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Tubo-ovarianabscessinOPAT
JamesHatcher
ConsultantinInfectiousDiseasesandMedicalMicrobiology
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OUTLINE
• Whatisatubo-ovarianabscess
• Currentrecommendations
• Ourexperienceandchallenges
• Howtoimproveservice
ImagesfromCDCPublicHealthImageLibrary
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Pelvicinflammatorydisease• Pelvicinflammatorydiseaseistheoveralltermforinfection
ascendingfromtheendocervix• NeisseriagonorrhoeaeandChlamydiatrachomatishavebeen
identifiedascausativeagents• IUDincreasesriskofPIDbutonlyfor4-6weekspostinsertion
• Symptoms– Lowerabdopain,discharge,dyspareunia,abnormalvaginalbleeding
• Signs– Bilaterallowerabdotenderness,fever– Adnexaltendernessonbimanualvaginalexamination
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Cervicitis
Endometritis
SalpingitisOophoritisTubo-ovarianabscess
PeritonitisSepsis
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2018UnitedKingdomNationalGuidelinefortheManagementofPelvicInflammatoryDisease
‘Admissionforparenteraltherapy,observation,furtherinvestigationand/orpossiblesurgicalinterventionshouldbeconsideredinthefollowingsituations(Grade1D)• Lackofresponsetooraltherapy• Clinicallyseveredisease• Presenceofatubo-ovarianabscess• Intolerancetooraltherapy’
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InpatientregimensIVceftriaxone2gODPLUSdoxycycline100mgBDPLUSmetronidazole400mgBDfor14days(Grade1A)IVtherapyshouldbecontinueduntil24hoursafterclinicalimprovementthenswitchedtooral(Grade2D)SurgicalmanagementLaparoscopymayhelpseverediseasebydividingadhesionsanddrainingabscessesUltrasoundguidedaspirationislessinvasiveandmaybeequallyeffective
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• Antimicrobialagentsaloneareeffectivein70%• Candidatesforantibiotictherapyalone(Grade2C):– Nosignsofrupture/sepsis– Abscess<9cmindiameter– Adequateresponsetoantibiotictherapy– Premenopausal
• Ifnoresponseafter48-72hrsthendrainageorsurgery
• Durationminimumof2weeksbutmayneed4-6weeks– ‘mostexpertsrecommendcontinuationofantibiotictherapyuntilthe
abscesshasresolvedonfollowupimaging’
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• Drainageisessentialifdiameterofabscessismorethan3cm(GradeB)
• Transvaginaldrainageispreferred(GradeC)
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ICHNTService
• LargeWestLondonService– CharingCrossHospital– StMary’sHospital
• >10yearsservice
• 73514beddayssaved• 3031patientepisodes
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Ourexperience
• OPATdatabase2012–2017• 19patientsepisodes– 18patientswithonepatienthaving2episodes
50%bilateralabscesses
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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
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0
2
4
6
8
10
12
14
Ceftriaxone Daptomycin Ertapenem Meropenem
OPATAntibioticRegime
47%hadoralfollowonCiprofloxacinandco-amoxiclavmostcommonchoice
4/18selfadministration
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Durationofantibiotictherapy
53daysMediantotalantibioticdurationIncludingadmissiondays,OPAT
daysandoralfollowon
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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
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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)
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Whataretheissues• Noclearguidanceonmanagementoftubo-ovarianabscesses– ?sizeofabscessneedingintervention– Durationofantibiotics– IVversusoralantibiotics
• NeedsanMDTapproachtomanagement– Gynae– InfectionSpecialists– Interventionalradiologists– OPATservices
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Howtoimproveourservice
• Clearlocalguidanceforamanagementstrategy/pathway
• Dedicatedinterventionalradiologist– Firstlinetrans-vaginalUSSandwilldrainatthetimeifamenable
– Willdofollowupscansatregularintervals
• EarlyinvolvementofInfectionteam+/-OPAT• GoodengagementfromanMDT
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OutpatientParenteralAntimicrobialTherapy
Nurses Pharmacists DoctorsClinicalTeam
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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.