Clinical Practice

Guidelines
on
SEXUALLY TRANSMITTED
INFECTIONS
 VAGINITIS
Bacterial Vaginosis
Candidiasis/ Vulvovaginal candidiasis
Trichomoniasis
Diagnostic Methods
• pH
• an elevated pH (i.e., ≥4.5) is common with BV or trichomoniasis
• A potassium hydroxide (KOH) test
• Amine odor upon application suggests BV or trichomoniasis
• To identify hyphae or blastospores seen with candidiasis
• Microscopic examination of fresh samples of the discharge
• By first diluting one sample in one or two drops of 0.9% normal
saline solution on one slide and a second sample in 10% KOH
solution
• Motile trichomonads or “clue cells” – BV
• NAAT (trichomoniasis) or Culture (yeast)
 Bacterial Vaginosis
• Polymicrobial clinical syndrome replacement of the vaginal flora (normal
hydrogen peroxide producing Lactobacillus sp) by an overgrowth of anaerobic
bacteria
• Prevotella sp., Mobiluncus sp., G. vaginalis, Ureaplasma, Mycoplasma, and
numerous fastidious or uncultivated anaerobes
• Is the most prevalent cause of vaginal discharge or malodor
• Associated with women who are sexually active, having multiple male or
female partners, a new sex partner, douching, lack of condom use, and lack of
vaginal lactobacilli
• And are at increased risk for the acquisition of some STDs complications after
gynecologic surgery, complications of pregnancy, and recurrence of BV, and
• Increases the risk for HIV transmission to male sex partners
• Gram stain
• gold standard laboratory method for diagnosing BV
• to determine the relative concentration of lactobacilli (long Gram-
positive rods)

• Clinical criteria require three of the following symptoms or signs:

• Homogeneous, thin, white discharge that smoothly coats the
vaginal walls;
• Clue cells (e.g., vaginal epithelial cells studded with adherent
coccoobacilli) on microscopic examination;
• Ph of vaginal fluid >4.5; or
• A fishy odor of vaginal discharge before or after addition of 10%
koh (i.e., the whiff test).
Treatment
Treatment
Vulvovaginal Candidiasis
• caused by C. albicans but
can occasionally be caused
by other Candida sp. or
yeasts
• Typical Symptoms of VVC
include
• Pruritus,
• Vaginal soreness,
• Dyspareunia
• External dysuria, and
• Abnormal vaginal discharge
• Uncomplicated VVC
• Diagnostic Considerations
• A diagnosis of Candida vaginitis is
suggested clinically by the presence
of:
• External dysuria, and
• Vulvar pruritus, pain, swelling,
and redness.
• Signs include
• Vulvar edema, fissures,
excoriations, and
• Thick curdy vaginal discharge
• The diagnosis can be made in a woman who has signs
and symptoms of vaginitis when either
1. A wet preparation (saline, 10% KOH) or Gram stain of
vaginal discharge demonstrates budding yeasts,
hyphae, or pseudohyphae or
2. A culture or other test yields a positive result for a
yeast species

• Candida vaginitis is associated with a normal vaginal pH

(<4.5)
• Treatment
• Short-course topical formulations (i.e., single dose and
regimens of 1–3 days) effectively treat uncomplicated
VVC.
• The topically applied azole drugs are more effective
than nystatin.
• Complicated VVC
• Diagnostic Consideration
• Vaginal cultures should be obtained from women with
complicated VVC to confirm clinical diagnosis and
identify unusual species, including nonalbicans
species.
Trichomoniasis
• Most prevalent nonviral sexually transmitted infection
• Symptoms
• Vaginal discharge that might be diffuse, malodorous, or yellow-green
with or without vulvar irritation for infected women
• Diagnostic Consideration
• NAAT (highly sensitive)
• often detecting three to five times more T. vaginalis infections than
wet-mount microscopy, a method with poor sensitivity (51%–65%)
• Microscopic Examination – most common method
• wet preparations of genital secretions
• convenience and relatively low cost
• low sensitivity
• Pap test
• Incidental finding
• Not considered as diagnostic tests
Treatment
Reduces symptoms and signs of T. Vaginalis
infection, and
Reduce transmission
Mucopurulent Cervicitis
Gonococcal Infection
Chlamydial Infection
Gonococcal Infection
• 2nd most common bacterial STI
• Neisseria gonorrhea (gram-negative diplococcus)
• Primary site of infection: ENDOCERVIX
• Risk factors: low socioeconomic status, urban residence, non-asian
and non-white race and ethnicity, early sexual activity, single status,
illicit drug use, prostitution, and previous history of gonococcal
infection
• Maternal infection: Gonorrheal ophthalmia neonatorum, PROM,
chorioamnionitis, prematurity, IUGR, neonatal sepsis, and postpartum
endometritis
Gonococcal Infection
• Clinical manifestation: Mucupurulent discharge, vaginal discharge, urethral
discharge, dysuria, abnormal uterine bleeding, and pelvic discomfort
• Cervical bleeding, friability and ectopy, and an increased in the number of
leukocytes on endocervical gram’s stain
• Culture –endocervical (women) or urethral (men) swab specimens
• Highly specific (99%) and sensitivity (95%)
• Polymorphonuclear leukocytes with intracellular Gram-negative diplococci
• NAAT – endocervical swabs, vaginal swabs, urethral swabs (men), and urine
(from both men and women)
• Screen for: chlamydia, syphilis, and HIV.
Gonococcal Infection
AMNIOTIC INFECTION SYNDROME
• Gonococcal infection in pregnancy
• Presents with placental, fetal, and umbilical cord inflammation after
premature rupture of membranes associated with a positive gastric
aspirate for N. gonorrhea, leucocytosis, neonatal infection, and
maternal fever
• High infant morbidity and mortality
Gonococcal Infection
• Recommended Regimen
• Ceftriaxone 250mg IM in a single dose PLUS
• Azithromycin 1g orally in single dose OR
• Doxycycline 100mg orally twice a day for 7 days
• Alternative Regimen
• Cefixime 400mg orally in single dose PLUS
• Azithromycin 1g orally in single dose OR
• Doxycycline 100mg orally twice a day for 7 days
Gonococcal Infection
• Other Alternative Regimen
• Gemifloxacin 320mg orally in single dose OR
• Gentamycin 240mg IM in single dose PLUS
• Azithromycin 2g orally in single dose
• Ceftizoxime 500mg IM in single dose OR
• Cefoxitin 2g IM with probenecid 1g orally OR
• Cefotaxime 500mg IM in single dose OR
• Spectinomycin 2g in a single IM OR
• Treatment for Chlamydia infection is not ruled out
Quinolone –Resistant N.
Gonorrhoeae (QRNG)
• Recommended Regimens (Uncomplicated gonococcal pharyngitis)
• Ceftriaxone 250mg IM in a single dose PLUS
• Azithromycin 1g orally in single dose OR
• Doxycycline 100mg orally twice a day for 7 days
• Recommended Regimens (Gonococcal Conjunctivitis)
• Ceftriaxone 1g IM in a single dose PLUS
• Azithromycin 1g orally in single dose OR
• Doxycycline 100mg orally twice a day for 7 days
Quinolone –Resistant N.
Gonorrhoeae (QRNG)
• Recommended Regimens (Disseminated Gonococcal Infection)
• Ceftriaxone 1g IM or IV in every 24 hours PLUS
• Azithromycin 1g orally in single dose OR
• Doxycycline 100mg orally twice a day for 7 days
• Alternative Regimens
• Ceftizoxime 1g IM every 8 hours OR
• Cefotaxime 1g IM every 8 hours PLUS
• Azithromycin 1g orally in single dose OR
• Doxycycline 100mg orally twice a day for 7 days
Management
• Management of Sex Partners
• evaluated and treat -sex partners within 60 days before
onset of symptoms or diagnosis
• Treat - Patient’s sex partner if last sexual intercourse is
beyond 60 days before onset of symptoms or diagnosis
• Patient should be instructed to avoid sexual intercourse
until therapy is completed and symptoms have resolved.
Management
• Pregnancy
• Contraindicated: Quinolones and Tetracyclines
• Treatment:
• Cefrtiaxone 250mg in a single IM dose AND
• Azithromycin 1 g orally as a single dose
• Alternative: Spectinomycin 2g double IM dose OR
• Azithromycin 2g orally
Chlamydial Infection
Among Adult and Adolescent
• Sequelae of Chlamydial trachomatis infections in women, includes:
• PID, ectopic pregnancy, and Infertility
• Annual screening of all sexually active women aged <25 years is
recommended. (chlamydia and gonococcal inf)

• Diagnostic Considerations
• First-catch urine or collecting swab specimens from the
endocervix or vagina
• Urethral swab or first-catch urine specimen
• Treatment
• To prevents adverse reproductive health complications and continued sexual
transmission, and
• Treating their sex partners can prevent reinfection and infection of other partners
• Treating pregnant women usually prevents transmission of C. trachomatis to
neonates during birth.
Among Neonates
• C. trachomatis infection of neonates results from perinatal exposure to
the mother’s infected cervix, causing Chlamydia ophthalmia.
• C. trachomatis has been the most frequent identifiable infectious cause
of ophthalmia neonatorum, and
• Prenatal screening and treatment of pregnant women is the best
method for preventing neonatal chlamydial infection
• Erythromycin ophthalmic ointments is used to prevent chlamydia
ophthalmia,

• Mucous membranes of the eye, oropharynx, urogenital tract, and

rectum,
• Conjunctiva
• Subacute, afebrile pneumonia
• Diagnostic Considerations
• A chlamydial etiology should be considered for all
infants aged ≤30 days that have conjunctivitis
• Specimen: everted eyelid using a dacron-tipped swab
• Tissue culture, and
• Nonculture tests
• direct fluorescence antibody [DFA]
• NAAT
Treatment
Treatment Among Infants and
Children
Diseases characterized by genital,
anal and perianal ulcers
• Syphilis

• Chancroid

• G e n i t a l H S V I n f e c ti o n s

• Granuloma Inguinale (Donovanosis)

• Ly m p h o g r a n u l o m a Ve n e r e u m ( L G V )
 Syphilis
• Syphilis is a systemic disease caused by Treponema pallidum.
• Three stages based on clinical findings:
• Primary syphilis infection – ulcers or chancre at the infection
site,
• Secondary syphilis – manifestations that include, but are not
limited to, skin rash, mucocutaneous lesions, and
lymphadenopathy
• Tertiary syphilis – cardiac, gummatous lesions, tabes dorsalis,
and general paresis
• Latent infections – those lacking clinical manifestations are
detected by serologic testing.
• T. pallidum can infect the central nervous system and result in
neurosyphilis, which can occur at any stage of syphilis.
• Early neurologic clinical manifestations – cranial nerve
dysfunction, meningitis, stroke, acute altered mental status,
and auditory or ophthalmic abnormalities.
• Late neurologic manifestations – tabes dorsalis and general
paresis
• Diagnostic Considerations • Treponemal Test
• Definitive Diagnosis • Fluorescent treponemal
antibody absorbed [FTA-ABS]
• Darkfield examinations and tests tests
to detect T. pallidum directly from • T. pallidum passive particle
lesion exudate or tissue agglutination [TP-PA] assay
• Presumptive Diagnosis –requires use • Enzyme immunoassays [EIAs]
of two tests: • Chemiluminescence
• Nontreponemal Test immunoassays,
• Immunoblots,
• Venereal Disease Research • Rapid treponemal assays
Laboratory [VDRL] or
• Rapid Plasma Reagin [RPR])
• Treatment
• Penicillin G –is the preferred drug for treating persons in all
stages of syphilis.
• The preparation used, dosage, and length of treatment
depend on the stage and clinical manifestations of the
disease.

• Primary and Secondary Syphilis

• Treatment
• Parenteral penicillin G – has been used effectively to
achieve clinical resolution and to prevent late sequelae
• Latent Syphilis
• Latent syphilis is defined as syphilis characterized by sero-
reactivity without other evidence of primary, secondary, or
tertiary disease.
• Individuals who are classified with having latent syphilis are:
• early latent syphilis - acquired syphilis during the preceding
year
• Reactive non-treponemal and treponemal tests whose only
possible exposure occurred during the previous 12 months,
early latent syphilis can be assumed
• Asymptomatic individuals should be considered to have
latent syphilis
• Persons can receive a diagnosis of early latent syphilis if, during
the year preceding the diagnosis, they had
• A documented sero-conversion or a sustained (>2 week)
fourfold or greater increase in non-treponemal test titers;
• Unequivocal symptoms of primary or secondary syphilis; or
• A sex partner documented to have primary, secondary, or
early latent syphilis.

• Treatment (Latent Syphilis)

• Not transmitted sexually
• to prevent complications and transmission from a pregnant
woman to her fetus.
Tertiary Syphilis
Tertiary syphilis refers to gummas and cardiovascular
• Neurosyphilis
• CNS involvement can occur during any stage of syphilis
• CSF laboratory abnormalities are common in persons with early syphilis, even in
the absence of clinical neurologic findings.
• Clinical evidence of neurologic involvement are
• Cognitive dysfunction
• Motor or sensory deficits
• Ophthalmic or auditory symptoms
• Cranial nerve palsies,
• Meningitis or stroke
• Syphilitic uveitis or other ocular manifestations can be associated with
neurosyphilis.
• Neuroretinitis
• Optic neuritis
• P r i m a r y a n d S e co n d a r y Sy p h i l i s a m o n g Pe rs o n s w i t h
H I V I n fe c ti o n

• Latent Syphilis among Persons with HIV Infection

Chancroid
• The combination of a painful genital ulcer and tender suppurative
inguinal adenopathy suggests the diagnosis of chancroid diagnosis of
chancroid criteria:
1. The patient has one or more painful genital ulcers;
2. The clinical presentation, appearance of genital ulcers and, if
present, regional lymphadenopathy are typical for chancroid;
3. The patient has no evidence of T. Pallidum infection by darkfield
examination of ulcer exudate or by a serologic test for syphilis
performed at least 7 days after onset of ulcers; and
4. An HSV PCR test or or HSV culture performed on the ulcer exudate is
negative.
Treatment
• Other Management Considerations includes:
• Tested for HIV infection at the time chancroid is
diagnosed. And if the initial test results were negative, a
serologic test for syphilis and HIV infection should be
performed 3 months after the diagnosis of chancroid.
• Sex partners of patients who have chancroid should be
examined and treated if they had sexual contact with
the patient during the 10 days preceding the patient’s
onset of symptoms.
Genital HSV Infections
• Genital herpes is a chronic, life-long viral
infection.
• Two types of HSV can cause genital herpes:
• HSV-1, and
HSV-1 • HSV-2.

• Most genital herpes infections are transmitted

by persons unaware that they have the
infection or who are asymptomatic when
transmission occurs,

HSV-2
• Diagnostic Considerations
• Clinical diagnosis
• (+) Painful multiple vesicular or ulcerative lesions
• Type-specific Virologic
• to determine which type of HSV is causing the infection
• Cell culture (low sensitivity)
• PCR (high sensitivity) with HSV DNA
• Type-specific Serologic Tests
• glycoprotein G2 (HSV-2) – 80-98% sensitivity
• HerpeSelect HSV-2 Elisa
• Biokit or Western Blot (confirmatory)
• glycoprotein G1 (HSV-1)
• Management of Genital Herpes
• Antiviral chemotherapy
• partially control the signs and symptoms of
genital herpes when used to treat first clinical
and recurrent episodes or when used as daily
suppressive therapy.
First Clinical Episode of
Genital Herpes

First Clinical Episode of Genital Hepes

Episodic Therapy for
Recurrent Genital Herpes
• Severe Disease
• Intravenous (IV) acyclovir therapy should be provided for patients
who have
• severe HSV disease or complications that necessitate
hospitalization (e.g., disseminated infection, pneumonitis, or
hepatitis) or CNS complications.
• acyclovir 5–10 mg/kg IV every 8 hours for 2–7 days, followed
by oral antiviral therapy to complete at least 10 days of total
therapy.
• HSV encephalitis requires 21 days of intravenous therapy.
• Impaired renal function warrants an adjustment in acyclovir
dosage.
Granuloma Inguinale (Donovanosis)
• Genital ulcerative disease caused by the intracellular gram-negative
bacterium Klebsiella granulomatis
• Painless, slowly progressive ulcerative lesions on the genitals or
perineum without regional lymphadenopathy; with subcutaneous
granulomas (pseudobuboes) also might occur.
• Highly vascular (BEEFY RED APPEARANCE) and bleed.
• Extragenital infection
• The lesions also can develop secondary bacterial infection and
• Can coexist with other sexually transmitted pathogens.
• Diagnostic
• Visualization of dark-staining Donovan bodies on tissue crush
preparation or biopsy.

• Treatment
• To halt progression of lesions, and healing typically
proceeds inward from the ulcer margins;
• Prolonged therapy is usually required to permit
granulation and re-epithelialization of the ulcers.
• Relapse can occur 6–18 months after apparently
effective therapy.
Lymphogranuloma Venereum (LGV)

• Caused by C. trachomatis serovars L1, L2, or L3.

• Clinical Manifestations
• Tender inguinal and/or femoral lymphadenopathy that
is typically unilateral.
• Clinical findings may include mucoid and/or
hemorrhagic rectal discharge, anal pain, constipation,
fever, and/or tenesmus.
• LGV is primarily an infection of lymphatics and lymph
nodes.
• Chlamydia trachomatis is the bacterium responsible for
LGV.
• It gains entrance through breaks in the skin, or it can
cross the epithelial cell layer of mucous membranes.

• The organism travels from the site of inoculation down

the lymphatic channels to multiply within mononuclear
phagocytes of the lymph nodes it passes.
• Diagnostic Considerations
• Clinical suspicion, epidemiologic information, and the
exclusion of other etiologies for proctocolitis, inguinal
lymphadenopathy, or genital or rectal ulcers.
• Genital lesions, rectal specimens, and lymph node
specimens (i.e., lesion swab or bubo aspirate) can be
tested for C. trachomatis by
• culture, direct immunofluorescence, or nucleic acid
detection
• Treatment
• Cures infection and prevents ongoing tissue damage, although
tissue reaction to the infection can result in scarring.
• Buboes might require aspiration through intact skin or incision and
drainage to prevent the formation of inguinal/ femoral ulcerations.
VIRAL INFECTIONS
Human Papilomavirus
Molluscum Contagiosum
HPV Infection
• Self-limited
• Asymptomatic

• Oncogenic, High-Risk HPV infection (HPV types 16 and 18) causes

most cervical, penile, vulvar, vaginal, anal, and oropharyngeal cancers
and precancers,
• Non-Oncogenic, Low-Risk HPV Infection (HPV types 6 and 11) causes
genital warts and recurrent respiratory papillomatosis.
• Persistent oncogenic HPV infection is the strongest risk factor for
development of HPV-associated pre-cancers and cancers.
• Prevention
• HPV Vaccines
• Bivalent vaccine (Cervarix) – prevents infection with HPV
types 16 and 18,
• Quadrivalent vaccine (Gardasil) –prevents infection with
HPV types 6, 11, 16, and 18,
• 9-valent vaccine – prevents infection with HPV types 6,
11, 16, and 18, 31, 33, 45, 52, and 58.
• Administered as a 3-dose series of IM injections over a 6-
month period, with the second and third doses given 1–2 and
6 months after the first dose.
• Either vaccine is recommended • For previously unvaccinated,
routinely at ages 11–12 years and can immunocompromised persons
be administered beginning at 9 years (including persons with HIV
of age infection) and MSM, vaccination is
• Girls and women aged 13–26 years recommended through age 26
who have not started or completed the years.
vaccine series should receive the
vaccine • HPV vaccines are not
recommended for use in pregnant
women.
• The quadrivalent or 9-valent HPV
vaccine is recommended routinely for
• Women who have received HPV
boys aged 11–12 years; boys can be vaccine should continue routine
vaccinated beginning at 9 years of age cervical cancer screening if they
• Boys and men aged 13–21 years who
are aged ≥21 years.
have not started or completed the • Abstaining from sexual activity is
vaccine series should receive the the most reliable method for
vaccine preventing genital HPV infection.
• Diagnostic Considerations
• HPV tests are available to detect oncogenic types of HPV
infection and are used in the context of cervical cancer
screening and management or follow-up of abnormal
cervical cytology or histology

• Treatment
• Treatment is directed to the macroscopic (e.g., genital warts)
or pathologic precancerous lesions caused by HPV
• Prevention of HPV
• Two HPV vaccines can prevent diseases and cancers caused by HPV.
• The Cervarix and Gardasil vaccines protect against most cases of
cervical cancer; Gardasil also protects against most genital warts.
• HPV vaccines are recommended routinely for boys and girls aged 11–
12 years; either vaccine is recommended for girls/women, whereas
only one vaccine (Gardasil) is recommended for boys/men

• Condoms used consistently and correctly can lower the chances of

acquiring and transmitting HPV and developing HPV-related diseases.
• Limiting number of sex partners
Anogenital Warts
• 90% are caused by non-oncogenic HPV types 6 or 11; these types
can be commonly identified before or at the same time
anogenital warts are detected.
• HPV types 16, 18, 31, 33, and 35
• are also occasionally found in anogenital warts (usually as co-
infections with HPV 6 or 11) and
• can be associated with foci of high-grade squamous
intraepithelial lesions (HSIL), particularly in persons who have
HIV infection.
• HPV types 6 and 11 have been • Anatomic location where it
associated with conjunctival, occur commonly:
nasal, oral, and laryngeal warts. • Vaginal introitus
• Under the foreskin of the
• Asymptomatic uncircumcised penis
• Depending on the size and • Shaft of the circumcised penis.
anatomic location, they can be • Anogenital epithelium or
painful or pruritic. within the anogenital tract
• Flat, papular, or pedunculated
growths on the genital mucosa.
• Diagnostic Considerations
• Visual inspection
• Biopsy – confirmatory

• Biopsy might also be indicated in the following

circumstances,
• The diagnosis is uncertain;
• The lesions do not respond to standard therapy; or
• The disease worsens during therapy.

• HPV testing is not recommended

• Treatment
• The aim of treatment is removal of the wart and amelioration of
symptoms, if present.
MOLLUSCUM CONTAGIOSUM
• Poxvirus
• Direct contact
• Affects the normal skin
• Hallmark: shiny, dome-shaped white papules with central umbilication
• Symptoms: pruritus, tenderness, and pain
• Sites: Labia majora, mons pubis, buttocks, and inner thighs
• Excision biopsy: enlarged epithelial cells w/ intracytoplasmic inclusion
bodies
• Treatment: self limiting, excisional curretage
ECTOPARASITIC INFECTION
PEDICULOSIS PUBIS
• Phthirus pubis (crab louse)
• Transmitted thru sexual contact or acquired through fomites
• Poor personal hygiene and overcrowding
• Hairy areas of the body
• Symptoms: Pruritus, movement of small lice or nits attached on the
base of the hair
• Diagnosis: magnifying glass or microscope
• Treatment: Permethrin 1% cream rinse applied to affected and
washed off after 10 mins OR
PEDICULOSIS PUBIS
Treatment:
• Permethrin 1% cream rinse applied to affected and washed off after
10 mins OR
• Pyrethrins with piperonyl butoxinade applied to the affected area and
washed off after 10 mins
• Alternative Regimen:
• Malathion 0.5% lotion applied for 8-12 hours and washed off OR
• Ivermectin 250ug/kg repeated in 2 weeks
SCABIES
• Human scabies (itch mite) by Sarcoptes scabiei
• Transmitted thru sexual contact with an infected person
• Symptoms: Pruritic, pleomorphic rash with an insidious onset
• Hallmark: raised sinnous burrow
• Diagnosis: history and PE, skin scrapping
SCABIES
Treatment:
• Permethrin 5% cream rinse applied to all ares of the body from the
neck down and washed off after 8-14 hours OR
• Ivermectin 250ug/kg repeated in 2 weeks
• Alternative Regimen:
• Lindane 1% 1 oz of lotion or 30g cream applied in a thin layer to all
areas from the neck down and washed off after 8 hours
PELVIC INFLAMMATORY
DISEASE
PELVIC INFLAMMATORY DISEASE
• Spectrum of inflammatory disorders of the upper female
genital tract
• Endometritis, salphingitis, tubo-ovarian abscess, and pelvic
peritonitis
• Risk factors: age (<25), history of sexual activity, history of
STD, contraceptive use (pills, IUD), douching, and invasive
gynecologic procedures
PELVIC INFLAMMATORY DISEASE
Minimum Criteria
• Lower abdominal tenderness, Adnexal tenderness, or Cervical motion
tenderness
Routine Criteria for Diagnosing PID
• Oral temperature >38C
• Abnormal cervical or vaginal discharge
• Leukocytosis on microscopy of vaginal secretions
• Elevated erythrocyte sedimentation rate
• Previous Cervical infection with N. gonorrhea or C. trachomatis
PELVIC INFLAMMATORY DISEASE
Definitive Criteria for Diagnosing PID
• Histopathologic evidence of endometritis on endometrial biopsy
• TVS UTZ or MRI showing thickened fluid-filled tubes w/ or w/o free
pelvic or tubo-ovarian complex
• Laparoscopic abnormalities consistent with PID
Treatment
Recommended:
• Ceftriaxone 250mg IM single dose OR
• Cefoxitin 2g IM single dose and probenecid 1g PO administered
concurrently in single dose OR
• Other parenteral 3rd gen cephalosporin (Ceftizoxime or Cefotaxime)
PLUS
• Doxycycline 100mg PO bid for 14 days WITH or WITHOUT
Metronidazole 500mg PO BID x 14 days
Treatment
Alternative
• Levofloxacin 500mg PO once daily x 14 days OR
• Ofloxacin 400mg PO once daily x 14 days OR
• Moxifloxacin 400mg PO daily x 14 days WITH Metronidazole 500mg
PO BID x 14 days
• Azithromycin 500mg IV daily for 1-2 doses, followed by 250mg PO
daily for 12-24 days, in combination w/ Metronidazole 500mg BID
• Ceftriaxone 250mg IM single dose PLUS Azithromycin 1g PO once a
week for 2 weeks
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