Pelvic inflammatory disease — Rapid

Synopsis

Diagnose pelvic inflammatory disease clinically, exclude pregnancy emergencies, start broad treatment without delay and manage abscess, partners and reproductive-health follow-up.

Pelvic inflammatory disease is ascending infection and inflammation of the endometrium, fallopian tubes, ovaries and adjacent peritoneum.
Maintain a low threshold for empirical treatment with pelvic pain and cervical-motion, uterine or adnexal tenderness after important alternatives are assessed.
A negative cervical chlamydia or gonorrhoea test does not exclude upper-genital-tract infection.
Perform a pregnancy test in every person who could be pregnant and urgently exclude ectopic pregnancy when positive or suspected.
BASHH outpatient treatment is ceftriaxone 1 g intramuscularly once plus doxycycline 100 mg twice daily and metronidazole 400 mg twice daily for 14 days.
Admit for severe illness, pregnancy, tubo-ovarian abscess, inability to take oral medicine, uncertain surgical diagnosis or inadequate outpatient response.
Arrange chlamydia and gonorrhoea NAAT, full STI testing, partner notification and abstinence until treatment and partner management are complete.
Review within 72 hours; lack of improvement requires ultrasound, reconsideration of appendicitis or ectopic pregnancy and possible drainage.

Key red flags

Positive pregnancy test with pain, bleeding, syncope or shoulder-tip pain requires emergency ectopic assessment.

Haemodynamic instability, high fever, vomiting or peritonism indicates severe disease needing hospital care.

Adnexal mass or persistent fever suggests tubo-ovarian abscess requiring imaging and possible drainage.

Right upper-quadrant pleuritic pain may reflect perihepatitis but hepatobiliary emergencies still need assessment.

Failure to improve within 72 hours requires diagnostic reconsideration, imaging and specialist review.

Systemic or abscess features

High fever, vomiting, marked focal adnexal tenderness, pelvic mass or peritonism suggests severe disease or tubo-ovarian abscess.

Ectopic pregnancy overlap

Amenorrhoea, positive pregnancy test, unilateral pain, bleeding, shoulder-tip pain or syncope requires immediate ectopic pregnancy assessment.

Investigation priorities

Pregnancy testFirst step

Identify ectopic pregnancy risk and alter antimicrobial and admission decisions.

Management branches

OUTPATIENTTreat clinically without delay

Pelvic inflammatory disease is likely, the patient is stable and no admission criterion or surgical emergency is present.

Perform pregnancy testing, pelvic assessment and STI sampling, but do not await results when the clinical treatment threshold is met.
Give ceftriaxone 1 g intramuscularly once plus doxycycline 100 mg twice daily and metronidazole 400 mg twice daily for 14 days.
Explain adherence, adverse effects, abstinence, partner notification and emergency features and arrange sexual-health follow-up.
Review response within 72 hours; escalate for worsening pain, fever, vomiting, syncope or inability to take treatment.

Key medicines

Ceftriaxone, doxycycline and metronidazoleGive ceftriaxone 1 g intramuscularly once, doxycycline 100 mg orally twice daily for 14 days and metronidazole 400 mg orally twice daily for 14 days.Check severe beta-lactam allergy and pregnancy, counsel about doxycycline oesophagitis and photosensitivity, metronidazole alcohol and warfarin interaction, and complete every component.

Ceftriaxone plus doxycycline inpatient regimenGive ceftriaxone 2 g intravenously once daily plus doxycycline 100 mg orally or intravenously twice daily until improvement, then complete 14 days with doxycycline and metronidazole.Use specialist guidance in pregnancy or severe allergy, review renal and hepatic function and ensure anaerobic cover with metronidazole during oral completion.

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