Treatment

Patients who are systemically unwell should be advised to rest and be prescribed adequate analgesia. Regular review to assess progress is required. If no improvement is observed after 3 days of antibiotic therapy then alternative diagnoses should be considered. Most patients can be managed as outpatients but those with severe symptoms, such as an acute abdomen, will require inpatient care. If the diagnosis is in doubt or if i.v. antibiotics are considered to be necessary then the patient should be admitted to hospital.

ANTIMICROBIALS

Broad spectrum antibiotic cover to include gonorrhoea, chlamydia and anaerobes is required. The optimal choice of antibiotics may be affected by knowledge of local bacterial resistance patterns, severity of disease, cost and patient convenience. Parenteral therapy should be continued until 24 h after clinical improvement and then switched to oral.

Randomized controlled trail evidence is available to support the use of the antibiotic regimens in Table 42.3 for outpatients and Table 42.4 for inpatients.

Quinolone resistance in gonorrhoea is common in many areas of the world and is rising in the UK. Ofloxacin should therefore be avoided if there is clinical suspicion

Table 42.3 Outpatient antibiotic regimens

Regimen 1* Regimen 2* Regimen 3

Ofloxacin Ceftriaxone 250 mg i.m. stat Moxifloxacin 400 mg BD (or cefoxitin 2 g i.m. stat plus 400 mg OD plus probenecid 1 g

Metronidazole orally stat) 400 mg BD

plus

Doxycycline 100 mg BD

plus

Metronidazole 400 mg BD

BD, twice daily; i.m., intramuscularly; OD, once daily. * To complete 14 days of therapy.

Table 42.4 Inpatient antibiotic regimens

Regimen 1

Regimen 2

i.v. cefoxitin 2 g QID

i.v. clindamycin 900 mg TID

(or cefotetan 2 g BD)

plus

plus

i.v. gentamycin 2 mg/kg

loading dose

i.v. or oral doxycycline

followed by 1.5 mg/kg TID (a

100 mg BD

single daily dose may also be

used)

followed by*

followed by*

oral doxycycline 100 mg BD

plus

oral doxycycline 100 mg BD

metronidazole 400 mg BD

plus

metronidazole 400 mg BD

Regimen 3

Regimen 4

i.v. ofloxacin 400 mg BD

i.v. ciprofloxacin 200 mg BD

plus

plus

i.v. metronidazole 500 mg

i.v. or oral doxycycline 100 mg

TID

BD

plus

followed by*

i.v. metronidazole 500 mg TID

oral ofloxacin 400 mg BD

followed by*

plus

oral metronidazole

oral doxycycline 100 mg BD

400 mg BD

plus

Metronidazole 400 mg BD

BD, twice daily; TID, three times daily; QID, four times daily; i.m., intramuscularly; i.v., intravenously.

* Parenteral therapy should be continued until 24 h after clinical improvement.

Oral therapy to continue to complete 14 days of antibiotics in total.

BD, twice daily; TID, three times daily; QID, four times daily; i.m., intramuscularly; i.v., intravenously.

* Parenteral therapy should be continued until 24 h after clinical improvement.

Oral therapy to continue to complete 14 days of antibiotics in total.

of gonococcal PID, for example, clinically severe disease, history of partner with gonorrhoea, sexual contact abroad. Oral metronidazole can be discontinued in those with mild to moderate PID if the patient is unable to tolerate it.

MANAGEMENT OF PARTNERS

PID is usually secondary to a sexually acquired infection so, unless the male partners are identified and either screened for infection or treated empirically, the woman with PID is at high risk of a recurrence. Current male partners should be offered screening for gonorrhoea and chlamydia, and attempts made to contact other partners within the past 6 months, although the exact time period will be influenced by the sexual history. If screening for sexually acquired infections is not possible then antibiotic therapy effective against gonorrhoea and chlamy-dia should be given empirically to the male partners (Fig. 42.3; see British Association for Sexual Health and HIV guidelines for up to date treatment recommendations - www.bashh.org). The patient and their partners should be advised to avoid intercourse until they have completed the treatment course.

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