Canadian Guidelines on Sexually Transmitted Infections

Supplementary statement for recommendations related to the diagnosis, management, and follow-up of Pelvic Inflammatory Disease: March 2014

Key Issue

The Gonococcal Infections chapter has been revised in response to emerging antimicrobial resistance. As a result, the 2010 print and online versions of the Pelvic Inflammatory Disease (PID) chapter of the Canadian Guidelines on Sexually Transmitted Infections also require updates.

This statement is intended to inform clinicians of key changes in the management of PID until such time as the full chapter revision is available. It addresses the key changes to the outpatient management of PID. The recommendations apply to non-pregnant HIV- negative women only.

Refer to the full chapter for hospitalization criteria (Table 3); special management considerations; and inpatient parenteral treatment recommendations (Table 4) for pregnant and breast feeding women, HIV-positive women, and adolescents.

Diagnosis

  • Evaluation for PID remains the same as outlined in the current chapter with the exception of the following laboratory testing considerations:
    • Detection of N. gonorrhoeae or C. trachomatis may be enhanced by the use of nucleic acid amplification tests (NAAT). Culture for N. gonorrhoeae is strongly recommended to evaluate PID as it allows for antimicrobial susceptibility testing. Consideration should be given to collection of samples for both culture and NAAT.

Treatment

The management of women with PID is considered inadequate unless their sexual partners are also clinically evaluated.

  • The recommended outpatient treatment regimens for PID remain the same as outlined in Table 5 of the current chapter, with the following exceptions/additions that clinicians should be aware of:
    • Due to the rapid increase in quinolone-resistant N. gonorrhoeae, quinolones such as ofloxacin, ciprofloxacin, and levofloxacin are no longer recommended for treating gonococcal infections in Canada, unless local resistance rates are known to be under 5%. Refer to the Gonococcal Infections chapter for detailed information on antimicrobial resistance in N. Gonorrhoeae.
    • Clinical trials have shown that quinolones are very effective at producing cure of acute PID. Due to the polymicrobial nature of PID, quinolones can still be useful in the treatment of acute infections that do not involve quinolone resistant N. gonorrhoeae.
  • Consultation with an experienced colleague is recommended for patients who have suspected or confirmed gonococcal PID and contraindications to treatment with cephalosporins and/or quinolones.

Follow-up

  • All outpatients treated for PID should undergo evaluation 2-3 days after the initiation of treatment.
  • Pain and tenderness resulting from acute PID should begin to resolve within 48 to 72 hours of initiating antibiotics.
    • If no improvement is observed:
      • Further work-up is essential;
      • Hospital admission for parenteral therapy and observation may be indicated.
  • Those who have confirmed gonococcal PID should be reported to local public health and followed up as per the recommendations in the Partner notification and Follow-up sections of the Gonococcal Infections chapter.
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