oral cephalosporins for the treatment of PID.
• addition of metronidazole should be considered to provide anaerobic coverage
• The recommended third-generation cephalsporins are limited in the coverage of anaerobes. Therefore, until it is known that extended anaerobic coverage is not important for treatment of acute PID, the addition of metronidazole to treatment regimens with third-generation cephalosporins should be considered
• Azithromycin has demonstrated short-term clinical effectiveness in one randomized trial when used as monotherapy) or in combination with metronidazole , and in another study, it was effective when used
• If allergy precludes the use of cephalosporin therapy, use of fluoroquinolones for 14 days (levofloxacin 500 mg orally once daily, ofloxacin 400 mg twice daily, or moxifloxacin 400 mg orally once daily) with metronidazole for 14 days (500 mg orally twice daily) can be considered

References:

1. http://www.cdc.gov/std/tg2015/pid.htm
2. National Antibiotic Guideline 2014
3. www.uptodate.com