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Tubo-Ovarian Abscess Management in OPAT

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Tubo-Ovarian Abscess Management in OPAT Tubo-ovarian abscess management in OPAT James Hatcher Consultant in Infectious Diseases and Medical Microbiology OUTLINE • Case • What is a tubo-ovarian abscess • Current recommendations • Our experience and challenges • How to improve service Images from CDC Public Health Image Library Day Clinical Case 1 • 51 year old female admitted on 14th May 2018 Para 2 with prev C section – 10days lower abdominal pain Post menopausal with – Associated fever, vomiting and loose stool normal smears CABG 2015 • On examination Hypertension – Afebrile Depression – BP 95/57 – Heart rate 83 bpm Aspirin Atorvastatin – Abdomen – tender ++ suprapubic region Bendroflumethiazide with guarding Bisoprolol Clopidogrel • WCC 20, CRP 300, lactate 0.7 NKDA Day Admission CT scan 1 • Pelvic collection – 7.5 cm x 4.9 cm gas forming collection – Surrounding inflammatory fat stranding. – Likely tubal in origin (tubo-ovarian abscess) Day Trans-abdominal/vaginal USS 2 • 5 cm x 5 cm collection containing mixed echogenicity which is part solid, part cystic. • The patient was uncomfortable but not tender during the scan. • No window for drainage was identified. The appearances are suspicious for a tubo-ovarian abscess or an adnexal collection Commenced on ceftriaxone, metronidazole Days 1-10 High Vaginal Swab - ESBL E. coli Changed to Changed to ertapenem meropenem Patient not taken for surgery Inflammatory markers slowly improving Abnormal clotting Patient wanted to avoid surgery Days 22-27 • US guided aspiration – Collection now 10.8 x 7cm – Enhancing wall, fluid density material and multiple gas locules – 400mls frank pus aspirated and drain placed • Converted to ertapenem and discharged on OPAT Days 28-30 • Following day – Reviewed on OPAT with fevers, haemodynamically stable – Readmitted to hospital – Stable 7x10cm collection, new anterior collection – US guided percutaneous pelvic drainage – Streptococcus anginosus from pus Days 31-44 • Patient had a tubogram and exchange of drains – aspirated to dryness • Removed same day and discharged to OPAT • Completed 37 days of total carbapenem therapy • Changed to oral co-amox – (most likely S. anginosus group) Day Seen Gynae Clinic 52 • CRP slowly climbing on oral co-amoxiclav • The size of the collection is now slightly larger than it was on the previous CT study, measuring 9.3 cm x 6.5 cm x 11 cm Laparoscopic Surgery Day 54 Bilateral salpingo-oopherectomy, appendicectomy, adhesiolysis, omental biopsy and peritoneal washings • 6 Consultants – (4 O&G, 2 Gen Surg) • 10cm right bilocular tubo-ovarian abscess in Pouch of Douglas • Adherent to surrounding structures (pelvic sidewall, uterus, rectum, appendix) • Tip of appendix in abscess cavity • Significant amount of green-white pus drained from abscess intra-op • Pus – ESBL-producing Klebsiella pneumoniae Post op progress • Need brief ICU admission for hospital-acquired pneumonia • Residual collection on subsequent CT scan • Completed 14 days meropenem and fluconazole as inpatient • Discharged on 2 weeks ciprofloxacin, metronidazole and fluconazole • Outpatient follow up scan 1 month later showed complete resolution ESBL E. coli S. anginosus group ESBL k. pneumoniae Meropenem Meropenem Fluconazole Ertapenem Ertapenem Ciprofloxacin Cefuroxime Metronidazole Metronidazole Co-amoxiclav Fluconazole Gentamicin Doxycycline Azithromycin 0 1 2 3 4 5 6 7 8 9 10 11 12 13 Pelvic inflammatory disease • Pelvic inflammatory disease is the overall term for infection ascending from the endocervix • Neisseria gonorrhoeae and Chlamydia trachomatis have been identified as causative agents • IUD increases risk of PID but only for 4-6 weeks post insertion • Symptoms – Lower abdo pain, discharge, dyspareunia, abnormal vaginal bleeding • Signs – Bilateral lower abdo tenderness, fever – Adnexal tenderness on bimanual vaginal examination Peritonitis Sepsis Salpingitis Endometritis Oophoritis Tubo-ovarian abscess Cervicitis 2018 United Kingdom National Guideline for the Management of Pelvic Inflammatory Disease ‘Admission for parenteral therapy, observation, further investigation and/or possible surgical intervention should be considered in the following situations (Grade 1D) • Lack of response to oral therapy • Clinically severe disease • Presence of a tubo-ovarian abscess • Intolerance to oral therapy’ Inpatient regimens IV ceftriaxone 2g OD PLUS doxycycline 100mg BD PLUS metronidazole 400mg BD for 14 days (Grade 1A) IV therapy should be continued until 24 hours after clinical improvement then switched to oral (Grade 2D) Surgical management Laparoscopy may help severe disease by dividing adhesions and draining abscesses Ultrasound guided aspiration is less invasive and may be equally effective • Antimicrobial agents alone are effective in 70% • Candidates for antibiotic therapy alone (Grade 2C): – No signs of rupture/sepsis – Abscess <9cm in diameter – Adequate response to antibiotic therapy – Premenopausal • If no response after 48-72 hrs then drainage or surgery • Duration minimum of 2 weeks but may need 4-6 weeks – ‘most experts recommend continuation of antibiotic therapy until the abscess has resolved on follow up imaging’ • Drainage is essential if diameter of abscess is more than 3cm (Grade B) • Transvaginal drainage is preferred (Grade C) ICHNT Service • Large West London Service – Charing Cross Hospital – St Mary’s Hospital • >10 years service • 73514 bed days saved • 3031 patient episodes Our experience • OPAT database 2012 – 2018 • 28 patients episodes – 25 patients with three patients having 2 episodes 48% bilateral abscesses E coli Unknown Enterococcus spp. Strep milleri anaerobes Chlamydia Gonococcus Morganella spp. Candida spp. 0 2 4 6 8 10 12 14 Nil Radiological drainage 44% Laparotomy Patients had no surgical or radiological Laparoscopic procedure intervention 0 2 4 6 8 10 12 8/25 self administration 43% had oral follow on Combination therapy most common choice - Ciprofloxacin and co-amoxiclav OPAT Antibiotic Regime 18 16 14 12 10 8 6 4 2 0 Ceftriaxone Daptomycin Ertapenem Meropenem Duration of antibiotic therapy 49 days Median total antibiotic duration Including admission days, OPAT days and oral follow on Comparing patients with/without surgical or radiological intervention Patient episodes Patient episodes P value without with intervention intervention (n=15) (n=13) Age (years) 44 47 0.51 Mean abscess 7.6 9.2 0.17 size (cm)* Mean duration 28 27 0.91 OPAT abx (days) Mean duration 48 53 0.52 TOTAL abx (days) *3 patients did not have size of abscess recorded in notes 100% Long Term Cure (25 patients) Infection Outcome Number episodes OPAT Outcome Number episodes Cure 10 Failure 3 Fail 3 Partial 2 Improved 7 Success 15 Infection Outcome BSAC OPAT Outcome BSAC Failure 15% Improved Partial 35% 10% Cure 50% Success Fail 75% 15% What are the issues • No clear guidance on management of tubo-ovarian abscesses – ?size of abscess needing intervention – Duration of antibiotics – IV versus oral antibiotics • Needs an MDT approach to management – Gynae – Infection Specialists – Interventional radiologists – OPAT services How to improve your service • Clear local guidance for a management strategy/pathway • Dedicated interventional radiologist – First line trans-vaginal USS and will drain at the time if amenable – Will do follow up scans at regular intervals • Early involvement of Infection team +/- OPAT • Good engagement from an MDT Outpatient Parenteral Antimicrobial Therapy Clinical Nurses Pharmacists Doctors Team References • Workowski KA, Bolan GA. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep, 2015 vol. 64(RR-03)pp.1-137 • Beigi RH. Management and complications of tubo-ovarian abscesses. www.uptodate.com. • Brun JL et al. Updated French guidelines for diagnosis and management of pelvic inflammatory disease. Int J Gynaecol Obstet, 2016 vol. 134(2) pp.121-5 • Ross J et al. 2017 European guidelines for the management of pelvic inflammatory disease. In J STD AIDS 2018 Feb;29(2):108-114 • Ross J et al. 2018 United Kingdom National guideline for the management of pelvic inflammatory disease. BASHH..
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