[Question #1105] About recommended inpatient regimen by the CDC

51 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.
Edward W. Hook M.D.
51 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

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51 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.
Edward W. Hook M.D.
51 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

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51 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.
Edward W. Hook M.D.
51 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

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