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A Cochrane review of antibiotic treatment for pelvic inflammatory disease (PID), found no definitive evidence that one regimen was more effective or safer than another. Study authors also found no conclusive evidence for the use of nitroimidazoles (eg, metronidazole) vs. other agents with activity over anaerobes.
The main treatment for acute PID is broad-spectrum intravenous (IV), intramuscular (IM) or oral antibiotics that are active against Chlamydia trachomatis, Neisseria gonorrhoeae, and anaerobes. In the review, authors aimed to assess the safety and efficacy of antibiotic regimens used to treat PID. They included randomized controlled trials that compared antibiotic use vs. placebo or other antibiotics for the treatment of PID in women of reproductive age. A total of 37 randomized controlled trials enrolling 6,348 women were included and the quality of evidence was rated using the GRADE criteria.
Azithromycin vs. Doxycycline: No clear difference was seen in cure rates for mild-moderate PID (risk ratio [RR] 1.18, 95% CI: 0.89–1.55; very low-quality evidence) or severe PID (RR 1.00, 95% CI: 0.96–1.05; low-quality evidence). Also, no clear difference was seen in adverse effects resulting in treatment discontinuation (RR 0.71, 95% CI: 0.38–1.34; low-quality evidence). A sensitivity analysis of a single study found azithromycin superior to doxycycline in curing mild-moderate PID (RR 1.35, 95% CI: 1.10–1.67; moderate-quality evidence).
Quinolone vs. Cephalosporin: No clear difference was seen in cure rates of mild-moderate PID (RR 1.04, 95% CI: 0.98–1.10; low-quality evidence) or severe PID (RR 1.06, 95% CI: 0.91–1.23; low-quality evidence). Also, no clear difference was seen in adverse effects resulting in treatment discontinuation (RR 2.24, 95% CI: 0.52–9.72; very low-quality evidence).
Nitroimidazole vs. No Use of Nitroimidazole: No clear difference was seen between the nitroimidazoles (eg, metronidazole) group vs. other anaerobe-active drugs (eg, amoxicillin-clavulanate) group in cure rates for mild-moderate PID (RR 1.01, 95% CI: 0.93–1.10; moderate-quality evidence) or severe PID (RR 0.96, 95% CI: 0.92–1.01; moderate-quality evidence). Also, no clear difference was seen in adverse effects resulting in treatment discontinuation (RR 1.00, 95% CI: 0.63–1.59; low-quality evidence). A sensitivity analysis showed that the findings did not vary much from the main analysis (RR 1.06, 95% CI: 0.98–1.15; high-quality evidence).
Clindamycin + Aminoglycoside vs. Quinolone: No clear difference was seen in cure rates of mild-moderate PID (RR 0.88, 95% CI: 0.69–1.13; very low-quality evidence) or severe PID (RR 1.02, 95% CI: 0.87–1.19; low-quality evidence). Also, no clear difference was seen in adverse effects resulting in treatment discontinuation (RR 0.21, 95% CI: 0.02–1.72; very low-quality evidence).
Clindamycin + Aminoglycoside vs. Cephalosporin: No clear difference was seen in cure rates of mild-moderate PID (RR 1.02, 95% CI: 0.95–1.09; low-quality evidence) or severe PID (RR 1.00, 95% CI: 0.92–1.06; moderate-quality evidence). Also, no clear difference was seen in adverse effects resulting in treatment discontinuation (RR 0.78, 95% CI: 0.18–3.42; very low-quality evidence).
A single study produced moderate-quality evidence that a macrolide (eg, azithromycin) may be more effective than a tetracycline (eg, doxycycline) for curing mild-moderate PID.
Some of the main limitations of the studies used for this review included serious risk of bias, serious inconsistency, and serious imprecision; due to this, the quality of evidence ranged from high to very low. Overall, the authors determined no conclusive evidence that one antibiotic regimen was superior than another for treating PID.
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