STI Part 2 – Canadian Guidelines

Management and Treatment of Specific Syndromes

  • diagnosis by syndrome and laboratory diagnosis by testing for specific organisms are both important and complementary

1. Asymptomatic & at risk for STI

  • Etiology: Neisseria gonorrhoeae, Chlamydia trachomatis, Treponema pallidum, HSV1/2, HPV, HIV, Viral hepatitis
  • Specimens and testing:
    • First-catch urine, Urethral swab, Cervical swab for: C. trachomatis N. gonorrhoeae
    • Serology for: Syphilis, HIV, Hepatitis A (particularly with oral-anal contact), Hepatitis B (if no history of vaccine), Hepatitis C (particularly in IDU), Pap testing if indicated (as per local or provincial/territorial recommendations)
  • An abnormal Pap test result (e.g., ASCUS, LSIL) is not diagnostic of HPV
  • If testing is done by methods other than NAAT and sexual contact occurred < 48 hours prior to testing, tests may be falsely negative
  • Window period for detection of early syphilis is 2-6 weeks depending on the screening test used
  • Typical window period for HIV is 3 months
  • If non-immune for hepatitis A and B, consider immunization
  • For chronic viral hepatitis, consult GI

2. Urethritis

  • Clinical syndrome:
    • Inflammation of the urethra, with or without urethral discharge.
    • Discharge, if present, can be mucoid, mucopurulent or purulent.
    • May also be manifested by dysuria, urethral pruritus or meatal erythema.
  • Microscopic definition: presence of ≥5 polymorphonuclear leukocytes (PMNs) per oil immersion field (x1000) in five non-adjacent, randomly selected fields on a smear.
  • Non-gonococcal urethritis (NGU) refers to urethritis not caused by N. gonorrhoeae.
  • Important causes to consider: Neisseria gonorrhoeae, Chlamydia trachomatis
  • Other possible causes: Trichomonas vaginalis, HSV, Mycoplasma genitalium, Ureaplasma urealyticum
  • Other, less common considerations: Adenovirus, Candida albicans

Natural history

  • Symptoms of gonococcal urethritis develop 2 to 6 days after acquisition.
  • Symptoms of NGU develop 1 to 5 weeks after acquisition (usually at 2–3 weeks).
  • Up to 25% of infections, especially NGU, can be asymptomatic.
Prevention and Control
  • Use clinical evaluation as an opportunity to review safer sexual practices
  • Advise on consistent condom use.
  • Advise patient to abstain from unprotected intercourse until 7 days after initiating treatment.
  • Urethral discharge.
  • Dysuria, Urethral itching or meatal erythema.
  • Often asymptomatic.
  • Although urinary frequency, hematuria and urgency can, on rare occasions, occur with urethritis, the presence of any of these symptoms requires more extensive evaluation.
Specimen collection
  • Discharge: obtain sample by having patient milk penis three to four times from base to glans.
  • Endourethral swab: pass swab 2 cm into the urethra, rotate and remove for Gram stain and testing.
  • Urine: obtain first 10–20 ml of first-catch urine, any time of day, but preferably after having not voided > 2 hr
Laboratory diagnosis
  • Testing for both gonorrhea and chlamydia is recommended
  • Obtain the following:
    • Gram stain of discharge or endourethral specimen for PMNs and Gram-negative diplococci

    If nucleic acid amplification tests (NAAT) are available:

    • NAAT of urine for C. trachomatis and culture of endourethral swab for N. gonorrhoeae.

    If NAAT is unavailable:

    • Direct fluorescent antibody (DFA), enzyme immunoassay (EIA), or culture for C. trachomatis and culture of endourethral swab for N. gonorrhoeae.
  • Although NAAT testing for gonorrhea may be considered in cases where transport and storage conditions are not conducive to maintaining the viability of N. gonorrhoeae or obtaining a swab is not possible, culture is the preferred method, because it allows for antimicrobial susceptibility testing.
  • Presence of the following symptoms suggest an alternative diagnosis:
    • Hematuria, Frequency, nocturia, urgency, Difficulties initiating and maintaining stream.
    • Fever, chills.
    • Perineal pain, scrotal masses, Lymphadenopathy
Management and Treatment
Gonococcal urethritis
  • Cefixime 400 mg PO x1 PLUS EITHER doxycycline 100 mg PO bid for 7 days OR azithromycin 1 g PO x 1 if poor compliance is expected.
  • Doxycycline 100 mg PO bid for 7 days OR azithromycin 1 g PO x 1 if poor compliance is expected.
  • Alternative regimens are available for G&C infections
  • Single-dose regimens offer improved compliance, useful in street youth, but most expensive.
  • Resolution of symptoms can take up to 7 days after therapy has been completed.
  • Patients and contacts should abstain from unprotected intercourse until treatment of both partners is complete (i.e. after completion of multiple dose treatment or for 7 days after single dose therapy).
  • Asymptomatic infections in men are common and should be treated.
Consideration for Other STIs
  • Obtain serology for syphilis.
  • Review hepatitis B immunity; offer vaccine and testing if the patient is at high risk.
  • Offer HIV testing and counselling.
  • In MSM, consider hepatitis A vaccine.
Reporting and Partner Notification
  • Urethritis caused by G&C is a notifiable communicable disease for provinces and territories. All conditions and diseases that are notifiable should be reported to public health departments in accordance with local regulations and laws.
  • Sexual partners be traced 60 days prior to symptom onset or date of diagnosis/ date of specimen collection (if asymptomatic) & tested and empirically treated regardless of clinical findings and without waiting for test results.
  • The length of time for the trace-back period should be extended:
    1. to include additional time up to the date of treatment
    2. If no partners during this period, then the last partner should be notified
    3. if all partners traced during this period test negative, then notify the partner prior to the trace-back period
  • Where possible, encourage the use of public health authorities or treating physician to conduct contact tracing on partners and increase the number of partners contacted.
  • If treatment is taken and symptoms resolve, test of cure is not routinely recommended.
  • Re-evaluate If symptoms persist or recur after completed therapy (1 week after initiation of therapy)
  • Symptoms alone are not sufficient for retreatment in the absence of laboratory findings or clinical signs.
  • If a test of cure is indicated and NAAT is being used for follow-up testing, testing should not be conducted until 3 weeks after treatment to avoid a false positive.
Special Considerations
Recurrent or persistent urethritis
  • Often a difficult problem: inform patient at the start of care for recurrent urethritis that it can be a difficult clinical problem to address, but that symptoms often resolve.
  • Critical to differentiate urethritis from functional complaints: Reconfirming the presence of urethritis using smear and Gram stain is essential.
  • If there is a microbiologically or clinically documented failure with persistent urethritis, consider the following:
    • Re-exposure to untreated partner.
    • Infection acquired from new partner.
    • Medication not taken correctly/not completed.
    • Infection with other pathogens.
    • Presence of resistant organisms
    • Other causes (e.g., UTI, prostatitis, phimosis, chemical irritation, urethral strictures, tumours).
  • Consider:
    • Repeat specimens (urine and endourethral) for Gram stain, culture and NAAT forN. gonorrhoeae and C. trachomatis.
    • Endourethral swabs or urine for T vaginalis.
    • Endourethral swab or urine for HSV culture, although usually associated with lesions
    • Endourethral specimen or first-void urine for culture for U urealyticum and M genitalium 
    • Urology or infectious diseases consultation if unresolved.
    • Determine whether other underlying etiologies, such as anxiety, contribute to symptoms.
Children with urethritis
  • Sexual abuse must be considered if there are symptoms of unexplained pyuria in prepubertal boys or young males who are not sexually active 
  • Practitioners need to follow provincial guidelines for reporting any suspected cases of child sexual abuse to appropriate authorities.
  • All persons named as suspects in child sexual abuse cases should be located and clinically evaluated; prophylactic treatment may or may not be offered and the decision to treat or not should be based on history, clinical findings and test results 
  • Young men and women with urethritis may be erroneously diagnosed with UTI.
  • In addition to symptoms present in adults, children with urethritis can also demonstrate the following:
    • Abdominal pain, Unwillingness to void, Enuresis.
  • Repeat testing should be offered to all children.
Urethritis in women
  • Urethritis caused by G&C in women can occur without cervicitis.
  • Dysuria and urinary frequency may be symptoms of urethritis and thus may mimic cystitis.
  • Specimens for G&C in women should be obtained from both urine and endocervical specimens.


3. Cervicitis

  • S/Sx: Mucopurulent cervical discharge, Cervical friability, Vaginal discharge, Strawberry cervix
  • Possible causes: N. gonorrhoeae, C. trachomatis, Trichomonas vaginalis, HSV
  • Testing:
    • Cervical swab for Gram-stain, N. gonorrhoeae and C. trachomatis (NAAT or culture)
    • Swab of cervical lesions for HSV
    • Vaginal swab for wet mount
  • Although not a sensitive test, Gram stain may be helpful in diagnosing mucopurulent cervicitis and gonorrhea in symptomatic females
  • Tx: See chlamydial / gonococcal infections section, or HSV infection section, or Vaginal d/c section

4. Genital Ulcer Dz

  • S/Sx: Ulcers (erosive or pustular), Vesicles, Papules, Inguinal LN
  • Most common etiology: HSV1/2, T. pallidum, C. trachomatis (LGV – Lymphogranuloma Venereum)Haemophilus ducreyi, Klebsiella granulomatis
    • Herpes: Painful lesions, Grouped vesicles, Erythematous base, Fever and malaise
    • Syphilis: Non-painful lesions, Indurated with serous exudate, Single lesion in over 70% of cases
  • Routine Testing:
    • Swab of lesion for culture (herpes) & serous fluid from lesion for dark-field microscopy or DFA for syphilis
    • Syphilis serology should include a non-treponemal test (e.g., [RPR], [VDRL])
    • Consider 1o syphilis – If the initial serologic testing is negative and syphilis is suspected, Repeat serology in 2-4 wk
  • Non-routine Testing: (MSM / Travel Hx)
    • Swab of lesion for C. trachomatis for culture or NAAT or consider serology for C. trachomatis.
    • Consider testing for chancroid and granuloma inguinale (link to travel)
  • Tx:
    • Consider genital herpes and empiric Tx for either primary or suspected recurrent infection – see HSV section
    • Syphilis empiric Tx should be considered if follow-up is uncertain
    • If LGV is suspected, Tx empirically (see LGV section)

5. Epididymitis

  • inflammation of the epididymis manifested by a relatively acute onset of unilateral testicular pain and swelling often with tenderness of the epididymis and vas deferens and occasionally with erythema and edema of the overlying skin.
  • The term epididymo-orchitis is primarily used when inflammation occurs in both the epididymis and the testes together.
  • In men < 35 yo,  STI accounts for ⅔ of epididymitis (47% Chlamydia trachomatis and 20% Neisseria gonorrhoeae).
  • In men > 35 yo, 75% of cases can be attributed to coliforms or pseudomonas. Isolation of Chlamydia trachomatis or Neisseria gonorrhoeae is unusual.
  • Determine the etiologic agent based on the evaluation of the STI risk
  • In children and young adults, it is important to consider non-infectious causes of scrotal swelling, such as trauma, torsion of the testicle and tumour. Torsion of the testicle, which has a high risk of testicular infarction if treatment is delayed, is a surgical emergency and should be suspected when the onset of scrotal pain is sudden.
Microbial etiology and predisposing factors in acute epididymitis
Age group Etiology and predisposing factors
Prepubertal children
  • Usual etiology: coliforms, P. aeruginosa
  • Unusual etiology: hematogenous spread from primary infected site
  • Predisposing factors: underlying genitourinary pathology
Men under 35
  • Usual etiology: C. trachomatis, N. gonorrhoeae
  • Unusual etiology: coliforms or P. aeruginosa, Mycobacterium tuberculosis
  • Predisposing factors: sexually transmitted urethritis
Men over 35
  • Usual etiology: coliforms or P. aeruginosa
  • Unusual etiology: N. gonorrhoeae, C. trachomatis, Mycobacterium tuberculosis
  • Predisposing factors: underlying structural pathology or chronic bacterial prostatitis
  • In adolescents with epididymitis, sexual behaviour should be ascertained, as the cause may be a sexually transmitted infection.
  • Coliforms may be a frequent cause of acute epididymitis in sexually active men in all age groups who practice unprotected insertive anal intercourse.
Prevention and Control
  • At the time of diagnosis of suspected sexually acquired epididymitis, safer-sex practices should be reviewed. – use barrier methods eg male condoms
  • The patient and contact(s) should abstain from unprotected intercourse until Tx is complete, or for 7 days in the single-dose Tx
  • Fever, Unilateral testicular pain/swelling ± erythema and edema of the overlying skin ± urethral discharge (urethritis s/sx in sexually transmitted epididymitis is often asymptomatic)
  • The onset of pain is generally gradual.
  • Testicular torsion should be considered in all cases, as it is a surgical emergency. Torsion is more likely if the onset of pain is sudden and the pain is severe. Torsion is more frequent in men less than 20 years of age, but it can occur at any age.

Signs of acute epididymitis may include any of the following:

  • Tenderness to palpation on the affected side.
  • Palpable swelling of the epididymis, Hydrocele, Erythema and/or edema of the scrotum on the affected side.
  • Urethral discharge.
  • Fever.
  • If diagnosis is questionable, a specialist should be consulted immediately, because in the case of testicular torsion, testicular viability may be compromised.
  • Evaluation for epididymitis should include the following:
    • Urethral swab for Gram stain.
    • Collection of specimens for identification of N. gonorrhoeae and C. trachomatis(intraurethral exudate or urine according to available laboratory techniques.)
    • Microscopy and culture of mid-stream urine.
  • If it can be arranged without delay, a Doppler ultrasound may be useful to help differentiate epididymitis from testicular torsion.
  • There is no role for epididymal aspiration in routine clinical practice. It may be useful in recurrent infection that fails to respond to therapy or in patients with suspected abscess formation.
Recommended regimens for the treatment of acute epididymitis
Epididymitis most likely caused by chlamydial or gonococcal infections
  • Doxycycline 100 mg PO bid for 10–14 days PLUS Ceftriaxone 250 mg IM in a single dose (c/i if anaphylacsis to penicillins)
    • preferred diluent for ceftriaxone is 1% lidocaine without epinephrine (0.9 mL/250 mg, 0.45 mL/125 mg) to reduce discomfort.
  • OR Ciprofloxacin 500 mg PO in a single dose
    • Due to the rapid increase in quinolone resistant Neisseria gonorrhoeae, quinolones such as ciprofloxacin and ofloxacin are no longer preferred drugs for the treatment of gonococcal infections in Canada.
    • Quinolones may be considered as an alternative treatment option ONLY IF:
      • antimicrobial susceptibility testing is available and quinolone susceptibility is demonstrated; OR
      • where antimicrobial testing is not available, a test of cure is essential.
  • Consultation ID for patients with a documented gonococcal epididymitis who have cC/I to treatment with cephalosporins and quinolones.
Epididymitis most likely caused by enteric organisms
  • Ofloxacin 200 mg PO bid for 14 days
Consideration for Other STIs
  • Depending on sexual history, G&C infections should be considered as the etiology of acute epididymitis in all sexually active men with acute epididymitis, especially those under age 35.
  • Consideration for testing for other STIs, including HIV, should be made according to the patient’s sexual history and the presence of risk factors for specific infections.
Reporting and Partner Notification
  • Patients with conditions that are reportable according to provincial and territorial laws and regulations should be reported to the local public health authority.
  • When treatment is indicated for the index case, and they are presumed to have sexually acquired epididymitis, all sexual partners from 60 days prior to symptom onset or the date of diagnosis (if asymptomatic) should be located, clinically evaluated and treated with an appropriate regimen regardless of clinical findings and without waiting for test results.


  • Follow-up should be arranged to evaluate the response to treatment. If a recommended regimen has been given and correctly taken, symptoms and signs have disappeared and there is no re-exposure to an untreated sexual partner, then repeat diagnostic testing for N. gonorrhoeae and C. trachomatis is not routinely recommended.

Special Considerations

  • Rare causes of clinical sterile acute epididymitis include amiodarone therapy, vasculitis, polyarteritis nodosa, Behçet disease and Henoch-Schönlein purpura and a proportion of cases remains idiopathic.
  • A condition described as “chronic epididymitis” has been recently characterized in the literature. Although defined by the author as the presence of “symptoms of discomfort and/or pain at >3mo in duration in the scrotum, testicle or epididymis localized to one or each epididymis on clinical examination,” there is no clear natural history of the condition.


 6. Pelvic Inflammatory Disease (PID)


  • PID is an infection of the female upper genital tract involving any combination of the endometrium, fallopian tubes, pelvic peritoneum and contiguous structures.


  • There are multiple causes of lower abdominal pain in women, including gynecologic disease or dysfunction (complications of pregnancy, acute infections, endometriosis, adnexal disorders, menstrual disorders), as well as gastrointestinal (appendicitis, gastroenteritis, inflammatory bowel disease), genitourinary (cystitis, pyelonephritis, nephrolithiasis), musculoskeletal and neurologic causes.
  • The most common infectious cause of lower abdominal pain in women is pelvic inflammatory disease (PID).
  • PID is a polymicrobial infection with multiple microbial etiologies; Most cases of PID are associated with more than one organism.
  • Pathogens can be categorized as sexually transmitted or endogenous organisms.

Sexually transmitted organisms

  • Chlamydia trachomatis & Neisseria gonorrhoeae
  • Viruses and protozoa (rare): HSV,  Trichomonas vaginalis

Endogenous organisms

  • Genital-tract mycoplasmas: Mycoplasma genitalium, Mycoplasma hominis, Ureaplasma urealyticum

Anaerobic bacteria

  • Bacteroides spp., Peptostreptococcus spp., Prevotella spp.

Facultative (aerobic) bacteria

  • Escherichia coli, Gardnerella vaginalis, Haemophilus influenzae, Streptococcus spp.


  • PID is a very significant public health problem (10–15% of women of reproductive age). Up to two-thirds of cases go unrecognized, and underreporting is common. Not nationally reportable.
  • There are approximately 100,000 cases of symptomatic PID annually in Canada, although PID is not nationally reportable, so exact numbers are unknown.
  • The incidence of long-term sequelae of PID: (tubal factor infertility, ectopic pregnancy, chronic pelvic pain) is directly related to the number of episodes of PID.
  • In jurisdictions with long-standing chlamydia control programs, PID rates and ectopic pregnancy rates have declined.


  • Health care providers should assume responsibility for primary prevention activities, such as risk-reduction counselling and patient education.
  • At the time of diagnosis of infection, health care providers should reinforce prevention and safer sex practices.
  • Patients and contacts should be counselled to abstain from unprotected sexual contact until treatment of both partners is complete.

Manifestations and Diagnosis

  • Abdominal pain may be a clinical feature of many disorders, and the symptoms of PID may overlap with other Gyne, GI, GU, MSK systems.
  • There is no single historical, physical or laboratory finding that is both sensitive and specific for the diagnosis of PID.
  • Only one-third of women with acute PID have a temperature above 38°C
  • Common findings O/E of patients with acute PID include bilateral lower abdominal, uterine, adnexal and cervical motion tenderness – sensitive, not specific.
  • The clinical diagnosis of PID is imprecise, and clinicians should have a high index of suspicion.

 Criteria for diagnosis

Minimum diagnostic criteria Additional diagnostic criteria Definitive diagnostic criteria
Clue cells are vaginal epithelial cells covered with numerous coccobacilli
  • Lower abdominal  / adenxal tenderness
  • Cervical motion tenderness
  • Oral temperature >38.3°C.
  • WBC on saline microscopy of vaginal secretions/wet mount
  • ↑ ESR/ CRP
  • Laboratory documentation of cervical infection with G&C
  • Endometrial biopsy with histopathologic evidence of endometritis
  • Transvaginal U/S or other imaging techniques showing thickened fluid-filled tubes, with or without free pelvic fluid or tubo-ovarian complex
  • Gold standard: Laparoscopy demonstrating abnormalities consistent with PID, such as fallopian tube erythema and/or mucopurulent exudates

Physical examination and specimen collection

  • A complete abdominal and pelvic examination (speculum + bimanual) should be performed in any patient with lower abdominal pain.
  • The external genital area, vagina and cervix should all be inspected.
  • With the aid of a speculum, endocervical swabs should be obtained for diagnostic tests for G&C.
  • Cervical lesions should be sampled with swabs for diagnostic tests for HSV, if suspected.
  • Vaginal swabs should be obtained for culture; pH testing; amine odour whiff testing; normal saline and potassium hydroxide wet preparations; and Gram stain.
  • Clinical assessment for BV includes three of four Amsel criteria: vaginal discharge, elevated pH, amine odour whiff test and clue cells on microscopy.
    • An aerobic and anaerobic culture may assist with the detection of unusual vaginal pathogens, such as Group A streptococcus.
  • Stat serum beta HCG to rule out ectopic pregnancy.

Laboratory diagnosis

  • Negative laboratory results & normal U/S do not rule out a diagnosis of PID.
  • Ultrasound may aid in the diagnosis, especially if tubo-ovarian abscess is suspected.
  • A STAT beta HCG pregnancy test should be done to exclude ectopic pregnancy
  • Detection of Gram-negative intracellular diplococci on a stained smear of endocervical secretions; positive results of a diagnostic test for N. gonorrhoeae or C. trachomatis; or both.
  • Detection of N. gonorrhoeae or C. trachomatis may be enhanced by using nucleic acid amplification tests (NAAT).
  • Other tests that may be helpful in the diagnosis of acute PID include complete blood count, erythrocyte sedimentation rate, C-reactive protein and endometrial biopsy.


  • Early diagnosis and treatment are crucial to the maintenance of fertility.
  • IV or PO abx (no sig different in long-term complication)  in inpatient or outpatient settings.
  • Outpatient Tx need careful follow-up and should be re-evaluated 2 to 3 days after therapy is initiated.
  • If no clinical improvement has occurred, hospital admission for parenteral therapy, observation and consideration for laparoscopy is required; consultation with colleagues experienced in the care of these patients should be considered.

Criteria for hospitalization

  • Surgical emergencies such as appendicitis cannot be excluded.
  • The patient is pregnant.
  • The patient does not respond clinically to oral antimicrobial therapy.
  • The patient is unable to follow or tolerate an outpatient oral regimen.
  • The patient has severe illness, nausea and vomiting, or high fever.
  • The patient has a tubo-ovarian abscess.
  • Consider hospitalization for observed oral or parenteral therapy in the following cases:
    • HIV infection
    • Youth/adolescents (particularly if compliance is an issue)


  • To control the acute infection and to prevent long-term sequelae: infertility, ectopic pregnancy and chronic pelvic pain.
  • Tx – empiric broad-spectrum due to polymicrobial nature & cover G&C, Gram-negative facultative bacteria and streptococci.
    • Consider Anaerobic coverage
  • Although quinolones are no longer recommended for the treatment of gonococcal infections in Canada, due to the polymicrobial nature of PID, they still can be useful in the treatment of acute infection that does not involve quinolone resistant N. gonorrhoeae. Recent clinical trials have shown that quinolones are very effective at producing cure of acute PID.
  • For patients with contraindications to treatment with cephalosporins or quinolones, recent evidence suggests that short course azithromycin at a dose of either 250 mg PO daily for one week or 1 gram PO weekly for two weeks combined with oral metronidazole is effective in producing a clinical cure for acute PID.
  • D/C IV Tx after clinical improvement x 24hr. Continue po abx for a total of 14 days of treatment.
  • If recovery does not occur, other differential diagnoses and a laparoscopy need to be considered.

Recommended parenteral treatment regimens

Regimen A

  • Cefoxitin 2 g IV Q6h PLUS doxycycline 100 mg IV or PO Q12h
    • D/C IV Tx after clinical improvement x 24hr. Continue po doxycycline for a total of 14 days of treatment.
    • po and Iv doxycycline provide similar bioavailability; IV only if can’t tolerate po

Regimen B

  • Clindamycin 900 mg IV every 8 hours PLUS gentamicin loading dose IV or IM (2 mg/kg of body weight), followed by a maintenance dose (1.5 mg/kg) every 8 hours.
    • Once-daily dosing may be substituted (5mg/kg of body weight IV every 24h)
    • D/C IV Tx after clinical improvement x 24hr & continue po doxycycline (100 mg bid) or clindamycin (450 mg PO qid) for a total of 14 days

Alternative regimens

  • Ofloxacin 400 mg IV every 12 hours ± metronidazole 500 mg IV every 8 hours
  • Levofloxacin 500 mg IV once daily± metronidazole 500 mg IV every 8 hours
  • Ampicillin/sulbactam 3 g IV every 6 hours PLUS doxycycline 100 mg IV or PO every 12 hours
  • Ciprofloxacin 200 mg IV every 12 hours PLUS doxycycline 100 mg IV or PO every 12 hours ± metronidazole 500 mg IV every 8 hours
    • Because ciprofloxacin has poor coverage against C trachomatis, it is recommended that doxycycline be added routinely
    • Because of concerns regarding the anaerobic coverage of both quinolones, metronidazole should be included with each regimenTable 4 – Footnote


  • Patients should not drink alcohol during and for 24 hours following treatment with metronidazole because of a possible disulfiram (antabuse) reaction.
  • The use of ofloxacin, ciprofloxacin, levofloxacin, and doxycycline is contraindicated for pregnant and lactating women. Pregnant women should not be treated with quinolones or tetracyclines.

Recommended outpatient treatment regimens

Regimen A

Experts recommend the addition of metronidazole 500 mg PO bid for 14 days to this regimen for additional anaerobic coverage and the treatment of BV

  • Ceftriaxone 250 mg IM in a single dose PLUS doxycycline 100 mg PO bid for 14 days
  • Cefoxitin 2 g IM PLUS probenecid 1 g PO in a single dose concurrently once PLUS doxycycline 100 mg PO bid for 14 days
  • Other parenteral third-generation cephalosporin (e.g.,ceftizoxime or cefotaxime) PLUS doxycycline 100 mg PO bid for 14 days

Regimen B

  • Ofloxacin 400 mg PO bid for 14 days ± metronidazole 500 mg PO bid for 14 days
  • Levofloxacin 500 mg PO qd ± metronidazole 500 mg PO bid for 14 days
    • Metronidazole is added to provide anaerobic coverage
    • Preliminary data suggest that oral levofloxacin is as effective as oral ofloxacin, with the advantage of once-daily dosing

Consideration for Other STIs

  • Following a diagnosis of PID, testing and counselling should be performed for other infections, including HIV and syphilis.
  • Immunization against hepatitis B is recommended if not already immune.
  • Discuss HPV vaccine as per the recommendations

Reporting and Partner Notification


  • PID Pain and tenderness should begin to resolve within 48 to 72 hours of initiating abx. If no improvement is observed, further work-up is essential.
  • Individuals treated as outpatients need careful follow-up and should be re-evaluated 2 to 3 days after treatment is initiated.
  • If no clinical improvement has occurred, hospital admission for parenteral therapy and observation is required.
  • Following a diagnosis of PID, patients should be informed that they are at risk of both
    • short-term consequences such as Fitz-Hugh-Curtis syndrome (perihepatitis) and tubo-ovarian abscess, and
    • long-term sequelae, including infertility, ectopic pregnancy and chronic pelvic pain.

Special Considerations

  • PID is uncommon in pregnancy, especially after the first trimester. Large ddx of acute abdominal pain in pregnancy, and consultation should be sought.
  • Pregnant patients with suspected PID should be hospitalized for evaluation and treatment with parenteral therapy
HIV infection
  • HIV-positive women with PID may represent a subgroup of patients with a more difficult clinical course.
  • Some studies have suggested that HIV-positive women with PID have longer hospital stays and are at higher risk for the development of tubo-ovarian abscesses and are more likely to require surgical intervention.
  • These women should be followed closely and managed aggressively, and consideration should be given to hospitalization.
  • Consultation with a colleague experienced in HIV care is recommended.
  • Consideration should be given to hospitalization for adolescents with suspected PID if compliance is expected to be an issue.
Patients with an intrauterine contraceptive device in situ
  • Pt with (IUD) in situ, the device should not be removed until after therapy has been initiated and at least two doses of antibiotics have been given.






Posted in 83 STI, FM 99 priority topics, Uncategorized

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