Empiric Therapy for Pelvic Inflammatory Disease: An Overview

What Is Empiric Therapy?

Empiric therapy refers to the initiation of treatment before the determination of a firm diagnosis. When the specific microorganism causing the infection in a person is not known, then empiric therapy is used. It is based on the basis of clinically evaluated guesses. Empiric antibiotics are normally broad-spectrum; they treat a wide variety of microorganisms. And when more information is collected from a blood culture, the empiric treatment may be changed to target antibiotic treatment.

What Is Pelvic Inflammatory Disease?

An infection of a women's reproductive organ is called a pelvic inflammatory disease (PID). It occurs when sexually transmitted infections spread from the vagina to the uterus, ovaries, or fallopian tubes. Pelvic inflammatory disease symptoms can be subtle or mild. Few women may not experience any symptoms. So, they may not be aware of having an infection until they have trouble getting pregnant or develop chronic pelvic pain.

What Is Empiric Treatment for Pelvic Inflammatory Disease?

Empiric treatment for pelvic inflammatory diseases is done for young women who are sexually active and women who are a risk for sexually transmitted diseases (STD) if they have pelvic tenderness and lower abdominal pain. In addition, empiric therapy for pelvic inflammatory disease is advised if one or more of the following are present on examination; uterine tenderness, cervical motion tenderness, or adnexal tenderness (pain or discomfort in the area of the female reproductive organs, which include the ovaries, fallopian tubes, and surrounding structures such as the uterus, bladder, and rectum).

Empiric therapy for pelvic inflammatory disease should be broad-spectrum and should include drugs that are effective against Chlamydia trachomatis and Neisseria gonorrhoeae.

The treatment of PID should also include anaerobic coverage. The regimes provided for outpatient have moderate coverage, while regimes provided for inpatient have excellent coverage. Some researchers suggest that all women should be given anaerobic antibiotics, while others suggest that only women with severe diseases and hospitalization or women with tubo-ovarian abscesses require this.

1) Parenteral Therapy for Severe PID:

This is recommended by the CDC (Center For Disease Control and Prevention).

• Cefoxitin, 2 grams IV (intravenous) for every six hours, with Doxycycline 100 mg orally or IV for every 12 hours. (or)

• Cefotetan, 2 grams IV for every 12 hours, and Doxycycline 100 mg orally or IV for every 12 hours. (or)

• Clindamycin 900 mg IV for every eight hours and Gentamicin 2 milligram per kilogram IV should be followed by a maintenance dose of 1.5 milligrams per kilogram for every eight hours. Gentamicin 3 to 5 milligrams per kilogram of single daily dosing can be substituted for three times daily dosing.

Alternative regimen as per CDC with limited data:

• Ampicillin-sulbactam three grams IV for every six hours with Doxycycline 100 milligrams orally or IV every 12 hours. (or)

• Clindamycin 900 milligrams IV for every eight hours and Gentamicin loading dose IM (intramuscular) or IV (2 milligrams per kilogram body weight) should be followed by a maintenance dose (1.5 milligrams per kilogram body weight) for every eight hours; single daily dosing (3 to 5 milligrams per kilogram body weight) can be substituted.

When using the Gentamicin and Clindamycin alternative parenteral regimen, if there is clinical improvement in the patient after 24 to 48 hours, they can be transitioned to Doxycycline (100 milligrams orally two times per day) or Clindamycin (450 milligrams orally four times per day) to complete the 14-day therapy. However, in women with tubo-ovarian abscesses, Metronidazole (500 milligrams orally two times per day) or Clindamycin (450 milligrams orally four times per day) should be taken to complete 14 days of therapy along with oral Doxycycline to provide effective anaerobic coverage.

2) Oral Therapy for Mild to Moderate Pelvic Inflammatory Disease:

As recommended by the CDC:

• Ceftriaxone 250 milligrams IM in a single dose with Doxycycline 100 milligrams orally two times a day for 14 days, with or without Metronidazole 500 milligrams orally times a day for 14 days. (or)

• Cefoxitin, 2 grams IM in a single dose and Probenecid one gram orally in a single dose with Doxycycline 100 milligrams orally two times a day for 14 days, with or without Metronidazole 500 milligrams orally two times a day for 14 days. (Or)

• Cefotaxime, 1 gram IM in a single dose or Ceftizoxime, 1 gram IM in a single dose, and Doxycycline 100 milligram orally twice a day for 14 days.

Ceftriaxone has the finest coverage against gonococcal disease, and Ceftriaxone is the preferred antibiotic in conjunction with Doxycycline. For women with bacterial vaginosis or Trichomonas vaginalis, it is advised to add Metronidazole.

Alternative oral therapy for Cephalosporin or Penicillin allergic patients

• Penicillin allergy patients who cannot tolerate Cephalosporins may be prescribed Fluoroquinolones (Ofloxacin 400 mg orally or Levofloxacin 500 mg orally two times a day for 14 days), with or without Metronidazole (500 mg orally two times a day for 14 days). This regimen cannot be prescribed to individuals whose suspicion of N. gonorrhea is resistant or low in the community is less than five percent.

• Fluoroquinolones are no longer recommended secondary to high resistance if N. gonorrhea is the suspected pathogen.

• If Fluoroquinolone is planned to prescribe for a patient, then N. gonorrhea should be cultured first for the patient.

• If cultures result in quinolone-resistant N. gonorrhea (QRNG) or if the antimicrobial susceptibility cannot be assessed, then parenteral Cephalosporin therapy is recommended. Even if the Cephalosporin therapy is not practical, Azithromycin two grams orally should be added to the normal regimen.

• The patient should be hospitalized with a Gentamicin loading dose of two milligrams per kilogram and Clindamycin 900 mg intravenously every eight hours. If the condition of the patient improves with this regimen, then treatment can be changed to oral Doxycycline 100 milligrams orally every 12 hours for 14 days.

Conclusion

Pelvic inflammatory disease is the infection of the female reproductive system. Some women may develop symptoms like severe pelvic pain as the infection spreads to all the reproductive organs, which can even lead to infertility. So empiric therapy is often recommended. In mild to moderate cases, oral therapy is recommended, and in severe cases, hospitalization may be required with prenatal therapy.