Objective To assess the effectiveness and safety of antibiotic regimens used to treat pelvic inflammatory disease (PID).
Design This is a systematic review and meta-analysis of randomised controlled trials (RCTs). Risk of bias was assessed using the criteria outlined in the Cochrane guidelines. Quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation.
Data sources Eight electronic databases were searched from date of inception up to July 2016. Database searches were complemented by screening of reference lists of relevant studies, trial registers, conference proceeding abstracts and grey literature.
Eligibility criteria RCTs comparing the use of antibiotics with placebo or other antibiotics for the treatment of PID in women of reproductive age, either as inpatient or outpatient treatment.
Results We included 37 RCTs (6348 women). The quality of evidence ranged from very low to high, the main limitations being serious risk of bias (due to poor reporting of study methods and lack of blinding), serious inconsistency and serious imprecision. There was no clear evidence of a difference in the rates of cure for mild-moderate or for severe PID for the comparisons of azithromycin versus doxycycline, quinolone versus cephalosporin, nitroimidazole versus no use of nitroimidazole, clindamycin plus aminoglycoside versus quinolone, or clindamycin plus aminoglycoside versus cephalosporin. No clear evidence of a difference between regimens in antibiotic-related adverse events leading to discontinuation of therapy was observed.
Conclusions We found no conclusive evidence that one regimen of antibiotics was safer or more effective than any other for the treatment of PID, and there was no clear evidence for the use of nitroimidazoles (metronidazole) compared with the use of other drugs with activity against anaerobes. More evidence is needed to assess treatments for women with PID, particularly comparing regimens with or without the addition of nitroimidazoles and the efficacy of azithromycin compared with doxycycline.
- pelvic inflammatory disease
- systematic reviews
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Handling editor Nicola Low
Contributors RFS: coordination, study design, statistical analysis and review, writing the manuscript, grading the evidence in GRADE, and final approval of the manuscript. DGF: data collection, extraction, grading the risk of bias and final approval of the manuscript. RVD: data collection, extraction, grading the risk of bias, writing the manuscript and final approval of the manuscript. SF: data collection, extraction, grading the risk of bias, grading the evidence in GRADE and final approval of the manuscript. JR: study design, writing the manuscript, grading the evidence in GRADE and final approval of the manuscript.
Funding NIHR’s 2012 Cochrane Review Incentive Scheme Award, UK.
Competing interests RFS, DGF, RVD and SF certify that they do not have any affiliations with, or involvement in, any organisation or entity with a direct financial interest in the subject matter of this review (eg, employment, consultancy, stock ownership, honoraria, expert testimony). JR declares the following interests: personal fees from GSK Pharma, Hologic Diagnostic and Janssen Pharma; ownership of shares in GSK Pharma and AstraZeneca Pharma; author of the UK and European Guidelines on Pelvic Inflammatory Disease; member of the European Sexually Transmitted Infections Guidelines Editorial Board; member of the National Institute for Health Research (NIHR) HTA Commissioning Board; NIHR Journals Editor; Editorial Board of the Cochrane Collaboration Sexually Transmitted Diseases Collaborative Review Group; and Sexually Transmitted Infections journal associate editor. The authors disclose that two of the authors (RFS and JR) had two publications used in the analysis. RFS and JR did not participate in the process for considering these studies for inclusion, data extraction, quality assessment and grading for risk of bias. The current article is based on a published Cochrane review.
Provenance and peer review Not commissioned; externally peer reviewed.
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