Pelvic Inflammatory Disease

Patient Population: Pediatric

This and other STI sections are not meant to be comprehensive references for all STI treatment but primarily focused on the most commonly used initial empiric antimicrobial therapy. Users should refer to linked resources (SFDPH City Clinic protocols, CDC guidelines) or other local resources to provide patients and their partners appropriate counseling and follow-up. For non-adolescent age patients, patients with STIs not addressed in these guidelines, or patients with contraindications to the listed therapies, we recommend referring to the linked resources, or Lexi-Comp for medication information, or consulting ID/ASP for individualized recommendations.   

Condition Major Pathogens  First Choice Therapy Alternative Therapy Comments

Pelvic inflammatory disease, inpatient therapy 

Need for inpatient therapy is based on clinical judgment and meeting any suggested criteria: 

Surgical emergencies (e.g., appendicitis) cannot be excluded 

Severe PID (vomiting, severe pain, high fever, overt peritonitis) 

Tubo-ovarian abscess 

Pregnancy 

Inability to follow or tolerate outpatient regimen 

Treatment failure on appropriate outpatient regimen 

Often polymicrobial 

Chlamydia trachomatis 

Neisseria gonorrhoeae 

Enteric gram-negative and anaerobic bacteria 

Cefoxitin
2000 mg IV q6h 

AND 

Doxycycline
100 mg enterally or IV q12h (enteral route preferred if tolerated) 

24 hours after clinical improvement: 

Stop Cefoxitin, continue Doxycycline 100 mg enterally bid, and ADD Metronidazole 500 mg enterally bid to complete 14 day total course* 

Penicillin or cephalosporin allergy with higher risk for allergic reaction

Clindamycin
900 mg IV q8h  

AND  

Gentamicin
2 mg/kg/dose IV x 1 dose, followed by 1.5 mg/kg/dose IV q8h  

24 hours after clinical improvement: 

Stop Clindamycin and Gentamicin, start Doxycycline 100 mg enterally  bid and Metronidazole 500 mg enterally bid to complete 14 day total course 

Refer to SFDPH City Clinic STI protocols section on PID for diagnostic criteria, recommended laboratory evaluation (including testing for other STIs), counseling (including abstinence from sex during treatment),  partner treatment, and follow up (including retesting in 3 months). 

*Metronidazole likely improves outcomes in all patients with PID, and is especially indicated if bacterial vaginosis or tubo-ovarian abscess cannot be ruled out 

Pelvic inflammatory disease, outpatient therapy 

Outpatient treatment is standard in those patients with mild to moderate symptoms and able to return for frequent reassessment. All patients who begin outpatient treatment should be clinically re-evaluated within 72 hours and if not improved should start parenteral therapy and consider additional diagnostics 

Same

Ceftriaxone 

Weight > 45 kg and <150kg: 500 mg IM x 1 dose 

Weight >=150kg: 
1000 mg IM x 1 dose 

AND 

Doxycycline
100 mg enterally bid x 14 days 

AND  

Metronidazole
500 mg enterally bid x 14 days* 

Penicillin or cephalosporin allergy with higher risk for allergic reaction:  

Consult ID/ASP

If anticipate significant challenges to adherence:

Consider replacing Doxycycline with: 

Azithromycin
1000 mg enterally qweek x 2 doses 

Refer to SFDPH City Clinic STI protocols section on PID for diagnostic criteria, evaluation, counseling, and follow up recommendations 

*Metronidazole likely improves outcomes in all patients with PID, and is especially indicated if bacterial vaginosis or tubo-ovarian abscess cannot be ruled out 

References: 

Workowski KA, et al. Centers for Disease Control and Prevention. Sexually transmitted infections treatment guidelines, 2021. MMWR Recomm Rep 2021;70:1-187.

Wiesenfeld, HC, et al.. (2020). A randomized controlled trial of ceftriaxone and doxycycline, with or without metronidazole, for the treatment of acute pelvic inflammatory disease. Clin Infect Dis 2020;72;1181-1189. 

St. Cyr S, et al. Update to CDC’s treatment guidelines for gonococcal infection, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1911–1916.

Pediatric Empiric Antimicrobial Therapy Guidelines

This is a subsection of the UCSF Benioff Children’s Hospitals Empiric Antimicrobial Therapy Guidelines, developed by the Pediatric Antimicrobial Stewardship Programs at each campus to inform initial selection of empiric antimicrobial therapy for children at the UCSF Benioff Children’s Hospitals and affiliated outpatient sites. 

These are guidelines only and not intended to replace clinical judgment. Modification of therapy may be indicated based on patient comorbidities, previous antibiotic therapy or infection history. Doses provided are usual doses but may require modification based on patient age or comorbid conditions. Refer to Pediatric Antimicrobial Dosing Guideline for further guidance on dosing in children, and Neonatal Dosing Guideline for infants < 1 month of age. Consult a pediatric pharmacist for individualized renal or hepatic dose adjustment. Durations provided are usual recommendations for patients who are responding appropriately to therapy. For additional guidance, please contact Pediatric Infectious Diseases (ID) or the Pediatric Antimicrobial Stewardship Program (ASP) at the campus where your patient is receiving care.  

For questions or feedback about these guidelines, please email primary content owners, Rachel Wattier, Pediatric ASP Medical Director at BCH SF and Prachi Singh, Pediatric ASP Medical Director at BCH OAK. 

The content of these guidelines was updated in July 2021. See Summary and Rationale for Changes (password login to Box needed) for detailed explanations of the content changes.