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gyn.pelvic-inflammatory-disease.core.v1PRODUCTION
gyn.pelvic-inflammatory-disease.core.v1

Pelvic inflammatory disease (PID) + tubo-ovarian abscess (TOA)

obstetricsacutesubacuteadultpregnancy
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Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm sexually active reproductive-age female with pelvic pain — minimum criteria threshold per CDC STI 2021 is intentionally LOW to prevent long-term sequelae (infertility / ectopic / chronic pelvic pain). Treat broadly when in doubt.

Inputs
2
Actions
0
Advance rule
Set
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scope confirmed: reproductive-age + sexual activity (CDC STI 2021)

Patient inputs (27)

Reproductive-age female with sexual activity is the eligibility frame (CDC STI 2021 minimum criterion 1)

Sexually active reproductive-age female is the eligibility frame; also drives partner-treatment + STI testing (CDC STI 2021)

Fever > 38.3 °C is CDC additional criterion + drives admission threshold (CDC STI 2021)

Tachycardia component of qSOFA / SIRS + systemic-toxicity marker (SSC 2021)

Pregnancy with PID is rare but mandates admission + IV abx + MFM consult + avoid doxycycline (ACOG PB 232; CDC STI 2021)

Recent IUD insertion (< 3 wk) raises PID risk; established IUD does NOT mandate removal if responding at 48-72 h (CDC STI 2021)

HIV coinfection raises TOA risk and lowers admission threshold; same regimens (CDC STI 2021)

Bilateral lower-abdominal / pelvic pain typical; duration informs acuity (CDC STI 2021; ACOG PB 232)

Bimanual-exam finding; one of the three CDC minimum criteria — low threshold to treat (CDC STI 2021)

Bimanual-exam finding; CDC minimum criterion (CDC STI 2021)

Bimanual-exam finding; CDC minimum criterion + raises TOA suspicion if unilateral mass (CDC STI 2021; ACOG PB 232)

Pregnancy test in every reproductive-age female — anchors ectopic ddx and pregnancy-specific PID pathway (ACOG PB 232; ACOG PB 193 ectopic)

Ddx with UTI / pyelo and screen for pyuria (CDC STI 2021)

NAAT for N. gonorrhoeae + C. trachomatis (and M. genitalium where available) — pathogen-targeted therapy + partner notification (CDC STI 2021; ACOG PB 232)

Leukocytosis as Eron-equivalent severity marker; baseline for inpatient course (CDC STI 2021)

Hypotension → sepsis pathway + SSC bundle; drives admission + ICU disposition (SSC 2021; CDC STI 2021)

Antibiotic renal dose adjustment (gentamicin in Regimen B; cephalosporins) (CDC STI 2021)

CT/MRI if TVUS equivocal, suspected rupture, atypical presentation, or to differentiate appendicitis / diverticulitis (ACOG PB 232)

Recurrent PID → fertility-counseling threshold + reproductive endocrinology referral + partner-screening adherence review (CDC STI 2021)

Post-procedural PID phenotype (D&C, HSG, IUD insertion, biopsy); raises pathogen breadth toward Gram-negative + anaerobic (ACOG PB 232)

Abundant WBCs on saline microscopy is CDC additional criterion (CDC STI 2021)

Elevated ESR / CRP is CDC additional criterion (CDC STI 2021)

Sepsis bundle when SIRS / hypotension present (SSC 2021)

Mandatory STI panel at diagnosis (CDC STI 2021)

Mandatory STI panel at diagnosis (CDC STI 2021)

Mandatory STI panel at diagnosis (CDC STI 2021)

Transvaginal ultrasound first-line imaging for TOA / pyosalpinx / fluid-filled tubes; bedside or radiology (ACOG PB 232; CDC STI 2021)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (10)

10 need judgement
  • informationallife_threateningtoa_rupture_emergent_or
    Suspected TOA rupture: peritonitis + free fluid on imaging + sepsis features — emergent OR / laparoscopy + broad-spectrum + ICU (ACOG PB 232; SSC 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningsevere_pid_with_sepsis_features
    PID with hypotension on adequate fluids + lactate > 2 OR qSOFA ≥ 2 + skin / pelvic source — routes to id.sepsis.core.v1 + SSC 2021 hour-1 bundle (SSC 2021; CDC STI 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepid_with_toa_at_diagnosis
    TVUS / CT-confirmed tubo-ovarian abscess at diagnosis — admit + IV antibiotics + drainage decision based on size and response (ACOG PB 232; CDC STI 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepid_in_pregnancy
    PID diagnosed in pregnant patient — rare but mandates admission, IV antibiotics, MFM consult, avoid doxycycline (ACOG PB 232; CDC STI 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereoutpatient_treatment_failure_at_72h
    Persistent fever / pain / tenderness at 72 h after appropriate outpatient regimen — admit for IV + repeat imaging for missed TOA + broaden coverage (CDC STI 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepid_with_mycoplasma_genitalium_macrolide_resistance
    PID with confirmed M. genitalium + macrolide resistance — switch from doxycycline to moxifloxacin 400 mg PO daily × 14 d (CDC STI 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehiv_coinfection_with_pid
    PID in HIV-positive patient — same regimens as non-HIV but higher TOA risk, lower admission threshold per CDC STI 2021
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateiud_in_situ_with_pid_diagnosis
    IUD in situ at time of PID diagnosis — IUD does NOT mandate removal if responding at 48-72 h; remove if no response (CDC STI 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderaterecurrent_pid_with_long_term_sequelae
    Recurrent PID (≥ 2 episodes) — fertility counseling + reproductive endocrinology referral + chronic-pelvic-pain workup + partner-treatment adherence review (CDC STI 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildexpedited_partner_therapy_eligible
    Sexual partners within 60 days of symptom onset — expedited partner therapy where legal reduces re-infection ~ 30 % (CDC STI 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

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Recommended regimen

Outpatient mild-moderate PID (no TOA, tolerating PO, reliable 72-h follow-up) — CDC STI 2021
axis: pid_outpatient_mild_moderate
Selected axis "Outpatient mild-moderate PID (no TOA, tolerating PO, reliable 72-h follow-up) — CDC STI 2021" by default fallback (first axis)
  • ceftriaxone
    first line
    3rd_gen_cephalosporin
    500 mg IM • IM • single dose
    triggers: outpatient, tolerating_PO, no_TOA, no_pregnancy_complication
    CDC STI 2021 — single IM dose covers N. gonorrhoeae + drives empiric coverage for outpatient PID
    rxcui 2193
  • doxycycline
    first line
    tetracycline
    100 mg PO • PO • BID × 14 d
    triggers: outpatient, not_pregnant
    CDC STI 2021 — covers C. trachomatis + atypicals + most M. genitalium (if not macrolide-resistant)
    rxcui 3640
  • metronidazole
    first line
    nitroimidazole
    500 mg PO • PO • BID × 14 d
    triggers: outpatient
    CDC STI 2021 — added 2021 to cover anaerobes + bacterial vaginosis-associated pathogens (vs 2015 guidance which made it optional)
    rxcui 6922
  • moxifloxacin
    comorbidity specific
    fluoroquinolone
    400 mg PO • PO • daily × 14 d
    triggers: mycoplasma_genitalium_macrolide_resistant
    CDC STI 2021 — M. genitalium-confirmed PID with macrolide resistance
    rxcui 139462

outpatient playbook — drug actions (5)

  1. 1. ceftriaxone
    500 mg IM × 1 • IM • single
    trigger: Mild-moderate PID, no TOA, tolerating PO (CDC STI 2021)
    CDC STI 2021 first-line single-dose IM for empiric coverage of N. gonorrhoeae
  2. 2. doxycycline
    100 mg PO BID × 14 d • PO • BID × 14 d
    trigger: Non-pregnant (CDC STI 2021)
    CDC STI 2021 — covers C. trachomatis + atypicals + most M. genitalium
  3. 3. metronidazole
    500 mg PO BID × 14 d • PO • BID × 14 d
    trigger: All outpatient PID (added 2021 vs 2015) (CDC STI 2021)
    CDC STI 2021 — added 2021 to cover anaerobes + bacterial vaginosis pathogens (no longer optional)
  4. 4. moxifloxacin (replace doxy if M. genitalium macrolide-resistant)
    400 mg PO daily × 14 d • PO • daily × 14 d
    trigger: M. genitalium-confirmed PID with macrolide resistance (CDC STI 2021)
    CDC STI 2021 — macrolide-resistant M. genitalium pathway
  5. 5. expedited partner therapy (CDC STI 2021 where legal)
    Per CDC EPT regimen (cefixime 800 mg PO + doxycycline 100 mg PO BID × 7 d) • PO • single + 7 d
    trigger: Sexual partners within 60 days where EPT is legal (CDC STI 2021)
    CDC STI 2021 — partner treatment reduces re-infection ~ 30 %

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Pelvic / lower abdominal pain in sexually active reproductive-age female (CDC STI 2021 minimum criterion); Cervical motion tenderness OR uterine tenderness OR adnexal tenderness on bimanual exam (CDC STI 2021 minimum criterion ≥ 1); Mucopurulent cervical discharge or cervical friability (CDC STI 2021 additional criterion improves specificity).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Pelvic inflammatory disease (PID) + tubo-ovarian abscess (TOA)** (gyn.pelvic-inflammatory-disease.core.v1).
Phenotype framing: Ectopic pregnancy, ovarian torsion, ruptured hemorrhagic cyst, acute appendicitis, diverticulitis, pyelonephritis, endometriosis flare, UTI; in older / postmenopausal patients PID is rare — refocus on malignancy / diverticulitis (CDC STI 2021; ACOG PB 232)
Scope: Confirm sexually active reproductive-age female with pelvic pain — minimum criteria threshold per CDC STI 2021 is intentionally LOW to prevent long-term sequelae (infertility / ectopic / chronic pelvic pain). Treat broadly when in doubt.

No severity triggers fired against current inputs.

Plan

Regimen axis: **Outpatient mild-moderate PID (no TOA, tolerating PO, reliable 72-h follow-up) — CDC STI 2021**.
1. ceftriaxone 500 mg IM IM single dose (3rd_gen_cephalosporin, first line) — CDC STI 2021 — single IM dose covers N. gonorrhoeae + drives empiric coverage for outpatient PID
2. doxycycline 100 mg PO PO BID × 14 d (tetracycline, first line) — CDC STI 2021 — covers C. trachomatis + atypicals + most M. genitalium (if not macrolide-resistant)
3. metronidazole 500 mg PO PO BID × 14 d (nitroimidazole, first line) — CDC STI 2021 — added 2021 to cover anaerobes + bacterial vaginosis-associated pathogens (vs 2015 guidance which made it optional)
4. moxifloxacin 400 mg PO PO daily × 14 d (fluoroquinolone, comorbidity specific) — CDC STI 2021 — M. genitalium-confirmed PID with macrolide resistance

Setting playbook (outpatient) — Manage mild-moderate PID with 14-day combination antibiotic regimen, partner treatment via expedited partner therapy where legal, 72-h reassessment, 3-month STI retest, fertility-sequelae counseling, and recurrent-PID prevention (CDC STI 2021; ACOG PB 232; PEACH long-term equivalence data Ness 2002)
5. ceftriaxone 500 mg IM × 1 IM single — Mild-moderate PID, no TOA, tolerating PO (CDC STI 2021) (CDC STI 2021 first-line single-dose IM for empiric coverage of N. gonorrhoeae)
6. doxycycline 100 mg PO BID × 14 d PO BID × 14 d — Non-pregnant (CDC STI 2021) (CDC STI 2021 — covers C. trachomatis + atypicals + most M. genitalium)
7. metronidazole 500 mg PO BID × 14 d PO BID × 14 d — All outpatient PID (added 2021 vs 2015) (CDC STI 2021) (CDC STI 2021 — added 2021 to cover anaerobes + bacterial vaginosis pathogens (no longer optional))
8. moxifloxacin (replace doxy if M. genitalium macrolide-resistant) 400 mg PO daily × 14 d PO daily × 14 d — M. genitalium-confirmed PID with macrolide resistance (CDC STI 2021) (CDC STI 2021 — macrolide-resistant M. genitalium pathway)
9. expedited partner therapy (CDC STI 2021 where legal) Per CDC EPT regimen (cefixime 800 mg PO + doxycycline 100 mg PO BID × 7 d) PO single + 7 d — Sexual partners within 60 days where EPT is legal (CDC STI 2021) (CDC STI 2021 — partner treatment reduces re-infection ~ 30 %)

Non-pharmacologic actions:
- Pelvic rest (no intercourse) until partner treated + symptoms resolved (CDC STI 2021)
- Counsel on long-term sequelae — infertility (1 ep 12 %, 2 ep 25 %, ≥ 3 ep 50 %), ectopic 6-10×, chronic pelvic pain 30-40 % — to drive adherence (CDC STI 2021; ACOG PB 232)
- Contraception counseling — IUD retention OK if responding at 48-72 h (no mandatory removal); barrier method counseled for ongoing STI prevention (CDC STI 2021)
- Partner notification + expedited partner therapy enrollment where legal (CDC STI 2021)
- STI retesting plan at 3 months (CDC STI 2021)
- Fertility counseling threshold — recurrent PID (≥ 2 episodes) → reproductive endocrinology referral (CDC STI 2021)
- HPV vaccination check + cervical cancer screening status (ACIP 2024; ACOG)
- Vaccination check: HBV if non-immune (CDC STI 2021)

AVOID / contraindication checks:
- Doxycycline pregnancy contraindication (FDA category D; CDC STI 2021 — use azithromycin in pregnancy)
- Fluoroquinolone tendon rupture and aortic dissection warning (FDA 2018 boxed warning)
- Fluoroquinolone pregnancy block (FDA / ACOG)
- Metronidazole alcohol disulfiram reaction counsel (CDC STI 2021)

Monitoring

Regimen monitoring:
- reassess at 72h for clinical response (CDC STI 2021)
- admit if no improvement at 72h for IV (CDC STI 2021)
- partner treatment within 60 days (CDC STI 2021 expedited partner therapy where legal)
- retest GC CT at 3 months (CDC STI 2021)

Setting (outpatient) monitoring:
- In-person or phone reassessment at 72 h — clinical response (fever, pain, exam) (CDC STI 2021)
- Admit for IV if no improvement at 72 h + reimage for TOA + broaden coverage (CDC STI 2021; ACOG PB 232)
- 14-day completion of antibiotic course (CDC STI 2021)
- 3-month STI retest for GC/CT (CDC STI 2021)
- Annual fertility counseling if recurrent PID (CDC STI 2021)

Follow-up plan: 3-month retest for GC / CT for repeat infection (per CDC STI 2021). Partner treatment within 60 d via expedited partner therapy where legal. Fertility counseling — recurrent-PID linkage to reproductive endocrinology. Chronic pelvic pain management. Repeat HIV / syphilis testing per CDC STI 2021. Counsel on long-term sequelae (infertility 12-50 % cumulative, ectopic 6-10×, chronic pelvic pain 30-40 %).
- Close-out criterion: follow-up plan + partner treatment + STI retesting plan documented

Monitoring phase: Reassess at 72 h on outpatient regimen — if no improvement, admit for IV + repeat imaging for TOA. Inpatient: trend fever + WBC + CRP; step-down to PO when afebrile + improving 24-48 h. TOA: repeat imaging at 48-72 h if no improvement; size reduction or persistence guides drainage (ACOG PB 232; CDC STI 2021)

Disposition

Current setting: outpatient — Manage mild-moderate PID with 14-day combination antibiotic regimen, partner treatment via expedited partner therapy where legal, 72-h reassessment, 3-month STI retest, fertility-sequelae counseling, and recurrent-PID prevention (CDC STI 2021; ACOG PB 232; PEACH long-term equivalence data Ness 2002)

Disposition criteria:
- Discharge: improving at 72 h on outpatient regimen + tolerating PO + reliable follow-up booked at 1-2 wk + partner-treatment plan documented + 3-month STI retest scheduled (CDC STI 2021)
- Admit if any escalation trigger fires (CDC STI 2021; ACOG PB 232)
- Transition to long-term gynecology follow-up if recurrent PID or chronic pelvic pain (CDC STI 2021)

Escalation triggers (move to higher acuity):
- No improvement at 72 h on outpatient regimen → admit + IV + repeat TVUS / CT for TOA + broaden coverage (CDC STI 2021; ACOG PB 232)
- TOA detected on imaging → admit + IV antibiotics + drainage decision (ACOG PB 232)
- Pregnancy with PID → admit immediately + ceftriaxone IV + azithromycin + MFM consult (avoid doxycycline) (ACOG PB 232; CDC STI 2021)
- Sepsis features (hypotension, lactate elevation, tachycardia, AMS) → ED + SSC 2026 Hour-1 bundle; routes to id.sepsis.core.v1 (SSC 2021)
- Cannot tolerate PO / vomiting → ED for IV + admission (CDC STI 2021)
- M. genitalium macrolide-resistant → switch to moxifloxacin pathway (CDC STI 2021)
- HIV co-infection with severe PID → lower admission threshold per CDC STI 2021
- Recurrent PID (≥ 2 episodes) → reproductive endocrinology referral + partner-treatment-adherence review + chronic-pelvic-pain workup (CDC STI 2021)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Suspected TOA rupture: peritonitis + free fluid on imaging + sepsis features — emergent OR / laparoscopy + broad-spectrum + ICU (ACOG PB 232; SSC 2021)
- [LIFE_THREATENING] PID with hypotension on adequate fluids + lactate > 2 OR qSOFA ≥ 2 + skin / pelvic source — routes to id.sepsis.core.v1 + SSC 2021 hour-1 bundle (SSC 2021; CDC STI 2021)
- [SEVERE] TVUS / CT-confirmed tubo-ovarian abscess at diagnosis — admit + IV antibiotics + drainage decision based on size and response (ACOG PB 232; CDC STI 2021)

Citations

- CDC STI Treatment Guidelines 2021 (Workowski MMWR Recomm Rep 2021 PMID 34292926) + ACOG Practice Bulletin 232 (2021) — Pelvic Inflammatory Disease + WHO STI Treatment 2021 + PEACH long-term outcome trial (Ness Am J Obstet Gynecol 2002 PMID 12015499) + CDC 2024 STI Treatment update (anticipated cycle — PMID NEEDS_SOURCE_REVIEW) [PMID:34292926](https://pubmed.ncbi.nlm.nih.gov/34292926/)
- Cited evidence (PMID 12015499) [PMID:12015499](https://pubmed.ncbi.nlm.nih.gov/12015499/)
- Cited evidence (PMID 26903338) [PMID:26903338](https://pubmed.ncbi.nlm.nih.gov/26903338/)
- Cited evidence (PMID 16625125) [PMID:16625125](https://pubmed.ncbi.nlm.nih.gov/16625125/)
- Cited evidence (PMID 32191793) [PMID:32191793](https://pubmed.ncbi.nlm.nih.gov/32191793/)

Last reconciled with current guidelines: 2026-05-15.
References
  • CDC STI Treatment Guidelines 2021 (Workowski MMWR Recomm Rep 2021 PMID 34292926) + ACOG Practice Bulletin 232 (2021) — Pelvic Inflammatory Disease + WHO STI Treatment 2021 + PEACH long-term outcome trial (Ness Am J Obstet Gynecol 2002 PMID 12015499) + CDC 2024 STI Treatment update (anticipated cycle — PMID NEEDS_SOURCE_REVIEW) — PMID:34292926
  • Cited evidence (PMID 12015499) — PMID:12015499
  • Cited evidence (PMID 26903338) — PMID:26903338
  • Cited evidence (PMID 16625125) — PMID:16625125
  • Cited evidence (PMID 32191793) — PMID:32191793