[Question #1105] About recommended inpatient regimen by the CDC
98 months ago
|
Hi, thank you for
receiving my question. I’m having
difficulty understanding PID information on the CDC. For inpatient treatment, one
of the CDC’s recommended regimens is
“Cefoxitin 2g IV
every 6 hours or Cefotetan 2g IV every 12 hours
Plus
Doxycycline 100mg orally or IV every 12 hours.”
According to the CDC information, “When using the
parenteral cefotetan or cefoxitin regimens, oral therapy with doxycycline 100mg
twice daily can be used 24-48 hours after clinical improvement to complete the
14 days of therapy.”
I would like to
know which one is right for recommended inpatient regimen by the CDC.
A)
Only
use Cefoxitin 2g IV every 6 hours or Cefotetan 2g IV every 12 hours
->continue using Cefoxitin IV or
Cefotetan IV for 24-48 hours after clinical improvement -> discharge from a
hospital and change to oral therapy -> start oral doxycycline 100mg twice
daily for 14 days
B)
Only
use Cefoxitin 2g IV every 6 hours or Cefotetan 2g IV every 12 hours
->continue using Cefoxitin IV or
Cefotetan IV for 24-48 hours after clinical improvement -> discharge from a
hospital and change to oral therapy ->
start oral doxycycline 100mg twice daily
for remainder of 14 days (ex: used Cefoxitin or Cefotetan 6 days + used 2 more
days after clinical improvement -> change to oral therapy and use oral
doxycycline for the remainder of 14 days, which is 6 days.)
C)
Use
Cefoxitin 2g IV every 6 hours or Cefotetan 2g IV every 12 hours & Doxycycline
100mg orally or IV every 12 hours altogether -> continue using Cefoxitin IV
or Cefotetan IV with Doxycycline orally or IV for 24-48 hours after clinical
improvement -> discharge from a hospital and change to oral therapy -> start
oral doxycycline 100mg twice daily for 14 days
D)
Use
Cefoxitin 2g IV every 6 hours or Cefotetan 2g IV every 12 hours & Doxycycline
100mg orally or IV every 12 hours altogether -> continue using Cefoxitin IV
or Cefotetan IV with Doxycycline orally or IV for 24-48 hours after clinical
improvement -> discharge from a hospital and change to oral therapy ->
start oral doxycycline 100mg twice daily for the remainder of 14 days
Edward W. Hook M.D.
98 months ago
|
I can understand that the CDC Guidelines are a bit difficult to follow. I will try to help with additional information. Before I get to specifics however, let me point out that most patients with PID are now not hospitalized but are treated as outpatients.
Recommended therapy for PID is a total duration of 14 days, irrespective of what regimen is used. As part of that therapy, doxycycline 100 mg twice daily for the entire 14 day period is recommended. the choice of whether the doxycycline is given IV or PO (by mouth) is up to the treating person and whether or not the patient can take pills. The other component of recommended treatment is a cephalosporin antibiotic - for outpatients this would usually be ceftriaxone given one time as an intramuscular injection while if the patient is hospitalized, then either Cefoxitin 2g IV every 6 hours or Cefotetan 2g IV every 12 hours is recommended until the patient begins to improve. 24 to 48 hours after improvement, if all else is OK< the patient can be discharged to complete their 14 day course of therapy with doxycycline (by mouth).
I hope this information is helpful to you. If there is a more specific question, please ask it directly. EWH
98 months ago
|
Thank you so much
for your kind answer to my confusing question. I didn’t know how to express my
confusion J I apologize for that. If I’m getting it right, the patient is
treated with oral/IV doxycycline and a cephalosporin antibiotic at the same
time as an initial treatment until the patient begins to improve. After improvement
of 28-48 hours, the patient can stop taking a cephalosporin antibiotic and
begin oral doxycycline to complete the rest of 14 days. Am I getting it right?
I guess what made
me confused with the recommended regimens was whether it is recommended to use
oral/IV doxycycline with a cephalosporin antibiotic (Cefotetan IV, Cefoxitin
IV, or Ceftriaxone Intramuscular Injection) at the same for treating PID.
I’m confused because
I read from some article (don’t remember exactly, but was not information related
with PID) that combining a cephalosporin antibiotic and doxycycline at the same
time could decrease their efficacy since doxycycline has bacteriostasis and
cephalosporines have bacteriocidal action.
It was saying that
it is desirable to take a cephalosporin antibiotic first, and take doxycycline
later since doxycycline has bacteriostasis and it will interfere bacteriocidal
action of a cephlosprin antibiotic.
I also checked
treatment plan on PatientInfo, and its current recommended PID treatment for
severely ill patient is “Initial treatment is with doxycycline, single-dose IV
ceftriaxone, and IV metronidazole, then change to oral doxycycline and
metronidazole to complete 14 days of treatment. Like the one on the CDC, Patientinfo
is also recommending using doxycycline and a cephalosporin antibiotic
altogether as an initial treatment even for severely ill patient.
So, here is my
question. Why combination of doxycycline and a cephalosporin antibiotic is
recommended as an initial treatment for treating PID by the CDC and
PatientInfo?
Why not using a
cephalosporin antibiotic first, stopping it after 24-48 hours of clinical
improvement, and starting to use oral doxycycline for 14 days? I’m wondering
whether the latter has more efficacies for treating PID.
Don’t I have to
worry about efficacy when I get to treated for PID with a combination of
doxycycline and a cephalosporin antibiotic at the same time as an initial
treatment?
Edward W. Hook M.D.
98 months ago
|
Your interpretation is correct. Two drugs to start, then once better and as an outpatient doxycycline alone for the remainder of the course of therapy. Also, please remember that for most patients with PID, all therapy is given in the outpatient setting and should start with a single injection of ceftriaxone, followed by the doxy. The issue of decreasing effectiveness of doxy with cephalosporin therapy is theoretical and when all is considered, not a concern.
As for why both drugs, the answer is that there is no evidence that using both together reduces the effectiveness of therapy, that in some instances, the other antibiotic does not effect some possible PID bacteria (for instance, doxycycline but not ceftriaxone, cefoxitin or cefotetan have activity against chlamydia.
I would not worry about PID therapy when both drugs are used together- this is the recommended approach. EWH
98 months ago
|
Thank you for your
clarification and explanation. It really clears everything out. I also see most
of PID treatment plans are based on the 14 days of therapy, like the ones on
the CDC and American Academy of Family Physician.
- Is it
recommended to at least complete the 14 days of therapy since the treatment
began? Is it a recommended minimum treatment period?
- Could patients
who are diagnosed with PID be completely cured after they take antibiotics for average
of 4-5 days or is it mostly not enough and they at least need to complete the
14 days of therapy?
- Is there any
possibility that patients are not completely cured even after 14 days of
therapy and need more treatment?
- Can people have
a recurrence of PID, if they stop the treatment and don’t complete the 14 days
of therapy?
- Can people have
a recurrence of PID even after completing the 14 days of therapy, just because
of too much stress?
Edward W. Hook M.D.
98 months ago
|
- Is it recommended to at least complete the 14 days of therapy since the treatment began? Is it a recommended minimum treatment period?
There is no minimum. Though the recommendation is for 14 days, many patients improve and stop taking therapy before completing the 14 day recommended course.
- Could patients who are diagnosed with PID be completely cured after they take antibiotics for average of 4-5 days or is it mostly not enough and they at least need to complete the 14 days of therapy?
This is a repetitive question- see above.
- Is there any possibility that patients are not completely cured even after 14 days of therapy and need more treatment?
That would be unusual but it is conceivable. In my practice I would need firm evidence that the infection had failed therapy to give more antibiotics.
- Can people have a recurrence of PID, if they stop the treatment and don’t complete the 14 days of therapy?
Women who have had PID once are at increased risk for getting it again.
- Can people have a recurrence of PID even after completing the 14 days of therapy, just because of too much stress?
Following PID many women who have had their infection cured have continue to have pelvic pain and discomfort which is the result of scarring form the infection. This is not a treatment failure but a consequence of the infection. It should be managed by the patient and her doctor.
This is my third response to your questions and therefore, as per Forum guidelines, there will be no further answers and the thread will be closed later this afternoon. Take care. EWH