Clinical Infectious Diseases

MAJOR ARTICLE

A Randomized Controlled Trial of Ceftriaxone and

Doxycycline, With or Without Metronidazole, for the
Treatment of Acute Pelvic Inflammatory Disease
Harold C. Wiesenfeld,1,2 Leslie A. Meyn,1,2 Toni Darville,3 Ingrid S. Macio,2 and Sharon L. Hillier1,2
1
Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA, 2Magee-Womens Research Institute, Pittsburgh, Pennsylvania, USA, and
3
Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA

(See the Editorial Commentary by Mitchell on pages 1190–91.)

Background. Anaerobic organisms are important pathogens in acute pelvic inflammatory disease (PID). The currently recom-
mended PID regimen of a single dose of ceftriaxone and doxycycline for 14 days has limited anaerobic activity. The need for broader
anaerobic coverage is unknown and concerns have been raised about metronidazole tolerability.
Methods. We conducted a randomized, double-blind, placebo-controlled trial comparing ceftriaxone 250 mg intramuscular
single dose and doxycycline for 14 days, with or without 14 days of metronidazole in women with acute PID. The primary outcome
was clinical improvement at 3 days following enrollment. Additional outcomes at 30 days following treatment were the presence of
anaerobic organisms in the endometrium, clinical cure (absence of fever and reduction in tenderness), adherence, and tolerability.
Results. We enrolled 233 women (116 to metronidazole and 117 to placebo). Clinical improvement at 3 days was similar be-
tween the 2 groups. At 30 days following treatment, anaerobic organisms were less frequently recovered from the endometrium in
women treated with metronidazole than placebo (8% vs 21%, P < .05) and cervical Mycoplasma genitalium was reduced (4% vs 14%,
P < .05). Pelvic tenderness was also less common among women receiving metronidazole (9% vs 20%, P < .05). Adverse events and
adherence were similar in each treatment group.
Conclusions. In women treated for acute PID, the addition of metronidazole to ceftriaxone and doxycycline was well ­tolerated
and resulted in reduced endometrial anaerobes, decreased M. genitalium, and reduced pelvic tenderness compared to ceftriaxone and
doxycycline. Metronidazole should be routinely added to ceftriaxone and doxycycline for the treatment of women with acute PID.
Clinical Trials Registration. NCT01160640.
Keywords. pelvic inflammatory disease; anaerobes; metronidazole.

Pelvic inflammatory disease (PID) results from ascension of
microorganisms from the vagina or endocervix to the endome-
trium and fallopian tubes. Organisms recognized to cause PID
and its sequelae include Chlamydia trachomatis and Neisseria
gonorrhoeae. Mycoplasma genitalium has been associated with
endometritis but its association with infertility is less certain
[1]. Facultative and anaerobic microbes associated with vaginal
dysbiosis have been associated with endometrial and tubal in-
fections and are recovered from the upper genital tract at higher
frequency than C. trachomatis or N. gonorrhoeae [2–4].
The Centers for Disease Control and Prevention (CDC) re-
commends a single intramuscular dose of a cephalosporin in
combination with oral doxycycline for the outpatient treatment
Received 27 October 2019; editorial decision 14 December 2019; accepted 31 January 2020;
published online February 13, 2020.
Correspondence: H. C. Wiesenfeld, Magee-Womens Hospital, 300 Halket St, Suite 2333,
Pittsburgh, PA 15213 (wieshc@upmc.edu).
Clinical Infectious Diseases®  2021;72(7):1181–9
© The Author(s) 2020. Published by Oxford University Press for the Infectious Diseases Society
of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.
DOI: 10.1093/cid/ciaa101
of PID [5]. This regimen is effective against N. gonorrhoeae and
C. trachomatis, but has limited activity against anaerobic or-
ganisms. Despite the frequent recovery of anaerobic organisms
in women with acute PID, the need for antimicrobial therapy
with broader anaerobic coverage is unknown. This uncertainty
is reflected in the CDC guidelines that list metronidazole as
an optional addition to ceftriaxone and doxycycline, while the
European guidelines recommend the addition of metronidazole
[6]. However, a recent systematic review and meta-analysis of
acute PID treatment did not show clear evidence for the use of
nitroimidazoles, although none of the studies in the analysis in-
volved the current CDC-recommended regimen of ceftriaxone
and doxycycline [7]. In addition to the uncertainty whether the
addition of metronidazole improves treatment outcomes, there
are concerns about the tolerability of metronidazole as part of
a 3-drug combination. To determine whether metronidazole
should be incorporated in the first-line recommended PID treat-
ment regimen, we compared a single dose of ceftriaxone and
14 days of doxycycline to the same regimen with the addition of
14 days of metronidazole in women diagnosed with acute PID.

Metronidazole in PID Treatment • cid 2021:72 (1 April) • 1181

METHODS
Trial Design and Oversight
In this randomized, double-blind, placebo-controlled trial, we
compared ceftriaxone and doxycycline to ceftriaxone, dox-
ycycline, and metronidazole for the treatment of acute PID.
The investigators initiated this National Institutes of Health–
funded study, which was conducted in accordance with the
Consolidated Standard of Reporting Trials guidelines and is
registered at ClinicalTrials.gov (NCT01160640). The study was
approved by the University of Pittsburgh’s Institutional Review
Board and was monitored by an independent data and safety
monitoring committee. Written informed consent was obtained
from each participant.
Participants
Enrollment occurred at the emergency departments at Magee-
Womens Hospital and University of Pittsburgh Medical
Center Mercy Hospital, and at the Allegheny County Health
Department Sexually Transmitted Diseases (STD) Clinic, all in
Pittsburgh, Pennsylvania. Clinicians referred women diagnosed
with acute PID for possible participation. Women 15–40 years
of age were eligible for enrollment if they met the following cri-
teria for acute PID: pelvic or lower abdominal pain, and the
presence of cervical motion tenderness, uterine tenderness,
or adnexal tenderness on pelvic examination [5]. Women re-
quiring inpatient treatment (tuboovarian abscess, severe ill-
ness, vomiting, inability to follow oral treatment) and women
who were pregnant were not eligible. Other exclusion criteria
included use of systemic or vaginal antibiotics within the pre-
ceding 7 days, allergy to cephalosporins, doxycycline, or met-
ronidazole, uterine procedure or miscarriage within the prior 6
weeks, hysterectomy, and menopause.
Study Procedures
At enrollment, a history and physical examination were per-
formed by trained study clinicians. Participants rated their
current pain on a 100-mm visual analogue scale. A clinical ten-
derness score was determined by assessing pelvic tenderness
using a modification of a previously established grading system
[8, 9]. Cervical motion tenderness, uterine tenderness, and ten-
derness of the right and left adnexae were each graded from 0
(no tenderness) to 3 (tenderness causing marked distress), with
a maximal tenderness score of 12. Vaginal fluid samples were
obtained by swabbing the lateral vaginal walls, and endocervical
swabs were collected. The cervix and endocervix were then
cleansed with povidone-iodine and excess disinfectant was
removed with a sterile swab. An endometrial aspirate was
obtained by passing a sterile suction catheter (Pipelle, Cooper
Surgical, Trumbull, Connecticut) through the endocervical
canal into the endometrial cavity. After removal, the external
catheter surface was wiped with alcohol to reduce surface con-
tamination. The endometrial sample was expulsed into a sterile
1182 • cid 2021:72 (1 April) • Wiesenfeld et al
dish for microbiologic processing. Women in whom endome-
trial sampling was unsuccessful were discontinued from further
participation and treated per routine clinical care.
Treatment Regimens
All women received combination antibiotic therapy of a single
intramuscular 250-mg dose of ceftriaxone and doxycycline
100 mg orally twice daily for 14 days [5]. All participants were
randomized, in 1:1 fashion, to also receive metronidazole
500 mg orally twice daily or matching placebo for 14 days, with
equal frequency to the 2 treatment arms using a permuted block
design with random block sizes of 2, 4, and 6. The research staff
was blinded to treatment allocation. Doxycycline, metronida-
zole, and placebo were distributed in blister cards. Women were
instructed to inform their partner(s) to seek evaluation and pre-
sumptive STD treatment.
Follow-up
All women were asked to return at 3 days (range, 2–7 days) after
enrollment, at which time an interim history and pelvic exami-
nation were performed. A final evaluation, performed at 30 days
(range, 25–45 days) after enrollment, included symptom as-
sessment and a pelvic examination. Vaginal and cervical swabs
were obtained as on enrollment, and endometrial sampling was
repeated.
Women without clinical improvement or who did not tol-
erate study medications were offered hospitalization for par-
enteral antimicrobial therapy. Those women were followed
for safety only and did not undergo further study procedures.
Women who were pregnant at the follow-up visits were with-
drawn from the study.
Microbiology
A Gram stain was prepared from a vaginal swab sample and
interpreted for bacterial vaginosis [10]. A score of 7 or greater
indicated bacterial vaginosis. Another vaginal swab was as-
sayed for Trichomonas vaginalis by transcription-mediated
assay (TMA, Hologic, San Diego, California). Endocervical
swabs and endometrial tissue were analyzed for C. trachomatis
and N. gonorrhoeae by TMA (Aptima Combo 2 Assay for CT/
NG, Hologic) and for Mycoplasma genitalium by TMA using
analyte-specific reagents supplied by Hologic, Inc. The endo-
metrial aspirate was transported in anaerobic transport me-
dium and culture cultivation was performed for facultative and
anaerobic microorganisms as previously described [11].
Outcomes
The primary study outcome was clinical improvement at the
3-day follow-up visit, defined by a reduction in the clinical ten-
derness score. Secondary outcomes included the presence of
anaerobic organisms in the endometrium at 30 days following
treatment, and clinical cure at 30 days (> 70% improvement in
the clinical tenderness score and the absence of fever [oral tem-
perature < 38°C]).
Adverse Events and Medication Adherence
Adverse events were assessed at each follow-up visit. Blister
cards were examined at the 30-day visit, and participants were
considered to be adherent with study medications if they re-
turned their blister card and took at least 75% of both the met-
ronidazole and doxycycline doses.
Statistical Analysis
Data analyses were conducted using SPSS statistical soft-
ware, release 26.0 (IBM Corporation, Armonk, New York)
and statistical tests were evaluated at the 2-sided .05 signif-
icance level. Differences in participant characteristics and
study outcomes were compared between the 2 treatment
arms using Fisher exact test, Student t test, and Mann-
Whitney U test, where appropriate. The intent-to-treat
analyses on the primary endpoint, clinical improvement at
3 days, included all participants as randomized and missing
data were treated as failure to improve. The secondary out-
comes were analyzed using participants who were evaluated
at the 30-day visit and who were not withdrawn because of
failure to improve on study medications or intolerance of
study medication.
RESULTS
From November 2010 through January 2015, we enrolled 233
women with acute PID. Of these women, 116 were randomly as-
signed to receive metronidazole and 117 received placebo. The
median age of the participants was 23 years, 59% were black,
and 28% were white (Table 1). The median age of women ran-
domized to metronidazole was slightly higher than the median
age of women in the placebo regimen (24 vs 22 years, P = .02).
A history of chlamydia, gonorrhea, or PID was reported by 140
(60%), 63 (27%), and 68 (29%) participants, respectively, and
was similar between the 2 study groups. At enrollment, the clin-
ical presentations were similar between the 2 treatment groups.
Clinical Outcomes
Two hundred eight (89.3%) women returned for the primary
outcome visit to assess clinical improvement at 3 days after en-
rollment (median, 3; interquartile range [IQR], 3–5) (Figure 1).
The proportion of women reporting pelvic pain and the se-
verity of pain were similar between the 2 study groups (Table 2).
Overall, 91.3% of the participants who returned for evaluation
had clinical improvement. Clinical improvement was similar in
the women receiving metronidazole and those randomized to
placebo, both in the per protocol and intent-to-treat analyses.
Thirteen women (8 receiving metronidazole and 5 random-
ized to placebo) failed to respond to their assigned treatment

Table 1. Participant Characteristics and Clinical Presentation at Enrollment

Ceftriaxone and Doxycycline Ceftriaxone and Doxycycline

Characteristic Plus Metronidazole (n = 116) Plus Placebo (n = 117) P Valuea

Age, y, median (IQR) 24 (21–28) 22 (20–26) .02b

Race .29
Black, non-Hispanic 58 (50.0) 66 (56.4)
Black, Hispanic 9 (7.8) 5 (4.3)
White, non-Hispanic 37 (31.9) 28 (23.9)
White, Hispanic 0 1 (0.9)
Other 12 (10.3) 17 (14.5)
Current smoker 77 (66.4) 67 (57.3) .18
Ever pregnant 87 (75.0) 87 (74.4) > .99
History of chlamydia 65 (56.0) 75 (64.1) .23
History of gonorrhea 35 (30.2) 28 (23.9) .30
History of PID 37 (31.9) 31 (26.5) .39
Currently using intrauterine device 14 (12.1) 19 (16.2) .45
New male sexual partner in last 30 d 19 (16.4) 19 (16.2) > .99
Pelvic pain duration, d .43
1–2 23 (19.8) 29 (24.8)
≥3 93 (80.2) 88 (75.2)
Pelvic pain severityc, mm, mean (SD) 62.4 (24.4) 59.6 (23.0) .36d
Clinical tenderness score, mean 9.9 (4.1) 9.9 (4.8) .94d
(SD) [8]
Data are presented as no. (%) unless otherwise indicated.
Abbreviations: IQR, interquartile range; PID, pelvic inflammatory disease; SD, standard deviation.
a
P value from Fisher exact test unless otherwise noted.
b
P value from Mann-Whitney U test.
c
Visual Analogue Scale (0–100 mm).
d
P value from Student t test.

Metronidazole in PID Treatment • cid 2021:72 (1 April) • 1183

Figure 1. Study screening, randomization, and follow-up. *Participants did return for 30-day evaluation. Abbreviations: ITT, intent-to-treat; PID, pelvic inflammatory disease.
and were either hospitalized for parenteral antibiotics or elected
alternate antimicrobial therapy. One woman in each arm was
determined to have another cause of pelvic pain after enroll-
ment (ovarian cyst, endometriosis).
One hundred eighty four (79%) women continued on study
medication and returned for the final assessment at a median
31 days from enrollment (IQR, 29–33) (Table 3). Improvement
in pelvic pain was similar between the 2 treatment groups.
Pelvic organ tenderness, however, was still present in 20% of
women who did not receive metronidazole, compared to 9%
of women randomized to metronidazole (P < .05). The clinical
1184 • cid 2021:72 (1 April) • Wiesenfeld et al
cure rates were similar in women randomized to metronidazole
compared to women in the placebo-containing treatment arm
(97% vs 90%, P = .38).
Microbiologic Outcomes
At enrollment, cervical C. trachomatis infection was identified
in 34 (15%) women, N. gonorrhoeae was detected in 17 (7%),
and 41 women (18%) tested positive for M. genitalium (Table 4).
Bacterial vaginosis was present in 127 (55%) women, and 20
women (9%) were infected with T. vaginalis. The proportions
of women at enrollment with C. trachomatis, N. gonorrhoeae,
Table 2. Clinical Outcomes at 3-Day Follow-up Visit

Outcome Standard Plus Metronidazole Standard Plus Placebo P Valuea

(n = 116) (n = 117)
Clinical improvement, intent-to-treat 96 (82.8) 94 (80.3) .74
n = 104 n = 104
Clinical improvement, per protocol 96 (92.3) 94 (90.4) .81
Pelvic pain 40 (38.5) 39 (37.5) > .99
Pelvic pain severity, mm, mean (SD)b 21.9 (24.7) 17.3 (23.0) .17c
Difference from enrollment, mean (SD) −39.8 (30.9) −42.4 (28.2) .53c
Clinical tenderness score, mean (SD) [8] 3.4 (3.3) 3.1 (3.4) .62c
Difference from enrollment, mean (SD) −6.6 (4.1) −6.8 (5.2) .78c
Data are presented as no. (%) unless otherwise indicated.
Abbreviation: SD, standard deviation.
a
P value from Fisher exact test unless otherwise noted.
b
Visual Analogue Scale (0–100 mm).
c
P value from Student t test.

M. genitalium, T. vaginalis, or bacterial vaginosis were similar
between the 2 treatment groups. At the 1-month follow-up visit,
6 of 182 women (3%) were positive for cervical N. gonorrhoeae (3
in each treatment group) and 1 woman in each group (1%) had
chlamydia. Even though metronidazole has no activity against
M. genitalium, cervical infection following PID treatment was
less frequent in women receiving metronidazole than in women
in the placebo-containing group (4% vs 14%, P < .05). Bacterial
vaginosis (20% vs 54%, P < .001) and T. vaginalis (5% vs 12%,
P = .10) were also less prevalent in women who were random-
ized to metronidazole.
Culture cultivation of the endometrial aspirate was avail-
able from 174 women at the 30-day follow-up visit (Table 4).
Women who were randomized to PID treatment with met-
ronidazole were less likely to have recovery of Atopobium va-
ginae, anaerobic gram-negative rods or anaerobic gram-positive
cocci from the endometrium following treatment compared to
women who received placebo (8% vs 21%, P < .05). Similarly,
recovery of Gardnerella vaginalis from the endometrium was
also less frequent in women receiving metronidazole (12% vs
33%, P = .001). Each case of persistent anaerobes in the endo-
metrial samples from women receiving only ceftriaxone and
doxycycline was reviewed. In 1 case, an isolate of Prevotella
timonensis recovered at enrollment persisted after treatment
even though the isolate had intermediate susceptibility to
ceftriaxone (minimum inhibitory concentration [MIC] >16)
and doxycycline (MIC = 8). In 4 additional cases, Anaerococcus
tetradius, Peptoniphilus harei, and Prevotella amnii persisted
despite susceptibility to both ceftriaxone and doxycycline at
baseline and follow-up, suggesting poor clearance of these
anaerobic microorganisms without metronidazole. In 1 addi-
tional patient, A. vaginae was recovered at follow-up, whereas
no persistent A. vaginae was recovered from those randomized
to metronidazole.
Following treatment, none of the participants random-
ized to metronidazole tested positive for C. trachomatis or
N. gonorrhoeae in the endometrium. Only 1 woman random-
ized to the placebo arm was positive for C. trachomatis in the
endometrium following treatment. Mycoplasma genitalium
was identified in the endometrium at the 30-day visit in only 1
woman (1%) receiving metronidazole and in 4 (4%) women in
the placebo arm (P = .37).
Adherence and Tolerability
Adherence with medication, defined as using 75% of all tablets,
was similar between the 2 treatment groups (84% in the met-
ronidazole arm and 82% in the placebo arm, P = .85). Adverse
events were reported by 104 women (89.7%) assigned to metro-
nidazole and 94 women (80.3%) in the placebo group (P = .07;
Table 5). Gastrointestinal symptoms (eg, nausea, vomiting,

Table 3. Clinical Outcomes at 30 Days

Outcome Standard Plus Metronidazole (n = 90) Standard Plus Placebo (n = 94) P Valuea

Clinical cure, No. (%) 87 (96.7) 85 (90.4) .13

Pelvic pain, No. (%) 8 (8.9) 11 (11.7) .63
Pelvic pain severityb, mm, mean (SD) 4.0 (9.3) 4.2 (8.8) .83c
Difference from enrollment, mean (SD) −58.5 (24.5) −56.6 (22.7) .60c
Pelvic tenderness, No. (%) 8 (8.9) 19 (20.2) .037
Abbreviation: SD, standard deviation.
a
P value from Fisher exact test unless otherwise noted.
b
Visual Analogue Scale (0–100 mm).
c
P value from Student t test.

Metronidazole in PID Treatment • cid 2021:72 (1 April) • 1185

Table 4. Lower Genital Tract and Endometrial Microorganisms Before and After Treatment

Standard Plus Metronidazole Standard Plus Placebo P

Organism (n = 116) (n = 117) Valuea

Lower genital tract

Cervical Chlamydia trachomatis
  Enrollment 18 (15.5) 16 (13.7) .71
  30 days 1/90 (1.1) 1/92 (1.0) > .99
Cervical Neisseria gonorrhoeae
  Enrollment 6 (5.2) 11 (9.4) .31
  30 days 3/90 (3.3) 3/92 (3.3) > .99
Cervical Mycoplasma genitalium
  Enrollment 17 (14.7) 24 (20.5) .30
  30 days 4/90 (4.4) 13/92 (14.1) .039
Vaginal Trichomonas vaginalis
  Enrollment 9 (7.8) 11 (9.4) .82
  30 days 4/88 (4.5) 11/92 (12.0) .10
Bacterial vaginosis (Nugent score ≥ 7)
  Enrollment 65 (56.0) 62 (53.0) .69
  30 days 18/88 (20.5) 51/92 (54.4) < .001
Endometrium
C. trachomatis
  Enrollment 12 (10.3) 12 (10.3) > .99
  30 days 0/84 (0) 1/90 (1.1) > .99
N. gonorrhoeae
  Enrollment 6 (5.2) 6 (5.1) > .99
  30 days 0/84 (0) 0/90
M. genitalium
  Enrollment 7 (6.0) 11 (9.4) .46
  30 days 1/84 (1.2) 4/90 (4.4) .37
Haemophilus influenzae
  Enrollment 1 (0.9) 5 (4.3) .21
  30 days 0/84 (0) 2/90 (2.2) .50
Gardnerella vaginalis
  Enrollment 24 (20.7) 31 (26.5) .36
  30 days 10/84 (11.9) 30/90 (33.3) .001
Atopobium vaginae
  Enrollment 13 (11.2) 13 (11.1) > .99
  30 days 2/84 (2.4) 13/90 (14.4) .006
Anaerobic gram-negative rods
  Enrollment 12 (10.3)b 10 (8.5)c .66
  30 days 4/84 (4.8) 11/90 (12.2) .11
Anaerobic gram-positive cocci
  Enrollment 11 (9.5)d 12 (10.3)e > .99
  30 days 6/84 (7.1) 10/90 (11.1) .44
A. vaginae and/or anaerobic gram-negative
rods and/or anaerobic gram positive cocci
  Enrollment 20 (17.2) 22 (18.8) .86
  30 days 7/84 (8.3) 19/90 (21.1) .020
Data are presented as no. (%). Endometrial samples were not obtained at the 30 day visit from 10/184 women (received non-study antibiotics for another infection following enrollment,
refused endometrial sampling, inadequate sampling at either visit)
a
P value from Fisher exact test.
b
Includes Dialister microaerophilus, Porphyromonas asaccharlytia (n = 2), Porphyromonas uenonis, Prevotella amnii, Provotella bivia, Prevotella denticola, Prevotella disiens, Prevotella
massiliensis, Prevotella melaninogenica, Prevotella timonensis, Prevotella novel species group 1.
c
Includes Dialister microaerophilus, Porphyromonas asaccharlytia, Porphyromonas bennonis, Prevotella amnii, Provotella bivia, Prevotella disiens, Prevotella massiliensis, Prevotella
melaninogenica, Prevotella timonensis, Bacteroides ureolyticus.
d
Includes Anaerococcus species, Anaerococcus tetradius, Anaerococcus vaginalis, Finegoldia magna, Gemella haemolysans, Gemella species, Peptoniphilus harei, Peptoniphilus ivorii,
Peptoniphilus lacrimalis, Peptoniphilus species, Petostreptococcus anaerobius.
e
Includes Anaerococcus tetradius, Anaerococcus vaginalis, Anaerococcus hyrdogenalis, Facklamia hominis, Finegoldia magna, Peptoniphilus harei, Peptoniphilus lacrimalis, Peptoniphilus
species, Peptococcus niger, novel anaerobic gram positive coccus (n = 3).

1186 • cid 2021:72 (1 April) • Wiesenfeld et al

Table 5. Incidence of Nonserious Adverse Events, by Study Arm

Standard Plus Metronidazole Standard Plus Placebo

Adverse Event (n = 116) (n = 117) P Valuea

Participants with at least 1 AE 104 (89.7) 94 (80.3) .07

Constitutional
Headache 12 (10.3) 10 (8.5) .66
Gastrointestinal complaint, any 93 (80.2) 86 (73.5) .28
Nausea 58 (50.0) 55 (47.0) .69
Vomiting 40 (34.5) 37 (31.6) .68
Diarrhea 42 (36.2) 35 (29.9) .33
Abdominal pain 12 (10.3) 9 (7.7) .50
Altered taste 8 (6.9) 5 (4.3) .41
Genitourinary complaint, any 55 (47.4) 48 (41.0) .36
Vulvovaginal candidiasis 18 (15.5) 7 (6.0) .02
Bleeding abnormality 11 (9.5) 10 (8.5) .82
Genital irritation 13 (11.2) 5 (4.3) .053
Vaginal itching 11 (9.5) 7 (6.0) .34
Pelvic pain 4 (3.4) 11 (9.4) .11
Vaginal discharge, abnormal 10 (8.6) 4 (3.4) .11
Bacterial vaginosis, symptomatic 4 (3.4) 8 (6.8) .38
Nervous system
Paresthesia/numbness of extremities 6 (5.2) 5 (4.3) .77
Respiratory
Upper respiratory infection 10 (8.6) 4 (3.4) .11
AE severity (any body system)
Grade 1 96 (82.8) 87 (74.4) .15
Grade 2 53 (45.7) 45 (38.5) .29
Grade 3 6 (5.2) 3 (2.6) .33
AE relatedness to study product (any body
system)
Related 95 (81.9) 84 (71.8) .09
Not related 63 (54.3) 65 (55.6) .90
Data are presented as no. (%). Each participant contributes only 1 observation per category.
Abbreviation: AE, adverse event.
a
P value from Fisher exact test.

diarrhea) were frequently reported but were similar in the 2
groups. Vulvovaginal candidiasis was more common among
women receiving metronidazole (15.5% vs 6.0%, P = .02).
Serious adverse events occurred in 7 women (6.0%) in the met-
ronidazole group and 5 women (4.3%) receiving placebo. Eleven
of the 12 serious adverse events were hospitalizations for inpa-
tient treatment. One patient in each group required a change in
antimicrobial therapy due to intolerance of study medications.
Five women in the metronidazole arm and 4 women receiving
placebo were withdrawn for other reasons: 5 women were
newly pregnant following study entry, 2 women stopped their
medications because of adverse events and were withdrawn (1
for vomiting and 1 for diarrhea and vertigo), 1 participant de-
clined therapy after enrollment, and 1 was withdrawn ­because
she was incarcerated.
DISCUSSION
In this randomized, double-blind, placebo-controlled trial of
PID treatment, women receiving oral metronidazole in addition
to ceftriaxone and doxycycline had fewer endometrial anaer-
obic organisms and reduced cervical M. genitalium at 1 month
after treatment than women treated with ceftriaxone and doxy-
cycline alone. Moreover, while early clinical response was sim-
ilar with either PID treatment regimen, fewer women treated
with metronidazole had pelvic tenderness at 1 month. Despite
the concern for side effects associated with metronidazole use,
medication adherence and tolerability were similar between the
2 regimens.
In addition to C. trachomatis and N. gonorrhoeae, the micro-
biologic etiology of PID includes endogenous anaerobic and
facultative microorganisms that ascend from the lower genital
tract into the endometrium and associated pelvic structures.
Targeted qualitative polymerase chain reaction of endometrial
samples has identified an association between bacterial vagi-
nosis–associated bacteria, including A. vaginae, and acute PID
[4]. Beyond the pathogenicity of anaerobic microorganisms
in PID, the presence of anaerobic organisms following treat-
ment of pelvic infections has been associated with subsequent

Metronidazole in PID Treatment • cid 2021:72 (1 April) • 1187

infectious morbidity when anti-anaerobic therapy has not been
administered. For example, the failure to administer antibiotics
with activity against anaerobes to women with postpartum en-
dometritis has been associated with abscess formation [12].
Our study demonstrated that enhancing the anaerobic cov-
erage of the CDC-recommended outpatient PID regimen was
associated with significantly fewer anaerobic organisms in the
endometrium after treatment, including organisms previously
associated with acute PID. While our study was not designed
to determine whether the presence of anaerobic organisms fol-
lowing treatment is associated with longer-term reproductive
complications such as infertility and ectopic pregnancy, the
pathogenicity of anaerobic organisms in PID suggests that erad-
ication of anaerobic organisms from the upper genital tract is of
importance. It was notable that some Prevotella, Peptoniphilus,
and Anaerococcus species persisted in the endometrium in 5
women treated with ceftriaxone and doxycycline alone even
though in vitro susceptibility testing suggested that the isolates
were susceptible to these drugs. These data suggest that the ad-
dition of metronidazole may be needed to effectively eradicate
anaerobic pathogens from the upper genital tract of women
with PID.
Mycoplasma genitalium is associated with male urethritis, but
its role in STD syndromes in women is less well understood [1].
Doxycycline has limited activity against M. genitalium, curing
about one-third of infections [13]. In our study, M. genitalium
was detected in only 4% of women following treatment with
metronidazole, significantly less often than in women not re-
ceiving metronidazole. The difference in M. genitalium infection
following the 2 treatment regimens, along with the infrequent
identification of M. genitalium following treatment with metro-
nidazole, was not anticipated. However, these results are sim-
ilar to those observed in a retrospective study demonstrating
microbiologic cure in 19 of 20 women with M. genitalium–as-
sociated PID who were treated with metronidazole and either
azithromycin or doxycycline, which was not different than the
cure rate of women receiving moxifloxacin [14]. These find-
ings raise important questions about the role of this organism
in PID and whether there is a need to address M. genitalium
when treating women with current PID treatment that includes
metronidazole. Additional studies are needed to understand the
role of M. genitalium in the pathogenesis of PID and subsequent
reproductive sequelae.
Despite concerns for tolerability of metronidazole and its im-
pact on adherence with a 2-week oral antibiotic regimen, ad-
verse effects and medication adherence were similar in each
treatment group. Gastrointestinal side effects were commonly
experienced by women whether or not they received metroni-
dazole. While vulvovaginal candidiasis was more common in
women receiving metronidazole than in women in the placebo
group, bacterial vaginosis at study completion was significantly
less common in women receiving metronidazole. Importantly,
1188 • cid 2021:72 (1 April) • Wiesenfeld et al
adherence to oral doxycycline was unaffected by the addition of
metronidazole.
A limitation of our study was that the diagnosis of PID was
based on minimal CDC criteria and was not confirmed by lap-
aroscopy. However, the clinical criteria are widely accepted and
would trigger treatment for PID in clinical practice [5]. A limi-
tation of this and most other PID studies is that we were unable
to evaluate long-term reproductive outcomes including recur-
rent PID, infertility, and ectopic pregnancy. Cultivation-based
techniques were used for the identification of anaerobic and
facultative organisms in the endometrium rather than nucleic
acid–based amplification. This approach was taken because of
the limited availability of endometrial tissue and the relative
sensitivity of cultivation from normally sterile sites when ap-
propriate anaerobic techniques are employed. It was notable
that some novel microorganisms were recovered including
Megasphaera phylotype I, microorganisms that had been con-
sidered to be noncultivable but had been associated with bac-
terial vaginosis [15]. Since a goal of the study was to perform
antibiotic susceptibility testing of endometrial isolates, the use
of cultivation was necessary [11].
Although the microbiologic etiology of PID commonly in-
volves anaerobic organisms, a single dose of a cephalosporin
with oral doxycycline provides limited anaerobic activity [5].
Outcomes of PID treatment have historically centered on
treating N. gonorrhoeae and C. trachomatis and the resolution
of clinical signs and symptoms. Our study is consistent with
these goals of PID treatment and demonstrates that the addition
of metronidazole to ceftriaxone and doxycycline is associated
with significantly less frequent recovery of anaerobic organisms
from the upper genital tract, decreased M. genitalium, and im-
proved clinical response compared to ceftriaxone and doxycy-
cline. This study supports the routine use of metronidazole with
ceftriaxone and doxycycline for the treatment of women with
acute PID and should inform the formulation of future treat-
ment guidelines.
Notes
Acknowledgments. The authors are indebted to the medical staff at the
emergency departments at Magee-Womens Hospital and University of
Pittsburgh Medical Center Mercy, and to the staff at the Allegheny County
Health Department’s Sexually Transmitted Diseases Clinic. The authors
thank the staff of the Reproductive Infectious Diseases Clinical Research
Unit at Magee-Womens Research Institute, including Tracy Campbell,
Jamie Haggerty, Carol Priest, Julie Mckechnie, Abi Jett, and Sarah Thase for
their invaluable assistance.
Financial support. This work was supported by the National Institutes of
Health (grant number AI084024).
Potential conflicts of interest. H. W. reports grants from SpeeDx Pty
Ltd. S. H. reports that testing reagents were supplied by Hologic during the
conduct of the study; she also reports grants from Becton-Dickinson Life
Sciences and personal fees from Hologic, outside the submitted work. All
other authors report no potential conflicts of interest. All authors have sub-
mitted the ICMJE Form for Disclosure of Potential Conflicts of Interest.
Conflicts that the editors consider relevant to the content of the manuscript
have been disclosed.
References
1. Wiesenfeld HC, Manhart LE. Mycoplasma genitalium in women: current know-
ledge and research priorities for this recently emerged pathogen. J Infect Dis
2017; 216:389–95.
2. Hillier SL, Kiviat NB, Hawes SE, et al. Role of bacterial vaginosis-associated
microorganisms in endometritis. Am J Obstet Gynecol 1996; 175:435–41.
3. Haggerty CL, Hillier SL, Bass DC, Ness RB; PID Evaluation and Clinical Health
study investigators. Bacterial vaginosis and anaerobic bacteria are associated with
endometritis. Clin Infect Dis 2004; 39:990–5.
4. Haggerty CL, Totten PA, Tang G, et al. Identification of novel microbes associ-
ated with pelvic inflammatory disease and infertility. Sex Transm Infect 2016;
92:441–6.
5. Centers for Disease Control and Prevention. Sexually transmitted diseases treat-
ment guidelines, 2015. MMWR Recomm Rep 2015; 64(RR-03):1–137.
6. Ross J, Guaschino S, Cusini M, Jensen J. 2017 European guideline for the manage-
ment of pelvic inflammatory disease. Int J STD AIDS 2018; 29:108–14.
7. Savaris RF, Fuhrich DG, Duarte RV, Franik S, Ross JDC. Antibiotic therapy for
pelvic inflammatory disease: an abridged version of a Cochrane systematic re-
view and meta-analysis of randomised controlled trials. Sex Transm Infect 2019;
95:21–7.
8. McCormack WM, Nowroozi K, Alpert S, et al. Acute pelvic inflammatory di-
sease: characteristics of patients with gonococcal and nongonococcal infection
and evaluation of their response to treatment with aqueous procaine penicillin G
and spectinomycin hydrochloride. Sex Transm Dis 1977; 4:125–31.
9. Wendel GD Jr, Cox SM, Bawdon RE, Theriot SK, Heard MC, Nobles BJ. A ran-
domized trial of ofloxacin versus cefoxitin and doxycycline in the outpatient
treatment of acute salpingitis. Am J Obstet Gynecol 1991; 164:1390–6.
10. Nugent RP, Krohn MA, Hillier SL. Reliability of diagnosing bacterial vaginosis is
improved by a standardized method of gram stain interpretation. J Clin Microbiol
1991; 29:297–301.
11. Petrina MAB, Cosentino LA, Wiesenfeld HC, Darville T, Hillier SL. Susceptibility
of endometrial isolates recovered from women with clinical pelvic inflammatory di-
sease or histological endometritis to antimicrobial agents. Anaerobe 2019; 56:61–5.
12. diZerega G, Yonekura L, Roy S, Nakamura RM, Ledger WJ. A comparison of
clindamycin-gentamicin and penicillin-gentamicin in the treatment of post-
cesarean section endomyometritis. Am J Obstet Gynecol 1979; 134:238–42.
13. Bradshaw CS, Jensen JS, Waites KB. New horizons in Mycoplasma genitalium
Treatment. J Infect Dis 2017; 216:412–9.
14. Latimer RL, Read TRH, Vodstrcil LA, et al. Clinical features and therapeutic re-
sponse in women meeting criteria for presumptive treatment for pelvic inflamma-
tory disease associated with Mycoplasma genitalium. Sex Transm Dis 2019; 46:73–9.
15. Fredricks DN, Fiedler TL, Thomas KK, Mitchell CM, Marrazzo JM. Changes in
vaginal bacterial concentrations with intravaginal metronidazole therapy for bac-
terial vaginosis as assessed by quantitative PCR. J Clin Microbiol 2009; 47:721–6.
Metronidazole in PID Treatment • cid 2021:72 (1 April) • 1189