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Literature review current through: Feb 2023. | This topic last updated: Mar 14, 2022.
INTRODUCTION
Pelvic inflammatory disease (PID) refers to acute infection of the upper genital tract structures
in females, involving any or all of the uterus, fallopian tubes, and ovaries and may involve the
neighboring pelvic organs. Early diagnosis and treatment are believed to be key elements in the
prevention of long-term sequelae, such as infertility and ectopic pregnancy. (See "Pelvic
inflammatory disease: Clinical manifestations and diagnosis".)
The treatment of PID will be reviewed here. The pathogenesis of, risk factors for, and sequelae
following PID are discussed separately. The management of tubo-ovarian abscess is discussed
separately. (See "Pelvic inflammatory disease: Pathogenesis, microbiology, and risk factors" and
"Long-term complications of pelvic inflammatory disease" and "Management and complications
of tubo-ovarian abscess".)
MICROBIOLOGIC CONSIDERATIONS
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Chlamydia and gonorrhea — PID is primarily a disease of sexually active females. The two
most important sexually transmitted organisms associated with acute PID, C. trachomatis and N.
gonorrhoeae, should be the main targets for treatment. Even if endocervical testing is not
positive for either of these pathogens, they should still be covered, as upper tract infection
cannot be ruled out [2].
Although several studies of females with PID have demonstrated the presence of anaerobes in
the genital tract at initial presentation, several regimens without dedicated anaerobic coverage
(eg, ceftriaxone plus doxycycline) result in excellent clinical cure rates among females with mild
to moderate PID [5,8]. However, there may be benefits to anaerobic coverage beyond short-
term clinical response:
● In one trial of 233 females with mild to moderate PID who were randomly assigned to
receive ceftriaxone (single dose) and doxycycline for 14 days with either metronidazole
(500 mg twice daily) or placebo for 14 days, clinical improvement rates at three days were
similar in the two groups (82.8 versus 80.3 percent, respectively) [6]. However, at 30 days,
females in the metronidazole group had a lower rate of pelvic tenderness (9 versus 20
percent); there was also a trend toward higher 30-day clinical cure rates with
metronidazole (96 versus 90 percent), but this was not statistically significant. Females
who received metronidazole were less likely to have bacterial vaginosis (21 versus 54
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percent), and there was a nonsignificant trend toward fewer T. vaginalis infections as well
(5 versus 12 percent). Metronidazole was also associated with lower rates of isolating
anaerobic bacteria from endometrium at 30 days, although the clinical significance of this
finding is uncertain.
There has been concern that the additional gastrointestinal side effects of anaerobic therapy
(eg, metronidazole) would result in nonadherence and inadequately treated PID. However, in
the trial described above, rates of adherence were similar with regimens with and without
metronidazole [6].
M. genitalium — M. genitalium infection has been associated with symptomatic PID. However,
we do not suggest including targeted M. genitalium coverage in empiric PID regimens.
Recommended treatment regimens are not highly effective against M. genitalium, yet clinical
response rates are high.
There are no data on the benefits of screening and treating females with acute PID for M.
genitalium, and there is no consensus on whether PID treatment regimens should include
coverage for this organism. (See "Mycoplasma genitalium infection in males and females".)
Clinicians should maintain a low threshold of suspicion for the diagnosis and treatment of PID.
The presumptive clinical diagnosis of PID is made in sexually active young women or women at
risk for sexually transmitted infections (STIs) who present with pelvic or lower abdominal pain
and have evidence of cervical motion, uterine, or adnexal tenderness on exam [2]. Occasionally,
acute PID can occur in females without recent sexual activity. Treatment is indicated for patients
with this presumptive clinical diagnosis of PID, even if findings are subtle or minimal, since the
risk of long-term complications is higher if treatment is withheld or delayed [1,2].
The evaluation and diagnosis of PID is discussed in detail elsewhere. (See "Pelvic inflammatory
disease: Clinical manifestations and diagnosis", section on 'Evaluation' and "Pelvic inflammatory
disease: Clinical manifestations and diagnosis", section on 'Diagnosis'.)
Evaluation for and diagnosis of tubo-ovarian abscess, a complication of PID, is also discussed in
detail elsewhere. (See "Epidemiology, clinical manifestations, and diagnosis of tubo-ovarian
abscess", section on 'Evaluation of patients with suspected TOA'.)
Most females with PID can be safely treated in outpatient settings. Indications for
hospitalization and parenteral antibiotics include [2]:
● Severe clinical illness (eg, fever ≥38.5°C [101°F], nausea and vomiting)
● Complicated PID with pelvic abscess (including tubo-ovarian abscess) (see "Epidemiology,
clinical manifestations, and diagnosis of tubo-ovarian abscess", section on 'Diagnosis')
● Possible need for invasive diagnostic evaluation for alternate etiology (eg, appendicitis or
ovarian torsion) or surgical intervention for suspected ruptured tubo-ovarian abscess
● Pregnancy
There has been a trend towards outpatient treatment of PID, with only the minority of females
being hospitalized [9,10]. Support for outpatient therapy for mild or moderate PID comes from
the Pelvic Inflammatory Disease Evaluation Clinical Health trial (ie, PEACH trial) [11]. In that trial,
831 females with lower abdominal pain, uterine or adnexal tenderness, and mucopurulent
cervicitis or untreated gonococcal or chlamydial infection were randomly assigned to inpatient
therapy with intravenous cefoxitin for at least 48 hours plus doxycycline or outpatient therapy
with a single intramuscular dose of cefoxitin with probenecid plus doxycycline. Short-term
clinical and microbiologic outcomes and long-term reproductive outcomes (eg, ectopic
pregnancy, chronic pelvic pain) were similar between the two groups.
There are no clinical data to suggest that older age or HIV infection should be considered
criteria for hospitalization [2,12].
ANTIBIOTIC SELECTION
Antibiotic therapy is the cornerstone of pelvic inflammatory disease (PID) treatment. The
therapeutic regimens for PID should provide broad empiric coverage for the wide array of
implicated pathogens, although the optimal treatment regimen remains undefined [13-16].
Regimen options depend on whether the patient is initially hospitalized or managed as an
outpatient, which generally depends on the severity of infection ( algorithm 1) (see
'Indications for hospitalization' above). The selection of a regimen additionally takes into
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account cost, convenience of administration, safety, formulary availability, and allergy history.
(See 'Hospitalized patients' below and 'Outpatient therapy' below.)
Meta-analyses have demonstrated that a variety of antibiotics from multiple classes are all
associated with clinical and microbiologic cure rates of greater than 90 percent [13,17,18].
However, the available clinical data have limitations. Some studies did not use objective criteria
to define PID, some have evaluated subjective pain outcomes without blinding of investigators,
and few randomized trials have long-term data on outcomes, such as risk of infertility, ectopic
pregnancy, and chronic pelvic pain following treatment.
Evaluation of regimen efficacy is also hampered by the inability to distinguish between relapse
versus reinfection. As an example, the Pelvic Inflammation Disease Evaluation Clinical Health
trial (ie, PEACH trial), which carefully assessed patients for N. gonorrhoeae and C. trachomatis
infections, demonstrated that 40 percent of the females had evidence of at least one of these
infections at baseline; by 30 days after treatment, approximately 3 percent still had evidence of
either infection, but whether this reflected relapse (and thus treatment failure) or new infection
is uncertain [11].
Hospitalized patients
Initial parenteral therapy — Initial therapy consists of a combination parenteral regimen that
provides antimicrobial coverage against a wide range of bacteria, including C. trachomatis, N.
gonorrhoeae, streptococci, gram-negative enteric bacilli (Escherichia coli, Klebsiella spp, and
Proteus spp), and anaerobic organisms (ie, bacterial vaginosis-associated flora) ( algorithm 1).
We suggest one of the following regimens, which are consistent with first-line regimens
recommended by the United States Centers for Disease Control and Prevention (CDC) [2]:
Oral administration of doxycycline is generally preferred, if the patient can tolerate it, because
of the pain associated with intravenous drug administration. The bioavailabilities of the oral and
parenteral formulations are equivalent for both doxycycline and metronidazole.
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Combination regimens that include a cephalosporin and doxycycline have been shown in
several trials to result in short-term clinical cure rates of more than 80 to 90 percent of cases
[17,18]. They have excellent in vitro activity against N. gonorrhoeae and C. trachomatis [2,19].
Cefoxitin and cefotetan have intrinsic anaerobic activity; metronidazole is added to the
ceftriaxone-based regimen to provide anaerobic activity. (See 'Anaerobic bacteria' above.)
Alternative regimens have more limited clinical data to support their use for hospitalized
patients or have other drawbacks. We do not routinely use them for patients with PID, but it is
reasonable to use them in case of allergy to or unavailability of the preferred regimens:
● Azithromycin (500 mg intravenously daily for one to two days followed by 250 mg orally
daily to complete a seven-day course) plus metronidazole (500 mg twice daily for 14 days).
This dose of azithromycin, with or without metronidazole, resulted in similarly high clinical
and microbiologic cure rates (>95 percent) for mild to moderate PID compared with a
combination beta-lactam and doxycycline regimen [21]. However, the regimen has not
been evaluated in patients with severe PID, and it should only be considered when N.
gonorrhoeae infection has been excluded or is unlikely because it does not provide
coverage against that pathogen. When using azithromycin for PID, we favor adding
metronidazole for anaerobic coverage. (See 'Anaerobic bacteria' above.)
Transition to oral therapy — Patients can usually be transitioned from parenteral to oral
therapy after 24 to 48 hours of sustained clinical improvement, as reflected by resolution of
fever, nausea, vomiting, and severe abdominal pain, if initially present ( algorithm 1) [22].
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Oral therapy consists of doxycycline 100 mg twice daily and metronidazole 500 mg twice daily
to complete a 14-day course. This regimen is also appropriate for females whose PID was
complicated by pelvic abscess and females with documented Trichomonas vaginalis infection or
bacterial vaginosis because it provides coverage for anaerobic bacteria. (See 'Anaerobic
bacteria' above.)
For those who cannot tolerate doxycycline, azithromycin (500 mg for one to two days followed
by 250 mg once daily to complete a 14-day course) is an alternative; for those who cannot
tolerate metronidazole, clindamycin 450 mg orally every six hours is an alternative. (See
'Anaerobic bacteria' above.)
Outpatient therapy — For females with mild to moderate PID who can tolerate oral
medications and are expected to reasonably adhere to therapy, we suggest the following
regimen ( algorithm 1) [2]:
Other appropriate cephalosporins to use with doxycycline and metronidazole include cefoxitin
(2 g intramuscularly) with probenecid (1 g orally), cefotaxime (1 g intramuscularly), and
ceftizoxime (1 g intramuscularly). Cephalosporin-based regimens result in clinical and
microbiologic cure rates of approximately 90 percent or higher [17,18]. The approach to
patients with allergies that potentially preclude cephalosporin administration is discussed
elsewhere. (See 'Penicillin-allergic patients' below.)
We favor the routine addition of metronidazole for coverage of anaerobic organisms based on
evidence of improved longer-term outcomes compared with regimens without anaerobic
coverage. (See 'Anaerobic bacteria' above.)
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An alternative to doxycycline is azithromycin (either 500 mg daily for one to two days then 250
mg orally for a 14-day course or 1 g once per week for two weeks), to be given with the single
cephalosporin dose and metronidazole. Small clinical trials suggest clinical efficacy [23],
although data on microbiologic cures are not available, and azithromycin results in lower
microbiologic cure rates for C. trachomatis in some anatomic locations compared with
doxycycline. (See "Treatment of Chlamydia trachomatis infection", section on 'Doxycycline as
preferred agent'.)
Directed therapy and duration — The empirically chosen antibiotic regimen is generally
continued for the duration of the course. The therapy should not be modified or cut short if N.
gonorrhoeae or C. trachomatis is not identified in clinical specimens.
The optimal duration of therapy is unknown. We treat for a total of 14 days. Most studies have
used this duration of therapy, and it is standard in other guidelines [2,7]. Shorter courses of
therapy have not been explored, mainly related to concerns regarding eradication of C.
trachomatis in the setting of upper tract disease [2].
ADJUNCTIVE CARE
Patients who are hospitalized for severe or complicated pelvic inflammatory disease (PID) may
also warrant volume repletion, particularly if nausea/vomiting prevents oral intake. Other
supportive measures include antiemetic, analgesic, and antipyretic medications.
Surgical interventions are usually reserved for patients with tubo-ovarian abscesses that are
associated with sepsis, are large, or do not improve with medical therapy. This is discussed in
detail elsewhere. (See "Management and complications of tubo-ovarian abscess", section on
'Clinical approach'.)
COUNSELING
Medication adherence — Compliance with a long course of oral antibiotics can be problematic
[24]. Patients should be educated about the importance of medication adherence and clinical
outcomes.
Sexual activity — Females with pelvic inflammatory disease (PID) should be counseled to
refrain from sexual activity until they have completed therapy, their symptoms have resolved,
and sex partners have been evaluated and/or treated for potential sexually transmitted
infections (STIs) (see 'Management of sex partners' below). Clinicians should also counsel
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patients regarding the route of acquisition for STIs and future safe sex practices. (See
"Prevention of sexually transmitted infections", section on 'Prevention counseling' and
"Prevention of sexually transmitted infections", section on 'Male condom use'.)
Screening and prevention of STIs — All patients diagnosed with acute PID should be screened
for other important STIs, including HIV and syphilis. (See "Screening for sexually transmitted
infections".)
They should also be evaluated for indications for vaccinations to prevent other STIs, including:
● Hepatitis B vaccination for those who have no evidence of immunity to hepatitis B virus
(eg, through vaccination history or serologic testing). (See "Hepatitis B virus immunization
in adults".)
● Human papillomavirus vaccination for those within the appropriate age range if they have
not previously been vaccinated. (See "Human papillomavirus vaccination".)
Management of sex partners — Male sex partners of females with PID should be examined
and treated if they had sexual contact with the patient during the 60 days prior to the patient's
onset of symptoms, regardless of the woman's STI test results. Evaluation and treatment of the
sex partner is essential to decrease the risk of reinfection. Regimens should include antibiotics
with activity against N. gonorrhoeae and C. trachomatis; these regimens are discussed
elsewhere. (See "Treatment of uncomplicated Neisseria gonorrhoeae infections", section on
'Initial treatment of urogenital and anorectal infection'.)
FOLLOW-UP
Close follow-up is essential. If outpatient therapy is selected, it is important to see the patient
within 48 to 72 hours to be certain that clinical improvement has occurred (eg, reduction in
abdominal tenderness and reduction in cervical motion tenderness) [25].
Those who have no clinical improvement after this period warrant further diagnostic evaluation
for complications (eg, pelvic abscesses) or for alternate diagnoses. Patients initially treated as
outpatients warrant hospitalization and parenteral therapy. For those who were already on
parenteral therapy, the initial regimen should be evaluated to ensure that it provided
appropriate coverage (eg, for N. gonorrhoeae and anaerobes), and it should be adjusted if not.
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(See 'Initial parenteral therapy' above and "Pelvic inflammatory disease: Clinical manifestations
and diagnosis", section on 'Additional evaluation for diagnostic uncertainty'.)
For females who had documented C. trachomatis or N. gonorrhoeae infection, additional follow-
up, including retesting, is discussed elsewhere. (See "Treatment of uncomplicated Neisseria
gonorrhoeae infections", section on 'Patient follow-up' and "Treatment of Chlamydia trachomatis
infection", section on 'Follow-up testing'.)
SPECIAL POPULATIONS
Penicillin-allergic patients
Assess whether cephalosporin can be used — For patients with penicillin allergies, our
approach depends on the type and severity of the allergy and the risk for gonococcal infection.
Most patients with a penicillin allergy can still receive a cephalosporin.
● Patients with a penicillin allergy that was mild and had no features of an IgE-mediated
reaction (eg, a maculopapular or morbilliform rash without angioedema, respiratory
symptoms, or hypotension) can receive a third-generation cephalosporin (eg, ceftriaxone)
normally ( algorithm 2). If needed, they can receive a second-generation cephalosporin
(eg, cefoxitin or cefotetan) with a test dose procedure.
● Patients with a penicillin allergy that did have features of an IgE-mediated reaction (eg,
anaphylaxis or angioedema) can receive a third-generation cephalosporin (eg, ceftriaxone)
with a test dose procedure ( algorithm 2).
A test dose procedure consists of giving one-tenth of the full dose (either intramuscularly or
intravenously) and observing the patient for 30 to 60 minutes. If no reaction develops, the
remainder of the dose can be given with continued observation for another hour. (See "Choice
of antibiotics in penicillin-allergic hospitalized patients", section on 'Test dose procedure
(graded challenge)'.)
For patients who receive a cephalosporin for PID treatment, it should be administered with
doxycycline and metronidazole. (See 'Initial parenteral therapy' above and 'Outpatient therapy'
above.)
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For outpatients who cannot use a cephalosporin, the management options depend on the risk
for gonorrhea, as outlined below.
For outpatients who cannot receive cephalosporins — For those who cannot use a
cephalosporin, options for outpatient therapy are limited. The main outpatient alternative is a
fluoroquinolone-containing regimen. However, while certain fluoroquinolones have activity
against C. trachomatis, high rates of fluoroquinolone resistance among N. gonorrhoeae isolates
limit the utility of such regimens for PID. Thus, the approach to empiric management in this
setting depends on the risk for fluoroquinolone-resistant N. gonorrhoeae (information on the
community prevalence of resistance may be obtained from the local department of public
health):
● High risk of resistant gonorrhea – For females with PID in a region where the prevalence
of fluoroquinolone resistance in N. gonorrhoeae is ≥5 percent, we suggest hospitalization
for treatment with clindamycin (900 mg intravenously every 8 hours) plus gentamicin (3 to
5 mg/kg intravenously once daily) until clinical improvement, at which point the regimen
can be transitioned to oral therapy. (See 'Transition to oral therapy' above.)
If there are major barriers to intravenous antibiotics, other alternative regimens for
gonorrhea can be substituted into the outpatient therapy regimens for PID (eg,
gentamicin 240 mg intramuscularly once plus azithromycin 2 g orally once in addition to
metronidazole); however, there are no data to inform PID outcomes with these regimens.
(See "Treatment of uncomplicated Neisseria gonorrhoeae infections", section on 'Alternate
regimens'.)
In such individuals, we submit cervical specimens for culture for N. gonorrhoeae and
request that susceptibility testing be performed on any isolate. If the patient has
persistent symptoms, an infectious diseases consultation should be obtained. If
retreatment is appropriate, potential options include desensitization to a cephalosporin or
alternative regimens based on susceptibility testing. (See "Treatment of uncomplicated
Neisseria gonorrhoeae infections", section on 'Monitoring for and managing treatment
failure'.)
● Low risk of resistant gonorrhea – For females who have a low risk of fluoroquinolone-
resistant N. gonorrhoeae (ie, infection acquired in a region where the prevalence is <5
percent, postmenopausal females who develop PID following uterine instrumentation), a
fluoroquinolone-containing regimen can be used. This consists of either the combination
of levofloxacin 500 mg orally once daily plus metronidazole 500 mg orally twice daily or
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monotherapy with moxifloxacin 400 mg orally once daily; each regimen is given for 14
days.
In situations in which N. gonorrhoeae has been excluded (ie, known negative NAAT) and the
patient cannot receive a cephalosporin or a fluoroquinolone, an alternative regimen is
azithromycin (500 mg orally daily for one to two days followed by 250 mg daily or 1 g orally
once per week for two weeks) with metronidazole (500 mg orally twice daily) for a total of 14
days [26].
Molecular tests that can identify mutations associated with fluoroquinolone resistance in N.
gonorrhoeae can help streamline this approach by identifying individuals who have susceptible
infection and could thus use a fluoroquinolone; however, these tests are not widely available.
(See "Treatment of uncomplicated Neisseria gonorrhoeae infections", section on
'Fluoroquinolones'.)
Females with IUDs — Intrauterine devices (IUDs) do not appear to be associated with an
increased risk of PID [27]. Removal of an IUD in a woman who develops PID is not necessary.
However, she should be followed closely, as with all females with PID, and removal may be
warranted if she does not clinically improve with antibiotic therapy. This is discussed in detail
elsewhere. (See "Intrauterine contraception: Management of side effects and complications",
section on 'Infection and/or pelvic inflammatory disease'.)
Pregnant patients — While it is quite rare to have PID during pregnancy, the infection can
occur in the first 12 weeks of gestation before the mucus plug and decidua seal off the uterus
from ascending bacteria [28]. As above, pregnancy is an indication for hospitalization and
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Patients with HIV — Females with HIV appear to respond to therapy for PID as well as females
without HIV [12]. Therefore, recommended antibiotic regimens for acute PID in patients with
HIV are the same as those for the general population.
Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Sexually transmitted
infections".)
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the
Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade
reading level, and they answer the four or five key questions a patient might have about a given
condition. These articles are best for patients who want a general overview and who prefer
short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more
sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading
level and are best for patients who want in-depth information and are comfortable with some
medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print
or e-mail these topics to your patients. (You can also locate patient education articles on a
variety of subjects by searching on "patient info" and the keyword(s) of interest.)
● Basics topic (see "Patient education: Pelvic inflammatory disease (The Basics)")
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indicated for patients with this presumptive clinical diagnosis of PID, even if findings are
subtle or minimal, since the risk of long-term complications is higher if treatment is
withheld or delayed. (See 'Threshold for treatment' above.)
• Severe clinical illness (eg, high fever, nausea/vomiting preventing oral intake, severe
abdominal pain)
• Suspected pelvic abscess
• Pregnancy
• A possible alternative diagnosis that could warrant surgery (eg, appendicitis)
• Initial parenteral therapy – For patients who are hospitalized for PID, we suggest
initial parenteral therapy with a second-generation cephalosporin plus doxycycline
( algorithm 1) (Grade 2B). We also suggest inclusion of anaerobic coverage (Grade
2C). Appropriate regimens include ceftriaxone (1 g intravenously every 24 hours) plus
doxycycline plus metronidazole (500 mg twice daily); cefoxitin (2 g intravenously every
six hours) plus doxycycline; and cefotetan (2 g intravenously every 12 hours) plus
doxycycline. The doxycycline dose is 100 mg every 12 hours. (See 'Initial parenteral
therapy' above.)
● Antibiotic regimens for outpatients – For patients with mild or moderate PID who are
treated as outpatients, we suggest ceftriaxone as a single intramuscular dose (500 mg, or
1 g for individuals ≥150 kg) plus doxycycline (100 mg orally twice daily for 14 days) plus
metronidazole (500 mg twice daily for 14 days) rather than other regimens
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28. Zeger W, Holt K. Gynecologic infections. Emerg Med Clin North Am 2003; 21:631.
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GRAPHICS
This algorithm represents our approach to antimicrobial selection for nonpregnant patients with PID. Treatm
the individual. Refer to other UpToDate content on PID therapy for details on and doses for alternative regim
management of PID in pregnant individuals (which is uncommon).
* Alternative regimens include clindamycin plus gentamicin, ampicillin-sulbactam plus doxycycline, and if Ne
been ruled out, azithromycin plus metronidazole. Because of various drawbacks, we reserve these for patien
preferred regimens.
¶ We prefer ceftriaxone because it has the best and most established activity against N. gonorrhoeae. Other
intramuscular cephalosporins include cefoxitin (with probenecid), cefotaxime, and ceftizoxime.
Δ Doxycycline and metronidazole can also be given intravenously at the same doses for those who cannot ta
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Approach to the patient with a past penicillin reaction who requires antibiotics
This algorithm is intended for use in conjunction with the UpToDate content on choice of antibiotics in penic
but also applies to outpatients if test dose procedures can be performed in an appropriately monitored sett
including anaphylaxis.
IgE: immunoglobulin E.
Δ This algorithm is intended for use in conjunction with additional UpToDate content. For a description of ho
on choice of antibiotics in penicillin-allergic hospitalized patients.
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◊ Consult allergist to perform skin testing. If skin testing is not possible, patient may still be able to receive
desensitization (also known as tolerance induction) procedure. Refer to the UpToDate topic on rapid drug de
Original figure modified for this publication. Blumenthal KG, Shenoy ES, Varughese CA, et al. Impact of a clinical guideline for prescrib
Immunol 2015; 115:294. Illustration used with the permission of Elsevier Inc. All rights reserved.
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Contributor Disclosures
Harold C Wiesenfeld, MD, CM No relevant financial relationship(s) with ineligible companies to
disclose. Jeanne Marrazzo, MD, MPH, FACP, FIDSA Equity Ownership/Stock Options: Osel Inc [Vaginal
infections]. Grant/Research/Clinical Trial Support: BD Diagnostics [Vaginal infections, STI].
Consultant/Advisory Boards: Gilead [HIV];Merck [HIV]. All of the relevant financial relationships listed have
been mitigated. Allyson Bloom, MD No relevant financial relationship(s) with ineligible companies to
disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must
conform to UpToDate standards of evidence.
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