In cases of moderate or severe PID, pelvic mass, or if the woman is pregnant, consider admission to hospital.
Clinicians should consider other causes of abdominal pain, including complications of pregnancy. All women with PID should be tested for Chlamydia trachomatis and Neisseria gonorrhoea, and where testing is available, for Mycoplasma genitalium, which has been implicated in upper genital tract infection in women.
For women presenting with clinically mild-moderate PID where admission is not required and where a sexually transmitted infection is suspected, use:
- Azithromycin 1 g taken as a single oral dose
- Doxycycline 100 mg bd for 14 days
- Metronidazole 400 mg bd for 14 days
If there is a history of recent sex with a partner from overseas or any other reason to suspect Neisseria gonorrhoea, add:
- Ceftriaxone 500 mg IM or IV (at least once, or daily for 3 - 5 days until improved)
If the woman is a contact of Mycoplasma genitalium, or the MG test is positive, omit / stop doxycycline and metronidazole and use moxifloxacin 400mg daily for 14 days.
Women should demonstrate significant clinical improvement within 3 days of initiation of therapy. If there is no significant improvement, consider admission to hospital for investigation and management.
Consider removing an IUCD in women with mild to moderate PID if there is no clinical improvement at 72 hours. There are limited data on whether an IUCD should be removed or left in place with a diagnosis of mild to moderate PID although there is a suggestion that short term clinical outcomes may be better if it is removed. Ideally at least 36 hours of antibiotics should be given prior to removal of the IUCD.
If clinically responding continue treatment for a full 2 weeks.
A repeat test to exclude re-infection is recommended at three months as re-infection rates are high. Test-of-cure is not recommended, apart from in pregnancy. However, repeat testing should be performed at least 3 weeks after completion of treatment if symptoms persist or if there is concern regarding adherence or reinfection from an inadequately treated partner.
Partner notification should be discussed with patients if a specific pathogen is detected. Consider referring patients to the Let Them Know website (www.letthemknow.org.au) which is designed to support patients to undertake partner notification and which facilitates sending of SMS and email messages to partners. Partners should be contacted, tested and treated without waiting for their test results. Individuals should abstain from sex with their partners until 7 days after both have received treatment.