Approach to managing pelvic inflammatory disease

Prompt treatment of pelvic inflammatory disease (PID) reduces the risk of tubal damage and, consequently, infertility, ectopic pregnancy and chronic pelvic painBritish Association for Sexual Health and HIV (BASHH), 2019Ong, 2023.

The choice of empirical antibiotic therapy for PID depends on the cause and the likelihood of a sexually transmissible infection (STI) and related complications.

Although a pathogen is not identified in most cases, the risk of complications associated with PID caused by a sexually transmissible pathogen necessitates prompt empirical antibiotic therapy. The empirical regimens for PID have activity against common sexually transmissible pathogens and are effective for most patients regardless of whether an STI is confirmed.

For specific management advice, see:

  • Intra-amniotic infection (chorioamnionitis)
  • Postpartum endometritis
  • Septic abortion for pelvic infection following either spontaneous abortion (miscarriage) or induced abortion (surgical, unsafe, or rarely, medical)
  • Treatment of postprocedural pelvic infection for pelvic infection following other transvaginal gynaecological procedures (including within the first 20 days after insertion of an intrauterine contraceptive device [IUD]) if STIs have been reliably excluded
  • Treatment of PID for
    • pelvic infection following other transvaginal gynaecological procedures (including within the first 20 days after IUD insertion) if STIs cannot be reliably excluded (eg the patient is sexually active and the STI could have been contracted after screening or patient was not investigated for STIs before the procedure)
    • patients with pelvic infection occurring more than 20 days after IUD insertion
    • other causes of PID, if STIs cannot be excluded.

For additional considerations for patients with an IUD, see Considerations for patients with an intrauterine contraceptive device.

Empirical therapy for severe PID is usually required for patients who are pregnant or who have any of the following features of severe PIDWorkowski, 2021:

  • inability to tolerate or absorb oral therapy
  • severe pain
  • fever (38°C or higher)
  • systemic features (eg tachycardia, vomiting)
  • sepsis or septic shock
  • suspicion of tubo-ovarian abscessChappell, 2012.

Empirical therapy for nonsevere PID is appropriate for nonpregnant patients who do not have any of the above features.

For principles of STI management, including investigations and counselling, see Principles of sexually transmissible infection management.