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<9cmindiameter–  Adequateresponsetoantibiotictherapy–  Premenopausal

•  Ifnoresponseafter48-72hrsthendrainageorsurgery

•  Durationminimumof2weeksbutmayneed4-6weeks–  ‘mostexpertsrecommendcontinuationofantibiotictherapyuntilthe

abscesshasresolvedonfollowupimaging’

•  Drainageisessentialifdiameterofabscessismorethan3cm(GradeB)

•  Transvaginaldrainageispreferred(GradeC)

ICHNTService

•  LargeWestLondonService– CharingCrossHospital– StMary’sHospital

•  >10yearsservice

•  73514beddayssaved•  3031patientepisodes

Ourexperience

•  OPATdatabase2012–2017•  19patientsepisodes– 18patientswithonepatienthaving2episodes

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–  ?sizeofabscessneedingintervention– Durationofantibiotics–  IVversusoralantibiotics

•  NeedsanMDTapproachtomanagement– Gynae–  InfectionSpecialists–  Interventionalradiologists– OPATservices

Howtoimproveourservice

•  Clearlocalguidanceforamanagementstrategy/pathway

•  Dedicatedinterventionalradiologist– Firstlinetrans-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.