All patients with presumed PID should have a pregnancy test, as PID in pregnancy is an indication for hospitalization, and ectopic pregnancy and septic abortion are in the differential diagnosis of PID.

A urinalysis is helpful to exclude urinary tract infection.

Of note, an elevated WBC count is not a CDC criterion for diagnosis, because fewer than two-thirds of women with PID have a WBC count of more than 10,000 cells/mcL.¹⁶

As the clinical diagnosis of PID is imprecise due to the nonspecific nature of the presenting signs and symptoms, the Centers for Disease Control and Prevention recommends that health care providers maintain a low threshold for diagnosis and empiric treatment for patients with presumed PID.

Recent guidelines recommend treatment for any patient who has lower abdominal tenderness on palpation, adnexal tenderness, and cervical motion tenderness in the absence of an established cause other than PID.¹⁵

Treatment

While PID was originally considered an indication for hospital admission and parenteral therapy, there is now a dominant trend toward outpatient treatment.

Currently, just 10%–25% of women diagnosed with PID are hospitalized.¹⁷ The CDC has established these criteria as indications for hospitalization:

pregnancy, lack of response to or intolerance of oral medications, nonadherence to therapy, severe clinical illness, pelvic abscess, or possible need for surgical intervention.¹⁸

Because the efficacy both of oral and parenteral therapies has been supported by randomized clinical trials, decisions concerning appropriate antimicrobial therapy are influenced instead by cost, allergy history, and resistance patterns.¹⁹

Regardless of whether oral or parenteral therapy is used, the CDC recommends a 14-day course of antibiotics.¹⁵

Recommended outpatient regimens include:¹⁵

• Ceftriaxone (250 mg IM) plus doxycycline (100 mg p.o. b.i.d. for 14 days).
• Cefoxitin (2 g IM) with probenicid (1 gram p.o. once) plus doxycycline (100 mg p.o. b.i.d. for 14 days).
• Any other third-generation cephalosporin in a single IM dose combined with doxycycline for 14 days.

The decision of whether to add metronidazole to the treatment regimen is addressed in the controversies section.

As of 2007, the CDC no longer recommends the use of fluoroquinolones as first-line therapy for PID, given increasingly high rates of gonorrheal resistance.¹⁵ Thus, outpatient therapy in the truly cephalosporin-allergic patient is very limited.

Depending on the severity of illness, the most effective treatment regimen is admission for parenteral therapy with clindamycin plus gentamicin.