Outpatient antibiotic regimen
› CDC 2021 preferred outpatient regimen
› Ceftriaxone 500 mg IM single dose
› If weight >150 kg, use ceftriaxone 1 g IM
› Plus doxycycline 100 mg PO twice daily for 14 days
› Take with food and water to reduce GI side effects
› Avoid dairy products within 1 to 2 hours of dose
› Plus metronidazole 500 mg PO twice daily for 14 days
› Provides anaerobic coverage
› Avoid alcohol during therapy (disulfiram-like reaction)
› Alternative outpatient regimen
› Cefoxitin 2 g IM single dose plus probenecid 1 g PO single dose
› Followed by doxycycline 100 mg PO twice daily for 14 days
› Plus metronidazole 500 mg PO twice daily for 14 days
› Fluoroquinolone regimens
› Not recommended first-line due to quinolone-resistant N. gonorrhoeae
› May be considered only when all of the following apply
› Cephalosporin allergy
› Low local gonorrhea prevalence
› Reliable follow-up confirmed
› NAAT negative for gonorrhea
Inpatient antibiotic regimens
› Preferred parenteral regimen A
› Ceftriaxone 1 g IV every 24 hours
› Continue until 24 to 48 hours of clinical improvement
› Plus doxycycline 100 mg PO or IV every 12 hours
› Oral preferred due to better bioavailability and less vein irritation
› Plus metronidazole 500 mg IV or PO every 12 hours
› Particularly important for TOA — anaerobic coverage essential
› Alternative parenteral regimen B
› Cefotetan 2 g IV every 12 hours
› Plus doxycycline 100 mg PO every 12 hours
› Or cefoxitin 2 g IV every 6 hours
› Plus doxycycline 100 mg PO every 12 hours
› Clindamycin plus aminoglycoside regimen
› For cephalosporin allergy
› Clindamycin 900 mg IV every 8 hours
› Excellent anaerobic and gram-positive coverage
› Plus gentamicin loading dose 2 mg/kg IV then 1.5 mg/kg IV every 8 hours
› Or single daily dosing 5 to 7 mg/kg IV every 24 hours
› Renal function monitoring required
› Particularly appropriate for TOA per CDC
› Transition to oral therapy
› After 24 to 48 hours of clinical improvement
› Defervescence and reduction in abdominal tenderness
› Complete 14 days total course
› Doxycycline 100 mg PO twice daily to complete course
› Metronidazole 500 mg PO twice daily if indicated
› Initial antibiotic selection for TOA
› Clindamycin plus aminoglycoside may be particularly appropriate
› Superior anaerobic coverage for abscess
› Or add metronidazole to cephalosporin-doxycycline backbone
› Enhances anaerobic coverage
› Minimum 14 days total antibiotic duration
› Drainage indications
› Failing IV antibiotics after 72 hours
› Persistent fever and leukocytosis
› No reduction in abscess size on imaging
› Ruptured TOA — emergent surgical management
› OB/GYN emergency
› Drainage approaches
› CT or ultrasound-guided percutaneous drainage
› Transvaginal ultrasound-guided drainage
› Laparoscopic drainage if percutaneous not feasible
Adjunctive and supportive measures
› Pain management
› NSAIDs for mild to moderate pain
› Adjunctive only — do not improve clinical outcomes of PID per evidence
› Opioid analgesics for severe pain
› Titrate to comfort while monitoring response
› IUD management
› IUD does not need to be removed in most cases
› Removal does not hasten resolution and may delay it
› All contraceptive methods can be continued during treatment
› Consider removal only if no clinical improvement after 72 hours
› Partner treatment
› All partners within prior 60 days treated empirically
› Expedited partner therapy where legally permitted
› Abstain from intercourse until both partners complete therapy and symptoms resolve
› Hydration and supportive care
› IV fluids if unable to tolerate oral intake
› Antiemetics for nausea
› Adequate nutrition during treatment
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