Tubo-ovarian abscess in OPATopat- ?· Pelvic inflammatory disease • Pelvic inflammatory disease is…

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Tubo-ovarianabscessinOPAT

JamesHatcher

ConsultantinInfectiousDiseasesandMedicalMicrobiology

OUTLINE

Whatisatubo-ovarianabscess

Currentrecommendations

Ourexperienceandchallenges

Howtoimproveservice

ImagesfromCDCPublicHealthImageLibrary

Pelvicinflammatorydisease Pelvicinflammatorydiseaseistheoveralltermforinfection

ascendingfromtheendocervix NeisseriagonorrhoeaeandChlamydiatrachomatishavebeen

identifiedascausativeagents IUDincreasesriskofPIDbutonlyfor4-6weekspostinsertion

Symptoms Lowerabdopain,discharge,dyspareunia,abnormalvaginalbleeding

Signs Bilaterallowerabdotenderness,fever Adnexaltendernessonbimanualvaginalexamination

Cervicitis

Endometritis

SalpingitisOophoritisTubo-ovarianabscess

PeritonitisSepsis

2018UnitedKingdomNationalGuidelinefortheManagementofPelvicInflammatoryDisease

Admissionforparenteraltherapy,observation,furtherinvestigationand/orpossiblesurgicalinterventionshouldbeconsideredinthefollowingsituations(Grade1D) Lackofresponsetooraltherapy Clinicallyseveredisease Presenceofatubo-ovarianabscess Intolerancetooraltherapy

InpatientregimensIVceftriaxone2gODPLUSdoxycycline100mgBDPLUSmetronidazole400mgBDfor14days(Grade1A)IVtherapyshouldbecontinueduntil24hoursafterclinicalimprovementthenswitchedtooral(Grade2D)SurgicalmanagementLaparoscopymayhelpseverediseasebydividingadhesionsanddrainingabscessesUltrasoundguidedaspirationislessinvasiveandmaybeequallyeffective

Antimicrobialagentsaloneareeffectivein70% Candidatesforantibiotictherapyalone(Grade2C): Nosignsofrupture/sepsis Abscess

Drainageisessentialifdiameterofabscessismorethan3cm(GradeB)

Transvaginaldrainageispreferred(GradeC)

ICHNTService

LargeWestLondonServiceCharingCrossHospitalStMarysHospital

>10yearsservice

73514beddayssaved 3031patientepisodes

Ourexperience

OPATdatabase20122017 19patientsepisodes18patientswithonepatienthaving2episodes

50%bilateralabscesses

58%Surgicalorradiological

intervention

0 1 2 3 4 5 6 7 8 9

Laparoscopicprocedure

Laparotomy

Radiologicaldrainage

Nil

0 1 2 3 4 5 6 7 8 9 10

Candidaspp.

Morganellaspp.

Strepmilleri

Enterococcusspp.

Ecoli

Unknown

0

2

4

6

8

10

12

14

Ceftriaxone Daptomycin Ertapenem Meropenem

OPATAntibioticRegime

47%hadoralfollowonCiprofloxacinandco-amoxiclavmostcommonchoice

4/18selfadministration

Durationofantibiotictherapy

53daysMediantotalantibioticdurationIncludingadmissiondays,OPAT

daysandoralfollowon

Comparingpatientswith/withoutsurgicalorradiologicalintervention

Patientswithoutintervention(n=8)

Patientswithintervention(n=11)

Pvalue

Age(years) 49 44 0.2997

Meanabscesssize(cm)*

9 9.6 0.7003

MeandurationOPATabx(days)

30 31 0.8974

MeandurationTOTALabx(days)

54 60 0.5694

*3patientsdidnothavesizeofabscessrecordedinnotes

Cure27%

Fail5%

Improved26%

NR42%

InfectionOutcomeBSAC

InfectionOutcomeCure 5Fail 1

Improved 5NR 8

GrandTotal 19

Failure5%

NR42%

Partial11%

Success42%

OPATOutcomeBSAC

OPATOutcomeFailure 1NR 8

Partial 2Success 8

GrandTotal 19

100%LongTermCure(18patients)

Whataretheissues Noclearguidanceonmanagementoftubo-ovarianabscesses ?sizeofabscessneedinginterventionDurationofantibiotics IVversusoralantibiotics

NeedsanMDTapproachtomanagementGynae InfectionSpecialists InterventionalradiologistsOPATservices

Howtoimproveourservice

Clearlocalguidanceforamanagementstrategy/pathway

DedicatedinterventionalradiologistFirstlinetrans-vaginalUSSandwilldrainatthetimeifamenable

Willdofollowupscansatregularintervals EarlyinvolvementofInfectionteam+/-OPAT GoodengagementfromanMDT

OutpatientParenteralAntimicrobialTherapy

Nurses Pharmacists DoctorsClinicalTeam

References WorkowskiKA,BolanGA.Sexuallytransmitteddiseasestreatment

guidelines,2015.MMWRRecommRep,2015vol.64(RR-03)pp.1-137

BeigiRH.Managementandcomplicationsoftubo-ovarianabscesses.www.uptodate.com.

BrunJLetal.UpdatedFrenchguidelinesfordiagnosisandmanagementofpelvicinflammatorydisease.IntJGynaecolObstet,2016vol.134(2)pp.121-5

RossJetal.2017Europeanguidelinesforthemanagementofpelvicinflammatorydisease.InJSTDAIDS2018Feb;29(2):108-114

RossJetal.2018UnitedKingdomNationalguidelineforthemanagementofpelvicinflammatorydisease.BASHH.

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