NICE vs BASHH: Management of Pelvic Inflammatory Disease (2025)
Pelvic Inflammatory Disease (PID) is a common and serious infection of the female upper genital tract, with significant potential for long-term sequelae including infertility, ectopic pregnancy, and chronic pelvic pain. In the UK, clinicians primarily rely on two key national guidelines for its management: those from the National Institute for Health and Care Excellence (NICE) and the British Association for Sexual Health and HIV (BASHH). While complementary, these guidelines have distinct focuses and nuances. This comparison aims to delineate the key similarities and differences between the NICE NG219 (2021) and BASHH (2019) guidelines to aid clinicians in practical, day-to-day decision-making.
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Overview: NICE guidelines provide a broad, primary-care friendly framework aimed at a wide audience, including GPs and non-specialists. BASHH guidelines offer a more detailed, specialist-focused approach, with extensive microbiological and complex management advice tailored for sexual health services. The 2025 perspective confirms that both remain current, with no major updates superseding them.
Diagnosis and Assessment
NICE NG219 (2021)
NICE emphasises a low threshold for empirical diagnosis and treatment to prevent long-term complications. The approach is pragmatic for non-specialist settings.
- Clinical Criteria: Diagnosis should be considered in sexually active women under 25, or any woman with new or multiple sexual partners, if they experience lower abdominal pain, pelvic pain, or deep dyspareunia. Adnexal or cervical motion tenderness on examination is a key sign.
- Investigations: Recommends taking swabs for Chlamydia trachomatis and Neisseria gonorrhoeae (via NAAT) prior to or at the time of antibiotic administration. However, treatment should not be delayed awaiting results.
- Threshold for Treatment: Advises offering empirical treatment if PID is suspected, even in the absence of classic signs, based on the principle that a false-positive diagnosis is preferable to the consequences of missed or delayed treatment.
BASHH (2019)
BASHH provides a more granular, multi-criteria approach, reflecting its specialist context.
- Diagnostic Criteria: Classifies findings into Essential (e.g., pelvic/abdominal pain, cervical motion tenderness), Additional (e.g., fever >38°C, abnormal vaginal discharge), and Investigative (e.g., histology confirming endometritis, tubo-ovarian abscess on scan).
- Investigations: Strongly recommends endocervical swabs for N. gonorrhoeae culture (for antimicrobial susceptibility testing) in addition to NAAT. Also recommends microscopy of Gram-stained genital secretions if available, where the presence of intracellular diplococci can support a gonococcal diagnosis.
- Laparoscopy: Retains a role for laparoscopy in cases of diagnostic uncertainty or failure to respond to therapy, which is not a focus in NICE.
Key Difference: BASHH offers a more definitive, tiered diagnostic framework and insists on culture for gonorrhoea. NICE prioritises a rapid, low-threshold empirical approach suitable for first-contact care.
First-Line Antibiotic Treatment
Both guidelines recommend regimens with broad anaerobic cover, crucial for treating polymicrobial infection.
NICE Recommended Regimen
- Regimen 1 (Oral): Ceftriaxone 500mg IM (single dose) PLUS Doxycycline 100mg BD orally for 14 days PLUS Metronidazole 400mg BD orally for 14 days.
- Regimen 2 (IV to Oral): For more severe cases: Ceftriaxone 500mg IM IV daily PLUS Doxycycline 100mg BD orally/IV PLUS Metronidazole 400mg BD orally/IV, with a switch to oral therapy after 24-48 hours of clinical improvement.
BASHH Recommended Regimen
- Regimen 1 (Oral/Outpatient): Ofoxacin 400mg BD orally for 14 days PLUS Metronidazole 400mg BD orally for 14 days.
- Regimen 2 (IV/Inpatient): Ceftriaxone 500mg IM IV daily (or Cefoxitin 2g IV QDS) PLUS Doxycycline 100mg BD orally/IV PLUS Metronidazole 400mg BD orally/IV.
Key Difference: The primary difference lies in the outpatient oral regimen. BASHH includes ofloxacin as a first-line option, while NICE does not. This is due to increasing quinolone resistance and NICE's broader audience. BASHH acknowledges ofloxacin but notes local resistance patterns should be considered. NICE's regimen with ceftriaxone provides more reliable cover for quinolone-resistant gonorrhoea.
Practical Takeaway: For most clinicians in a GP or A&E setting, the NICE regimen (Ceftriaxone + Doxycycline + Metronidazole) is the most pragmatic and robust choice. In specialist settings where local resistance data supports its use, BASHH's ofloxacin regimen remains an option.
Special Situations and Complexities
Intrauterine Device (IUD) in Situ
- NICE: States that the IUD does not necessarily need to be removed if the patient is responding well to antibiotics. Removal may be considered if symptoms do not improve within 48-72 hours.
- BASHH: Provides a more nuanced discussion. Suggests that for mild-moderate PID, the device can remain initially. However, recommends removal if there is no clinical improvement after 48-72 hours, or in cases of severe infection or actinomyces-like organisms on smear.
Consensus: Both agree that removal is not mandatory initially, but is indicated if the response to treatment is suboptimal.
Tubo-ovarian Abscess (TOA)
- Both guidelines recommend inpatient IV antibiotic therapy.
- BASHH provides more detailed guidance on the potential role of ultrasound-guided drainage in conjunction with antibiotics.
Pregnancy
- PID in pregnancy is rare but serious. Both guidelines recommend urgent specialist assessment and inpatient management.
- Antibiotic regimens require modification (e.g., doxycycline and ofloxacin are contraindicated).
Practical Clinical Flow for UK Clinicians
- Suspicion: A sexually active woman presents with lower abdominal/pelvic pain. Maintain a low threshold for suspicion (per NICE).
- Assessment & Tests: Take a sexual history. Perform a bimanual exam (if competent and appropriate). Take NAATs for Chlamydia and Gonorrhoea. In a specialist setting (GUM), consider adding a gonococcal culture.
- Immediate Treatment: Do not delay treatment. Initiate empirical antibiotics. The most universally applicable regimen is Ceftriaxone 500mg IM stat + Doxycycline 100mg BD for 14d + Metronidazole 400mg BD for 14d.
- Referral/Admission: Admit for IV therapy if severely unwell (e.g., febrile, vomiting, signs of TOA). Refer to GUM for partner notification and further STI screening.
- Follow-up: Review within 72 hours to assess clinical improvement. Adjust management if no improvement (consider admission, IUD removal, further investigation). Ensure partner notification is undertaken.
Frequently Asked Questions (FAQs)
1. Which guideline should I follow in primary care?
For GPs and other first-contact clinicians, the NICE guideline is generally more practical. Its low threshold for empirical treatment and clear, simple regimen (Ceftriaxone/Doxycycline/Metronidazole) are designed for non-specialist settings. Prompt treatment and referral to sexual health services for partner notification is the key action.
2. Why does BASHH still recommend ofloxacin?
BASHH guidelines are specialist-focused and acknowledge that ofloxacin can be an effective single oral agent with good anaerobic cover when combined with metronidazole. However, they stress it should only be used in areas with known low gonorrhoea resistance or when gonorrhoea has been confidently excluded. NICE's omission reflects a population-wide precaution against rising resistance.
3. Is a pelvic ultrasound required for diagnosis?
No. Neither guideline recommends ultrasound for routine diagnosis, as findings are often normal in uncomplicated PID. Ultrasound is primarily indicated if a tubo-ovarian abscess or other complex pathology is suspected, or if the diagnosis is uncertain.
4. How should we manage sexual partners?
This is a critical component. Both guidelines strongly recommend partner notification for all sexual partners from the previous 6 months. They should be offered epidemiological treatment (for Chlamydia and Gonorrhoea) and full STI screening, ideally through dedicated sexual health services.
5. What is the single most important practical takeaway?
A low threshold for empirical treatment. The most significant harm in PID management is delayed treatment. Initiating antibiotics based on clinical suspicion, even without confirmatory tests, is the cornerstone of preventing long-term reproductive damage.
Source Links and Further Reading
- NICE Guideline NG219 (2021) - Pelvic inflammatory disease: diagnosis and management: NICE NG219
- BASHH Guideline (2019) - UK National Guideline for the Management of Pelvic Inflammatory Disease: BASHH PID guideline (2019)
Disclaimer: This comparison is for informational purposes within a clinical context. Always refer to the full guidelines for comprehensive detail and in complex cases.