From Clinical guidelines — Diagnosis and treatment manual › Chapter 9: Genito-urinary diseases · Médecins Sans Frontières, Current online edition (last update March 2023)
Diagnosis and antibiotic treatment of endometritis and salpingitis for clinicians in resource-limited settings.
- Issuer
- Médecins Sans Frontières
- Edition
- Current online edition (last update March 2023)
- Audience
- Clinicians working in resource-limited settings, particularly MSF field staff
- Evidence
- Expert consensus based on MSF field experience
- Reviewed
- 21 Oct 2026 · GMJ
What this guideline says
GMJ summary
This MSF guideline addresses bacterial infections of the uterus (endometritis) and fallopian tubes (salpingitis), which may be sexually transmitted or arise after childbirth or abortion. The guideline distinguishes two clinical scenarios with different pathogen profiles and treatment approaches: sexually transmitted UGTI (requiring coverage of gonococci, chlamydiae, and anaerobes) and post-partum/post-abortion infections (requiring coverage of anaerobes, Gram negatives, and streptococci).
For sexually transmitted UGTI, ambulatory treatment consists of cefixime or ceftriaxone (single dose) plus doxycycline (100 mg twice daily for 14 days) plus metronidazole (500 mg twice daily for 14 days). For post-partum/post-abortion infections, ambulatory treatment (early stages only) uses amoxicillin/clavulanic acid for 7 days or amoxicillin plus metronidazole for 7 days. Hospitalisation is recommended for severe or complicated infections, diagnostic uncertainty, or failure to improve after 48 hours of outpatient treatment.
The guideline emphasises the importance of partner treatment in sexually transmitted cases, removal of intrauterine devices, and surgical consultation when peritonitis or pelvic abscess is suspected. For post-partum infections with retained placenta, digital curettage or manual vacuum extraction should be performed 24 hours after initiating antibiotics.
Key points
For clinicians — doses and thresholds as stated in the guideline
- Sexually transmitted UGTI ambulatory treatment: cefixime 400 mg single dose (or ceftriaxone 500 mg IM single dose) + doxycycline 100 mg twice daily for 14 days + metronidazole 500 mg twice daily for 14 days
- Post-partum/post-abortion UGTI ambulatory treatment (early stages only): amoxicillin/clavulanic acid 3000 mg daily (ratio 8:1) or 2625 mg daily (ratio 7:1) for 7 days, or amoxicillin 1 g three times daily + metronidazole 500 mg three times daily for 7 days
- Hospitalisation criteria: severe or complicated infection, diagnostic uncertainty, significant obstacles to ambulatory treatment, or no improvement/deterioration within 48 hours of outpatient treatment
- Hospital treatment for sexually transmitted UGTI: ceftriaxone 1 g once daily + doxycycline 100 mg twice daily + metronidazole 500 mg twice daily; continue triple therapy for 24–48 hours after improvement, then complete 14 days with doxycycline and metronidazole
- Hospital treatment for post-partum/post-abortion UGTI: amoxicillin/clavulanic acid 1 g IV every 8 hours + gentamicin 5 mg/kg IM once daily; stop 48 hours after resolution of fever and symptoms
- In pregnant/breastfeeding women, replace doxycycline with erythromycin 1 g twice daily or 500 mg four times daily for 14 days; single-dose azithromycin is not effective for UGTI
- Remove intrauterine devices in sexually transmitted UGTI cases and treat partners with single-dose gonorrhoea and chlamydia treatment regardless of symptoms
- For retained placenta, perform digital curettage or manual vacuum extraction 24 hours after initiating antibiotic therapy
Treatment regimens for upper genital tract infections by aetiology and setting
Table extracted from the guideline
| Aetiology | Setting | Regimen | Duration |
|---|---|---|---|
| Sexually transmitted | Ambulatory | Cefixime 400 mg PO single dose (or ceftriaxone 500 mg IM single dose) + doxycycline 100 mg PO twice daily + metronidazole 500 mg PO twice daily | 14 days (doxycycline + metronidazole) |
| Sexually transmitted | Hospital | Ceftriaxone 1 g IM/IV once daily + doxycycline 100 mg PO twice daily + metronidazole 500 mg PO/IV twice daily | Triple therapy 24–48 h after improvement, then doxycycline + metronidazole to complete 14 days |
| Post-partum/post-abortion | Ambulatory (early stages) | Amoxicillin/clavulanic acid 3000 mg daily (ratio 8:1) or 2625 mg daily (ratio 7:1) OR amoxicillin 1 g three times daily + metronidazole 500 mg three times daily | 7 days |
| Post-partum/post-abortion | Hospital | Amoxicillin/clavulanic acid 1 g IV every 8 h + gentamicin 5 mg/kg IM once daily OR ampicillin 2 g IV every 8 h + metronidazole 500 mg IV every 8 h + gentamicin 5 mg/kg IM once daily | Stop 48 h after resolution of fever and symptoms |
Source: Médecins Sans Frontières, Upper genital tract infections (UGTI) — MSF Clinical guidelines. Reproduced in summary form.
From the guideline
Verbatim
“Antibiotic therapy combines 3 antibiotics to cover the most frequent causative organisms: gonococci, chlamydiae, and anaerobes.”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As Editor-in-Chief of the Georgian Medical Journal and Chair of the Public Health Institute of Georgia, I recognise the critical importance of evidence-based UGTI management for our region. Georgia has made significant progress in strengthening sexual and reproductive health services through our Universal Health Coverage programme since 2013, but timely diagnosis and appropriate antibiotic selection for UGTI remain challenging, particularly in distinguishing sexually transmitted from post-partum aetiologies. I would emphasise to Georgian clinicians the necessity of the full 14-day doxycycline-metronidazole regimen for sexually transmitted cases—incomplete treatment contributes to chronic pelvic inflammatory disease and infertility. The main implementation caveat for Georgia is ensuring reliable access to cefixime and appropriate amoxicillin/clavulanic acid formulations (8:1 or 7:1 ratios) across primary care facilities, as well as establishing functional referral systems for the hospitalisation criteria outlined, which may be difficult in rural areas of Georgia, Armenia, and Azerbaijan where geographical barriers to specialist care persist.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 21 Oct 2026
Applicability
Georgia and the South Caucasus
This guideline is highly relevant for Georgia and the South Caucasus, where both sexually transmitted infections and post-partum complications remain public health concerns. National programmes would need to ensure availability of the recommended antibiotics (particularly ceftriaxone, doxycycline, metronidazole, and amoxicillin/clavulanic acid) in appropriate formulations and ratios. Implementation would require strengthening the capacity for differential diagnosis between sexually transmitted and post-partum/post-abortion aetiologies, establishing clear referral pathways for hospitalisation criteria, and ensuring access to partner notification and treatment services for sexually transmitted cases. Georgian clinicians should adapt these recommendations to local antimicrobial resistance patterns, particularly for gonorrhoea, and consider integrating these protocols with existing maternal health and STI control programmes.
Questions this guideline answers
Quick answers
When should a patient with suspected UGTI be hospitalised rather than treated as an outpatient?
Hospitalisation is indicated for: suspected severe or complicated infection (peritonitis, abscess, septicaemia), diagnostic uncertainty (possible ectopic pregnancy or appendicitis), significant obstacles to ambulatory oral treatment, or no improvement after 48 hours or deterioration within 48 hours of outpatient treatment.
Why can't azithromycin be used as a single dose for chlamydia in UGTI treatment?
The guideline explicitly states that single-dose azithromycin is not effective against chlamydia in the treatment of sexually transmitted UGTI, unlike in uncomplicated urogenital chlamydia infections. A 14-day course of doxycycline (or erythromycin in pregnancy) is required.
What antibiotic regimen should be used for post-partum UGTI in a penicillin-allergic patient requiring hospitalisation?
Use clindamycin IV 900 mg every 8 hours plus gentamicin IM 5 mg/kg once daily. Continue until 48 hours after resolution of fever and clinical signs and symptoms.
When should retained placenta be removed in post-partum UGTI, and what technique should be used?
Digital curettage or manual vacuum extraction should be performed 24 hours after initiation of antibiotic therapy. This delay allows antibiotics to begin controlling infection before the procedure.
Related on GMJ
Interconnected resources
Dictionary of Public Health
GMJ News coverage
Quality & accreditation
Same guideline
- Genital ulcers — MSF Clinical guidelinesChapter 9: Genito-urinary diseases
- Abnormal vaginal discharge — MSF Clinical guidelinesChapter 9: Genito-urinary diseases
- Urethral discharge — Clinical guidelines — Diagnosis and treatment manual — MSF Clinical guidelinesChapter 9: Genito-urinary diseases
- Genital infections — Clinical guidelines — MSF Clinical guidelinesChapter 9: Genito-urinary diseases
- Acute prostatitis — MSF Clinical guidelinesChapter 9: Genito-urinary diseases
- Acute pyelonephritis — MSF Clinical guidelinesChapter 9: Genito-urinary diseases
Other guidelines on this topic
- Latent tuberculosis infection — MSF Tuberculosis
- Genital ulcers — MSF Clinical guidelines
- Abnormal vaginal discharge — MSF Clinical guidelines
- Summary of clinical presentations of tuberculosis — MSF Tuberculosis
- Urethral discharge — Clinical guidelines — Diagnosis and treatment manual — MSF Clinical guidelines
- Issuer
- Médecins Sans Frontières
- Guideline
- Clinical guidelines — Diagnosis and treatment manual
- Chapter
- Chapter 9: Genito-urinary diseases
- Type
- Clinical guideline (chapter)
- Edition
- Current online edition (last update March 2023)
- Status
- Current
- Published
- 2026-10-14
- Scope
- Upper genital tract infections (endometritis and salpingitis)
- Audience
- Clinicians working in resource-limited settings, particularly MSF field staff
- Evidence
- Expert consensus based on MSF field experience
- Record history
- Created 21 Oct 2026 · updated 21 Oct 2026 · next check Apr 2027
Médecins Sans Frontières. Upper genital tract infections (UGTI). In: Clinical guidelines — Diagnosis and treatment manual. Chapter 9: Genito-urinary diseases [Internet]. Paris: MSF; 2023 Mar [cited 2026 Oct 14]. Available from: https://medicalguidelines.msf.org/en/viewport/CG/english/GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
Was this article helpful?
