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.
