Diagnosis and management of tubo-ovarian abscesses

Risk factors for antibiotic therapy failure in women with tubo-ovarian abscess: A systematic review and meta-analysis

AIM

Medical therapy with antibiotics only and surgical drainage are the treatment options of tubo-ovarian abscess (TOA). It is not yet known exactly which cases need surgical treatment. The aim of this systematic review and meta-analysis was to evaluate the risk factors leading antibiotic therapy failure in women with TOA.

METHODS

We searched the following databases from inception to June 1, 2022: PubMed, Ovid MEDLINE, The Cochrane Library, and Scopus. We also searched reference lists of eligible articles and related review articles. The observational cohort, cross-sectional, and case-control studies were included in the meta-analysis. At least four review authors independently selected eligible articles, assessed risk of bias, and extracted data. The random effect model was used in the meta-analysis.

RESULTS

A total of 29 studies, including 2890 women, were included in the study. The age, abscess size, history of intrauterine device use, postmenopausal status, history of diabetes mellitus, fever, white blood cell count, erythrocyte sedimentation rate, C-reactive protein level, and history of pelvic inflammatory disease were found as significant risk factors for antibiotic therapy failure in women with TOA.

CONCLUSIONS

The findings of this study clarified the risk factors for antibiotic therapy failure in women with TOA.

Bilateral or unilateral tubo-ovarian abscess: exploring its clinical significance

OBJECTIVES

To assess the characteristics of patients with unilateral and bilateral tubo-ovarian abscess (TOA).

METHODS

Women diagnosed with TOA during 2003-2017 were included in this retrospective cohort study. TOA was diagnosed using sonography or computerized tomography and clinical criteria, or by surgical diagnosis. Demographics, sonographic data, clinical treatment, surgical treatment, and post-operative information were retrieved.

RESULTS

The study cohort included 144 women who met the inclusion criteria, of whom 78 (54.2%) had unilateral TOA and 66 (45.8%) had bilateral TOA. Baseline characteristics were not different between the groups. There was a statistical trend that women with fewer events of previous PID were less likely to have with bilateral TOA (75.3% vs. 64.1%, respectively; p = 0.074). Women diagnosed with bilateral TOA were more likely to undergo surgical treratment for bilateral salpingo-oophorectomy compared to unilateral TOA (61.5% vs. 42.3%, respectively; p = 0.04). There was no difference in maximum TOA size between groups.

CONCLUSIONS

This study detected a trend toward increased need for surgical treatment in women diagnosed with bilateral TOA. These findings may contribute to determining the optimal medical or surgical treatment, potentially leading to a decrease in the duration of hospitalization, antibiotic exposure, and resistance. However, it is important to acknowledge that the results of the current study are limited, and further research is warranted to validate these potential outcomes.

Image-guided drainage management of tubo-ovarian abscess and the role of C-reactive protein measurements in monitoring treatment response: a single-center experience

PURPOSE

We aimed to compare the results of image-guided drainage in addition to antibiotic therapy (antibiotherapy) with antibiotherapy alone in the treatment of tubo-ovarian abscesses (TOAs) and evaluate C-reactive protein (CRP) levels in predicting the success of antibiotherapy.

METHODS

This was a retrospective study of 194 patients hospitalized with TOA. Patients were divided into the following two groups: those who underwent image-guided drainage in addition to parenteral antibiotherapy and those who did not undergo image-guided drainage and received antibiotherapy alone. CRP levels on the day of admission (day 0), day 4 of hospitalization (day 4), and day of discharge (last day) were recorded. The percentage of decrease in CRP levels during day 4 and the last day compared with that on day 0 was calculated.

RESULTS

A total of 106 patients (54.6%) underwent image-guided drainage with antibiotherapy, whereas 88 patients (45.4%) did not undergo drainage and received antibiotherapy alone. At admission, the mean CRP level was 203.4 (± 96.7) mg/L and was similar in both groups. The mean decrease in the CRP level on day 4 compared with that on day 0 was 48.5% and was statistically higher in the group that underwent image-guided drainage. Antibiotherapy failed in 18 patients, and a statistically significant difference was observed between treatment failure and the rate of decrease in the CRP level on day 4 compared with that on day 0. According to the receiver operating characteristic (ROC) analysis, if the CRP level measured on day 4 decreased by < 37.1% compared with that on day 0, the probability of treatment failure would increase (area under the curve = 0.755; 95% confidence interval, 0.668-0.841; sensitivity, 73.6%; specificity, 60%).

CONCLUSIONS

Image-guided drainage combined with antibiotherapy in the treatment of TOA has high success rates, lower recurrence rates, and lower surgical requirement, and the mean decrease in the CRP level on day 4 can be monitored at treatment follow-up. In patients receiving antibiotherapy alone, if the CRP level on day 4 decreases by < 37.1%, the treatment protocol should be changed.

Cecal Perforation Secondary to Large Bowel Obstruction From a Tubo-Ovarian Abscess

With the continued specialization of medicine, we as physicians often fall into the trap of placing pathologies into silos, focusing on what we are most practiced in caring for. When managing acute patients, it is important that we consider complications that can arise across systems and specialties which could place our patients at increased risk for morbidity and mortality. Tubo-ovarian abscesses (TOAs) are complex infections often arising in the setting of pelvic inflammatory disease. The resultant reactive inflammation is frequently the culprit of potentially fatal sequelae. This article looks to highlight a case of TOA that resulted in inflammation and obstruction of the adjacent large bowel which subsequently led to large bowel obstructions (LBOs) and perforation. Although LBO management is well described in the literature, perforation secondary to inflammatory compression from a TOA is rarely documented.

We present the case of a middle-aged female with significant comorbid conditions and recent prolonged retention of a tampon which likely acted as the nidus for the infection that led to her presenting pathology and need for admission, a left-sided TOA measuring 8.1 × 4.7 × 3.4 cm. Consultation by obstetrics-gynecology and interventional radiology determined that admission for observation and intravenous antibiotics alone was appropriate. The patient’s hospital course was complicated by enlarging TOA with peri-colonic abscess and acute decompensation in the setting of LBO and cecal perforation. Emergency laparotomy and right hemicolectomy by the acute care surgical team were performed. Postoperative management was complicated by septic shock which prolonged her hospital stay. Following inpatient optimization of nutrition and management of comorbid conditions, the patient was able to make a full recovery.

In patients with suspected TOA, special consideration should be given to surrounding structures, and potentially fatal complications should be kept in the forefront of the primary team’s minds. This case report aims to urge physicians caring for patients with TOA to maintain a high level of suspicion and consider how the benefits of aggressive management may outweigh those of conservative options.

Identification and Treatment of Acute Pelvic Inflammatory Disease and Associated Sequelae

Pelvic inflammatory disease (PID) is an ascending polymicrobial infection of the upper female genital tract. The presentation of PID varies from asymptomatic cases to severe sepsis. The diagnosis of PID is often one of exclusion. Primary treatment for PID includes broad-spectrum antibiotics with coverage against gonorrhea, chlamydia, and common anaerobic and aerobic bacteria. If not clinically improved by antibiotics, percutaneous drain placement can promote efficient source control, as is often the case with large tubo-ovarian abscesses. Ultimately, even with treatment, PID can result in long-term morbidity, including chronic pelvic pain, infertility, and ectopic pregnancy.

Tubo-ovarian abscess: A proposed new scoring system to guide clinical management

OBJECTIVE

To create a risk scoring system comprised of clinical and radiological characteristics that can predict the likelihood of antibiotic treatment failure of tubo-ovarian abscesses. The score should guide clinicians in identifying patients to whom early intervention should be offered instead of a prolonged trial of antibiotics.

METHODS

A multicenter, retrospective cohort study carried out between January 1, 2013 and September 30, 2019, identified consecutive patients with tubo-ovarian abscess. Using a chronological split, patients were allocated to two groups for the development and subsequent validation of the postulated scoring system. Univariate and bivariate analyses were performed to identify statistically significant variables for the failure of intravenous antibiotic treatment.

RESULTS

In total, 214 consecutive patients with tubo-ovarian abscesses were identified. Data from the first 150 patients were used for the development of the postulated scoring system; data from the subsequent 64 patients were used for validation. Statistically significant clinical features between those having successful and unsuccessful management were: temperature (median = 37.1℃ vs 38.2℃, P = 0.0001), C-reactive protein (151 mg/L vs 243 mg/L, P = 0.0001), and tubo-ovarian abscess diameter (6.0 cm vs 8.0 cm, P = 0.0001). These parameters were used to create a risk prediction score. A score of four or more was predictive of requiring surgical/radiological intervention of tubo-ovarian abscess (P < 0.001). The score had a sensitivity of 69% and a specificity of 88%, with area under the curve (AUC) = 0.859.

CONCLUSION

Currently, there is no guidance for clinicians on when to operate on a tubo-ovarian abscess. Our prediction score is simple, using only three easily obtained clinical characteristics.

The Combination of Clindamycin and Gentamicin Is Adequate for Pelvic Inflammatory Disease: A Retrospective Cohort Study

Pelvic inflammatory disease (PID) affects 4.4% of women aged 18-44 in the United States, and may cause infertility if it is ineffectively treated. A combination of clindamycin and gentamicin is generally used for the treatment of PID. The benefit of adding metronidazole into the treatment combination still remains unclear, and this study was designed to evaluate its effectiveness. We retrospectively included 107 women who were diagnosed with PID from May 2013 to September 2020 in a single hospital. Based on their used antibiotic regimens, the patients were divided into three groups-those who were treated with clindamycin + gentamicin (group 1, n = 46), those who took regular antibiotics plus metronidazole (group 2, n = 27), and others (group 3, n = 34). Primary outcomes included the rates of taking surgery after failed antibiotics, occurrence/rupture of tubo-ovarian abscesses, and readmission within the following 6 months of first treatment. Secondary outcomes to assess were the length of stay (LOS) and expenditure for PID. There were no significant differences in the surgical rates, readmission rates, LOS and expenditure noted between the three groups. Subgroup analysis showed that visual analogue pain scores being 5 or more would increase the LOS by 3.83 days (p < 0.001), and body temperature > 38.3 °C or more would increase the treatment total expenditure (p < 0.001). Our study results suggest that the combination of clindamycin + gentamicin is a convincible treatment protocol for PID.

Perioperative Complications of Laparoscopic versus Open Surgery for Pelvic Inflammatory Disease

STUDY OBJECTIVE

To compare complications in patients undergoing laparoscopic vs open surgery for acute pelvic inflammatory disease (PID).

DESIGN

We performed a retrospective cohort study of patients who underwent surgery for PID, using the American College of Surgeons National Surgical Quality Improvement Program database from 2010 to 2015. Propensity score matching was used to balance baseline characteristics and compare complications in patients who underwent laparoscopic vs open surgery.

SETTING

Surgical management of acute PID.

PATIENTS

Patients with a preoperative diagnosis of PID were identified using International Classification of Diseases, Ninth Revision, codes. We excluded patients with chronic PID, gynecologic malignancy, and those for whom the surgical route was unknown.

INTERVENTIONS

Surgery for acute PID.

MEASUREMENTS AND MAIN RESULTS

The study included 367 patients. The mean age was 43.0 ± 11.1 years, body mass index was 30.9 ± 11.2 kg/m², and American Society of Anesthesiology class was 2 (interquartile range 2-3). Preoperative signs of sepsis were noted in 33.8% of the patients, and septic shock was present in 1.4%. Hysterectomy was performed in 67.6%, oophorectomy in 12.0%, and salpingectomy in 4.6%. Complications were experienced by 114 patients (31.1%), 11 (3.0%) of which were potentially life-threatening. Multivariate logistic regression identified the following to be independently associated with complications: laparoscopy (adjusted odds ratio [aOR] 0.48; 95% confidence interval [CI], 0.3-0.8; p <.01), operative time (aOR 1.01; 95% CI, 1.00-1.01; p <.01), appendectomy (aOR 2.36; 95% CI, 1.0-5.4; p = .04), elevated international normalized ratio (aOR 2.30; 95% CI, 1.3-4.2; p <.01), and low hematocrit level (aOR 2.53; 95% CI, 1.4-4.5; p <.01). Propensity scores were calculated and used to generate a matched cohort of patients who underwent laparoscopic vs open surgery; the groups were similar, with p <.05 for all covariates. After balancing confounding variables, a laparoscopic approach to surgery remained significantly associated with a lower risk of complications (coefficient -0.07; 95% CI, -0.11 to -0.02; p = .008).

CONCLUSION

Laparoscopy was associated with lower complication rates than open surgery in this well-matched cohort of patients who underwent surgery for acute PID.

Hydronephrosis Due to Bilateral Tubo-ovarian Abscess

A 27-year-old female presented to the emergency department with fevers, nausea, chills, and non-specific bilateral lower quadrant abdominal pain. A pregnancy test was negative. Computed tomography demonstrated moderate left hydronephrosis secondary to tubo-ovarian abscess (TOA). The abscess was so large it distorted local anatomy and compressed the ureters. She was prescribed merepenem and admitted for care by obstetrics/gynecology.