Title of Guideline (must include the word “Guideline” (not
protocol, policy, procedure etc)
Author: Contact Name and Job Title
Directorate & Speciality
Date of submission
Explicit definition of patient group to which it applies (e.g.
inclusion and exclusion criteria, diagnosis)
Changes from previous guideline
Version
If this version supersedes another clinical guideline
please be explicit about which guideline it replaces
including version number.
Statement of the evidence base of the guideline – has the
guideline been peer reviewed by colleagues?
Evidence base: (1-5)
1a meta analysis of randomised controlled trials
1b at least one randomised controlled trial
2a at least one well-designed controlled study
without randomisation
2b at least one other type of well-designed
quasi-experimental study
3 well –designed non-experimental descriptive
studies (ie comparative / correlation and
case studies)
4 expert committee reports or opinions and / or
clinical experiences of respected authorities
5 recommended best practise based on the
clinical experience of the guideline developer
Consultation Process
Ratified by:
Date:
Review date:
This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The
interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If
in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date.
Nottingham Antimicrobial Guidelines Committee Page 1 of 11
Antibiotic Guideline for the Treatment of Acute Pelvic
Inflammatory Disease in Adults.
Dr Stephen Holden, Consultant Microbiologist
Alice Hill and Annette Clarkson, Antimicrobial Pharmacists
Diagnostics and clinical support, microbiology
January 2016
Female adult patients with pelvic inflammatory,
uncomplicated Chlamydial or Gonococcal disease
Additional counselling advice specified. Updated
references.
4.0
To replace 1468
British Association for Sexual Health and HIV guidelines:
Pelvic inflammatory disease June 2011.
http://www.bashh.org/documents/3572.pdf
Management of gonorrhoea in adults 2011.
http://www.bashh.org/documents/3920.pdf
Chlamydia infection revised 2006.
http://www.bashh.org/documents/65.pdf
2015 UK national guideline for the management of
infection with Chlamydia trachomatis 2015
http://www.bashh.org/documents/2015_UK_guideline_for_
the_management_of__Chlamydia_trachomatis_final_12...
.pdf
Scottish Intercollegiate Guideline Network (2009) –
Guideline 109: Management of genital Chlamydia
trachomatis.
http://www.sign.ac.uk/pdf/sign109.pdf
GRASP 2014 Report: The Gonococcal Resistance to
Antimicrobials Surveillance Programme Nov 2015
https://www.gov.uk/government/uploads/system/uploads/a
ttachment_data/file/476582/GRASP_2014_report_final_11
1115.pdf
Dr Deb, Obstetrics & Gynaecology Consultant
Dr Herbert, Genitourinary Medicine Consultant
NUH Antimicrobial Guidelines Committee (AGC).
NUH Antimicrobial Guidelines Committee
20/01/2016
December 2019
Contents Page
1. Overview of Acute Pelvic Inflammatory Disease 3

Antibiotic treatment of:

2. Pelvic Inflammatory Disease 4-5
3. Uncomplicated Chlamydia Infection 6
4. Uncomplicated Gonococcal Infection 7

PID Antimicrobial Audit Form 8

Chlamydia Antimicrobial Audit Form 9
Uncomplicated Gonococcal Infection Antimicrobial Audit Form 10

NUH Antimicrobial Guidelines Committee Page 2 of 11

 1. Overview of Acute Pelvic Inflammatory Disease (PID)
Symptoms: Low abdominal pain, pyrexia, vaginal discharge, intermenstrual bleeding
(IMB).

Clinical Features: Abdominal tenderness, peritonism, tenderness right sub costal

in Fitz-Hugh-Curtis syndrome, cervical discharge, cervicitis,
cervical excitation tenderness, adnexal tenderness

Aetiology: Chlamydia trachomatis, Gonococcus, Mycoplasmas, Ureaplasmas,

Streptococci, often mixed with Gram negatives and anaerobes
(previous GUM attendance - increases likelihood of Chlamydia or
Gonococcal infection)
Uncommon: Tuberculous PID and actinomycosis
Also: secondary to appendicitis or diverticulitis, or following IUCD insertion
(the highest risk of developing PID is within the first three weeks)

Diff. Diagnosis: Appendicitis, diverticulitis, ovarian cyst accident, urinary tract infection,
ectopic pregnancy, torsion of fallopian tube, endometriosis

Risks: Septicaemia – can be life threatening, abscess formation, infertility,

chronic PID, adhesion formation and recurrent pelvic pain

Investigations: Two types of testing are currently available: culture and a nucleic acid
amplification test (NAAT). If result was obtained by NAAT, it is important to
confirm the result by sending swabs for culture and antimicrobial
sensitivity testing, due to the possibility of false positive NAAT result,
and to ensure that appropriate antibiotic therapy is given.

Triple swabs: 1. High Vaginal swab for C&S,

2. Endocervical swab for C&S (to cover Neisseria
gonorrhoeae (GC) and Chlamydia trachomatis (CT)
3. Endocervical swab for dual NAAT for GC/CT

Full Blood Count (FBC) & C-reactive protein (CRP)

Pregnancy test
Urinalysis and mid-stream urine (MSU)
Consider referral to general surgery for opinion (appendicitis/diverticulitis)

Management: Inform Registrar who will review the patient after admission (preferably
before initiating treatment)

NUH Antimicrobial Guidelines Committee Page 3 of 11

 Treatment:
 IUCD removal may not be required in uncomplicated cases, discuss with the registrar or
higher grade before removal

 Antibiotics as outlined below

 IV therapy is required if :
o A surgical emergency cannot be excluded
o Lack of response to oral therapy
o Clinically severe disease (temp >38oC, signs of pelvic peritonitis, signs of a tubo-
ovarian abscess)
o Intolerance to oral therapy
o Disseminated Gonococcal infection

 Analgesia and anti-emetics, as required

 4-hourly temperature, pulse & respiration checks

 Consider laparoscopy if no improvement in pain and/or temperature after 24 hours of antibiotic

treatment (take swabs for C&S laparoscopically) – emergency list

 Adjust antibiotics according to C&S results only if no improvement, and after discussion with
microbiology (in view of rising resistance in Gonococcal isolates)

 Discharge information should include safer sexual practices, and referral of patient and partner
to GUM clinic for investigations/treatment/contact tracing if necessary.

2. Antibiotic Treatment of Pelvic Inflammatory Disease (PID)

This is a common condition, which is difficult to diagnose and it is based on a combination of

clinical symptoms and signs. i.e. lower abdominal pain with pelvic tenderness and cervical
excitation (see above).

Swabs should be taken for investigation for chlamydia and gonococcal infection.

Antibiotic Treatment

Mild / moderate disease

1st line: Doxycycline 100mg bd PO for 14 days plus

Metronidazole 400 mg bd PO for 14 days plus
Ceftriaxone 500mg IM single dose (Ceftriaxone 1g IV, if IM route contraindicated)
plus Azithromycin 1g PO single dose

Alternative – if vomiting and initially unable to take oral medication:

Ceftriaxone 500mg IM single dose plus

Metronidazole 500 mg tds IV plus
Clarithromycin 500 mg bd IV

 When oral route is available give Azithromycin 1g PO single dose plus Doxycycline plus
Metronidazole as above.

NUH Antimicrobial Guidelines Committee Page 4 of 11

Severe disease:

1st line: Ceftriaxone 2g od IV plus

Metronidazole 500 mg tds IV plus
Doxycycline 100mg bd PO or Clarithromycin 500 mg bd IV if unable to take oral
medication plus
Azithromycin 1g PO single dose

 Change to oral Doxycycline plus Metronidazole to complete 14 days treatment when

clinically improved for 24 hours, doses as above.

Alternative if serious allergy to penicillins (e.g. anaphylaxis, angioedema or immediate onset

urticarial rash) or allergic to cephalosporins and NOT pregnant:

Ofloxacin 400mg bd PO for 14 days plus

Metronidazole 400mg bd PO for 14 days.

 If patient is nil by mouth (NBM), please discuss with medical microbiologist.

 NB due to rising quinolone resistance in gonococci, patients treated with this regimen
should be monitored closely and any cultures reviewed for sensitivity.

Alternative if contraindication e.g. pregnancy:

Ceftriaxone 500 mg IM single dose plus
Metronidazole 400 mg bd PO for 14 days plus
Azithromycin 1g PO single dose followed by a second dose after 1 week.
OR Erythomycin 500mg qds for 14 days (see information below about use of
Azithromycin in pregnancy).

Using Azithromycin in pregnancy:

Azithromycin is not known to be harmful but data is limited. WHO Guidelines recommend use for
the treatment of Chlamydia trachomatis in pregnancy, the BNF recommends its use in pregnancy
and lactation only if no alternative is available. Azithromycin is required to provide cover for
Neisseria gonorrhoeae and Chlamydia trachomatis. National guidance recommends dual therapy
i.e. Azithromycin plus Ceftriaxone to cover for N. gonorrhoeae, due to increasing resistance. If
the patient chooses not to have Azithromycin then Erythromycin can be given, but the patient
needs to be aware that this potentially does not cover gonococcal infection as effectively.

If severe penicillin allergy AND pregnant – please discuss with microbiology.

A “test of cure” is required all confirmed gonococcal and for pregnant confirmed chlamydia
infection cases. This is usually done at 2-3 weeks (3 weeks for chlamydia). Patients should
abstain from sexual intercourse until this time.

Advice for patients:

 Patients prescribed doxycycline should be warned of photosensitivity reaction.
They should also be counselled on the impaired absorption of doxycycline
with simultaneous administration of antacids, calcium, iron, zinc and
magnesium preparations.
 Alcohol should be avoided with metronidazole throughout and for 48 hours
after Guidelines
NUH Antimicrobial completing course.
Committee Page 5 of 11

 3. Antibiotic Treatment of Uncomplicated Chlamydia Infection in Women
Uncomplicated infection is defined as no cervical excitation or abdominal pain, presenting with
IMB, cervicitis or asymptomatic carriage

Treatment

1st line: Azithromycin 1g PO single dose

Alternatives: Doxycycline 100 mg PO bd for 7 days (contraindicated in pregnancy)

If pregnant: Erythromycin 500 mg PO qds for 10-14 days or see below.

Using Azithromycin in pregnancy:

Where compliance with erythromycin is likely to be a problem the patient can be offered
azithromycin 1g PO as a single dose following a discussion around the potential risks and
benefits of its use with the patient. Azithromycin is not known to be harmful but data is limited.
WHO Guidelines recommend use for the treatment of Chlamydia. trachomatis in pregnancy, the
BNF recommends its use in pregnancy and lactation only if no alternative is available.
A “test of cure” is required for all pregnant cases. This is usually done after 3 weeks. Patients
should abstain from sexual intercourse until this time.

If allergic to macrolides - Amoxicillin 500mg tds for 7 days (NB amoxicillin may not always
eradicate and may render the infection latent, practitioners should maintain a high index of
suspicion should symptoms suggestive of chlamydial infection develop in the infant.

 Note all patients should be referred to GUM clinic for follow-up and contact tracing.

Treatment of Rectal Chlamydia:

1st line: Doxycycline 100mg PO BD for 7 days (contraindicated in pregnancy)

Alternatives: Azithromycin 1g PO single dose

Advice for patients:

 Patients prescribed doxycycline should be warned of photosensitivity reaction.
They should also be counselled on the impaired absorption of doxycycline
with simultaneous administration of antacids, calcium, iron, zinc and
magnesium preparations.

NUH Antimicrobial Guidelines Committee Page 6 of 11

 4. Antibiotic Treatment of Uncomplicated Gonococcal Infection in Women
Both locally and nationally, resistance in gonococcal isolates has meant that both the penicillin,
cefixime and quinolone antibiotics can no longer be relied upon for empirical treatment of
gonococcal disease. Intramuscular ceftriaxone is now the standard treatment for infections where
sensitivity results are unknown.

Indications for therapy

 Identification of intracellular Gram-negative diplococci on microscopy of a smear from the
genital tract.
 A positive culture for N. gonorrhoeae from any site.
 A positive NAAT for N. gonorrhoeae from any site and confirmed by culture or clinical
presentation.
 Recent sexual partner (s) of confirmed cases of gonococcal infection.
 Consider offering on epidemiological grounds following sexual assault.

Treatment

1st line: Ceftriaxone 500 mg IM plus Azithromycin 1g PO (single dose of each)

Alternative: If known ciprofloxacin sensitive strain and not pregnant or breastfeeding:

Ciprofloxacin 500mg PO plus Azithromycin 1g PO (single dose of each)

If above treatment contraindicated due to allergy or resistance, please discuss treatment with a
GUM physician

Notes:
 Azithromycin co-treatment is recommended irrespective of the results of chlamydia
testing, to delay the onset of widespread cephalosporin resistance. There is some in-vitro
evidence of synergy between azithromycin and cephalosporins, and improved eradication
of pharyngeal gonorrhoea has been reported when azithromycin was combined with
cephalosporin therapy.
 A “test of cure” is required for all cases. This is usually done at 2 weeks. Patients should
abstain from sexual intercourse until this time and for 7 days after partner(s) have been
treated.

NUH Antimicrobial Guidelines Committee Page 7 of 11

 PID Antimicrobial Audit Form
MS word copies available from the authors if adaptation required

Demographics Date of audit

Hosp Number
Initials
DOB
Allergies
Nature of Severity of disease
allergy
Mild/moderate
Pregnant? and able to take
Ward oral medicines
Mild to moderate
unable to take
oral medicines
Antimicrobial treatment given Severe and able
to take oral
Ceftriaxone Number of doses medicines
500mg IM Severe and
500mg IV unable to take
1000mg IV oral medicines
2000mg IV

Additional comments
Doxycycline Frequency Duration
Dose (mg) prescribed

Metronidazole Frequency Duration

Oral Dose prescribed
(mg)

Metronidazole. Frequency Duration

IV Dose (mg) prescribed

Clarithromycin Frequency Duration

IV Dose (mg) prescribed

Ofloxacin…….. Frequency. Duration

Dose (mg) prescribed
Tick
As per PID guideline
Erythromycin Frequency Duration Not as per PID Guideline but
PO Dose (mg) prescribed justified
Not as per Guideline and not
justified

Azithromycin Frequency. Duration

(mg) prescribed

NUH Antimicrobial Guidelines Committee Page 8 of 11

 Chlamydia Antimicrobial Audit Form
MS word copies available from the authors if adaptation required

Demographics Date of audit

Hosp Number
Initials
DOB
Allergies
Nature of Additional Comments
allergy
Pregnant?
Ward

Antimicrobial treatment given

Azithromycin Number of doses
Dose (mg)

Doxycycline Frequency Duration

Dose (mg) prescribed

Erythromycin Frequency Duration

Dose (mg) prescribed
Tick
As per guideline
Not as per Guideline but
Amoxicillin Frequency Duration
justified
Dose (mg) prescribed
Not as per Guideline and not
justified

NUH Antimicrobial Guidelines Committee Page 9 of 11

 Uncomplicated Gonococcal Infection Antimicrobial Audit Form
MS word copies available from the authors if adaptation required

Demographics Date of audit

Hosp Number
Initials
DOB
Allergies
Nature of Additional Comments
allergy
Pregnant?
Ward

Antimicrobial treatment given

Azithromycin Number of doses
Dose (mg)

Ceftriaxone IM Number of doses

Dose (mg)

Tick
Ciprofloxacin Number of doses As per guideline
Dose (mg) Not as per Guideline but
justified
Not as per Guideline and not
justified

NUH Antimicrobial Guidelines Committee Page 10 of 11

Equality Impact Assessment Report

1. Name of Policy or Service

Response to external best practice policy

2. Responsible Manager
Owen Bennett (Clinical Quality, Risk and Safety Manager)

3. Name of person Completing EIA

Annette Clarkson

4. Date EIA Completed

22/01/2016

5. Description and Aims of Policy/Service

The clinical guidelines procedure has been written to inform hospital staff of the process for writing,
registering and disseminating clinical guidelines.

This procedure is required in order to encourage the delivery of excellent clinical practice for patients cared
for by Nottingham University Hospitals NHS Trust, based on best evidence and local expertise. The
procedure supports the Trust Clinical Effectiveness and Audit Policy.

6. Brief Summary of Research and Relevant Data

There is no research or relevant data at the present time.

7. Methods and Outcome of Consultation

Consultations have been carried out with the following:

NUH Antibiotics Guidelines Committee

NUH Drugs and therapeutics committee
Dr Herbert, Genitourinary Medicine Consultant
Dr Deb Gynaecology Consultant

Comments from the above consultations have been received and where appropriate incorporated.

8. Results of Initial Screening or Full Equality Impact Assessment:

Equality Group Assessment of Impact

Age No Impact Identified
Gender No Impact Identified
Race No Impact Identified
Sexual Orientation No Impact Identified
Religion or belief No Impact Identified
Disability No Impact Identified
Dignity and Human Rights No Impact Identified
Working Patterns No Impact Identified
Social Deprivation No Impact Identified

9. Decisions and/or Recommendations (including supporting rationale)

From the information contained in the procedure, and following the initial screening, it is my decision that a
full assessment is not required at the present time.

10. Equality Action Plan (if required)

Not applicable.

11. Monitoring and Review Arrangements

Review November 2018.

NUH Antimicrobial Guidelines Committee Page 11 of 11