Can antibiotic treatment failure in tubo-ovarian abscess be predictable?

Value of multi-parameter assessment in predicting antibiotic treatment failure and surgical intervention in pelvic abscess

OBJECTIVE

We aimed to develop a predictive model for the failure of antibiotic therapy in patients with pelvic abscesses and to determine the need for surgical intervention.

METHODS

We conducted a retrospective analysis of 368 female patients with pelvic abscesses in the Affiliated Hospital of Zunyi Medical University between 2014 and 2023. Participants were stratified into two distinct cohorts predicated on their therapeutic responses: those who achieved treatment success following medical intervention, while the second cohort included those who underwent surgical intervention subsequent to medical intervention failure.We evaluated demographic characteristics, clinical symptoms, laboratory findings, and imaging data. A multivariate analysis was performed on parameters including age, abscess dimensions, WBC, NLR, PLR, MLR, SII, and SIRI.

RESULTS

Among the 368 patients, 80 (80/368, 21.74%) were treated successfully with antibiotics, while 288 (288/368, 78.26%) needed surgery. The multivariate analysis revealed that age, abscess size, WBC, and PLR were significant predictors of the requirement for surgery following antibiotic failure. The combined model showed superior discriminative power (AUC 0.85) to any single parameter, though abscess size demonstrated the strongest univariate association (AUC 0.776). A column-line graph prediction model for predicting the failure of drug anti-infective therapy for patients with pelvic abscess was developed using R software based on the four independent predictors affecting the failure of drug therapy for pelvic abscess. This model had an AUC of 0.850 (95% CI: 0.801-0.899), a corresponding sensitivity of 0.76, and a specificity of 0.80.The calibration curve of the model basically coincides with the trend of the ideal curve, indicating that the prediction is in good agreement with the actual clinical observations and has good calibration.

CONCLUSION

Our findings present a novel predictive model that identifies key predictors of antibiotic failure in patients with pelvic abscesses. This model could facilitate the early identification of patients likely to fail antibiotic therapy, aiding in the timely adjustment of treatment strategies and potentially enhancing clinical efficacy.

The Tubo-ovarian abscess study (TOAST): A single-center retrospective review of predictors of failed medical management

OBJECTIVE

Tubo-ovarian abscesses (TOAs) cause significant morbidity. Surgical intervention is required if broad-spectrum intravenous antibiotics are unsuccessful. This study aimed to describe admission characteristics that predict failed medical management and to evaluate a previously developed risk score for predicting the need for surgical intervention in cases of TOA.

DESIGN

Single centre, retrospective cohort study.

SETTING AND PATIENTS

Patients admitted to a tertiary-level public teaching hospital with a radiologically or surgically proven TOA between January 1, 2012 and December 31, 2018.

MEASURES

Demographic and clinical details were obtained from electronic clinical records. Medical treatment was considered "failed" when surgical intervention was required beyond 24 h of antibiotics. Multivariable analyses using logistic regression was used to determine predictors of failed medical management. Risk scores were calculated as per Fouks et al. and a receiver operating characteristic curve was constructed to assess correlation with outcomes.

RESULTS

There were 425 patients and 522 admissions with TOA. In the first 24 h, 14% (72/522) of admissions were treated with a surgical intervention in addition to intravenous (IV) antibiotics, while 86% (450/522) were treated with IV antibiotics alone. In those treated with IV antibiotics alone, medical treatment was successful in 65% (293/450) of cases, with 35% (159/450) requiring additional surgical or radiological intervention prior to discharge. Variables independently associated with failed medical treatment were fever at admission (adjusted odds ratio [aOR] 1.72, 95% confidence interval [CI] 1.11-2.67), larger mean diameter of TOA (2% higher odds for every 1-mm increase in abscess size) and higher C-reactive protein value (1% higher odds for every unit increase) at admission. The area under the curve (95% CI) for Fouks et al. scoring system was 0.63 (0.58-0.68), indicating poor discriminatory ability.

CONCLUSIONS

A third of TOAs managed medically required surgical intervention. Fever, higher inflammatory markers, and larger mass were predictive of requiring surgery. However, a scoring system using these variables had poor discriminatory ability to predict treatment failure. Prospective studies are needed to determine whether earlier recourse to surgery can improve outcomes.

Determination of intraoperative complication rate and risk factors in patients undergoing surgery for tubo-ovarian abscess: A retrospective cohort study

This study aimed to assess intraoperative complication rates and risk factors in patients who underwent surgery for tubo-ovarian abscess. A retrospective review of the medical records of 170 patients who underwent tubo-ovarian abscess surgery between January 2014 and December 2023 was conducted. Four patients were excluded due to a histopathologic diagnosis of cancer, and 166 patients were included in the final analysis. Intraoperative complications were observed in 10 (6.0%) patients, including 8 (4.8%) and 2 (1.2%) patients with bowel and bladder injuries, respectively. The included patients were categorized into complication-positive (n = 10, 6.0%) and complication-negative (n = 156, 94.0%) groups, with between groups comparisons based on demographic, clinical, and surgical characteristics. The complication-positive group had significantly higher mean age and serum c-reactive protein (CRP) levels than the complication-negative group (46.6 ± 7.4 years vs 40.6 ± 8.5 years; P = .03, and 199.2 ± 89.4 mg/L vs 112.2 ± 84.2 mg/L; P ≤ .01, respectively). Extensive surgery, such as hysterectomy with bilateral adnexectomy, was more commonly performed in the complication-positive group than in the complication-negative group (8/10 [80.0%] vs 43/156 [27.5%], P < .01). Receiver operating characteristic curve analysis identified a serum CRP level of 186.5 mg/L as the optimal cutoff for predicting intraoperative complications. Binary logistic regression analysis showed that elevated serum CRP levels (≥186.5 mg/L) (odds ratio: 7.9; P < .01) and extensive surgery (odds ratio: 11.0, P = .01) were independently associated with intraoperative complications. Our findings indicate that elevated serum CRP levels and extensive surgery are associated with increased intraoperative complication risks, which may have important implications in clinical practice, potentially informing preoperative assessments, and surgical planning. This study was reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology statement.

Perioperative care of a patient with immune thrombocytopenia purpura undergoing tubo-ovarian abscess incision and drainage: Case report

Key Clinical Massage

Tubo-ovarian abscess (TOA) is a serious health hazard for women, causing severe sepsis. Antimicrobial treatment is effective, but one-third of patients experience unfavorable outcomes. ITP, an autoimmune condition, can lead to bruising and bleeding. Diagnosing TOA in women of childbearing age is crucial, and combining emergency surgery with ITP patients can increase treatment costs and reduce quality of life. ITP can lead to severe complications, including postoperative hemorrhage, and may require platelet transfusions, glucocorticosteroids, and immunoglobulin. These treatments increase costs, decrease quality of life, and impact prognosis. Preventing ITP is crucial. Patients should be administered blood products based on platelet count and anemia or spontaneous bleeding tendencies. Perioperative blood management should aim for a target platelet level of 30 × 109/L and a hemoglobin concentration of 80 g/L before surgery. Post-surgery, perioperative care is crucial and vigilant for secondary bleeding.

Abstract

A tubo-ovarian abscess (TOA) is a frequently encountered inflammatory mass in therapeutic settings. TOA is a serious consequence of pelvic inflammatory disease (PID) that can lead to severe sepsis. In recent years, the incidence of TOA has increased, presenting a significant health hazard for women. To effectively target the diverse range of bacteria responsible for TOA, it is essential to use antimicrobial medicines that have a wide spectrum of activity. Nevertheless, the efficacy of antibiotic treatment stands at approximately 70%, while a significant proportion of patients, around one-third, experience unfavorable clinical outcomes necessitating drainage or surgical intervention. Immune thrombocytopenia (ITP) is an autoimmune condition characterized by a marked decrease in the quantity of platelets present in the bloodstream. ITP is characterized by thrombocytopenia, which leads to a heightened susceptibility to bruising and bleeding. The diagnosis of ITP and the prediction of treatment response continue to pose important and persistent issues in the field of hematology. The platelet count is commonly employed as a surrogate indicator of disease severity in patients with ITP and thus plays a crucial role in determining the necessity of treatment. A 25-year-old woman with a history of sexual activity underwent open abdominal exploration due to the sudden onset of lower abdominal pain. During the operation, a left TOA was discovered, and an incision and drainage were performed. Symptomatic treatments, such as anti-infectives and abdominal drainage, were administered. The culture of pus in the abdominal cavity suggested the presence of Escherichia coli. However, the patient presented with ITP and had a platelet count of less than 50 × 109/L before the operation. After the operation, the patient developed incisional and pelvic hematomas with signs of infection. As a result, the patient was discharged from the hospital after undergoing another laparotomy and receiving platelet transfusions and immunotherapy. Clinicians should be vigilant when diagnosing TOA in women of childbearing age, even in the absence of high-risk factors. A timely antibiotic or surgical intervention is necessary to preserve fertility and ensure quality of life. Combining emergency surgery with ITP patients poses a significant challenge for clinicians in terms of treatment. ITP can lead to serious complications, such as postoperative bleeding, which may require platelet transfusions, glucocorticoids, and immunoglobulin. This can increase the cost of treatment, reduce the quality of life, and seriously affect the prognosis. Therefore, preventing ITP is crucial. It is important to pay attention to the perioperative care of patients after surgery and be alert to the possibility of secondary hemorrhage.

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.

The role of systemic immune inflammation index in predicting treatment success in tuboovarian abscesses

PURPOSE

The aim of this study was to determine the predictability of the systemic immune inflammation index (SII) on the response to medical treatment in tubo-ovarian abscess (TOA).

METHODS

296 patients with TOA in a tertiary center were enrolled in the study. Patients were divided into two groups: Group1 (n  =  165) included patients in whom medical treatment was successful, and Group2 (n  =  131) included patients in whom surgery was required. Demographic, sonographic and laboratory findings were compared between groups. SII was calculated using peripheral blood parameters [SII  =  (platelets ∗ neutrophils)/lymphocytes].

RESULTS

Age, BMI, gravida, parity, smoking and menopausal status, CRP levels of patients were similar in both groups (p  >  0.05). Mass size (4.398 ± 0.306 vs 7.683 ± 0.689, p  <  0.001), white blood cell (WBC) (8685.08 ± 3981.98 vs 9994.35 ± 4468.024, p = 0.008), Hb (12.18 ± 1.65 vs 11.68 ± 1.65, p = 0.010), platelet to lymphocyte ratio (PLR) (151.26 ± 74.83 vs 230.77 ± 140.25, p < 0.001), neutrophil to lymphocyte ratio (NLR) (4.21 ± 3.27 vs 6.07 ± 6.6, p  =  0.003), monocyte to lymphocyte ratio (MLR) (0.300 ± 0.177 vs 0.346 ± 0.203, p = 0.041) and SII (1014.18 ± 781.71 vs 2094.088 ± 2117.58, p < 0.001) were statistically higher in group 2. ROC Analysis was used to determine the predictability of the variables and PLR (AUC = 0.718, p  <  0.001), NLR (AUC = 0.593, p  =  0.593), MLR (AUC = 0.576, p  =  0.024), SII (AUC  =  0.723, p  <  0.001) and size of mass (AUC = 0.670, p  <  0.001) were found to be significant. The SII, size of mass and bilateral involvement of adnexa were found to be the strongest prognostic factors for surgical intervention (OR:1.004 (1.002-1.005), OR:1.018 (1.010-1.027), OR:3.397 (1.338-8.627); p  <  0.001, p  <  0.001, p  =  0.010 resspectively).

CONCLUSION

SII, size of mass and bilaterality can be used to predict medical treatment success in patients with TOA.

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.

Antibiotic Resistance and Mechanisms of Pathogenic Bacteria in Tubo-Ovarian Abscess

A tubo-ovarian abscess (TOA) is a common type of inflammatory lump in clinical practice. TOA is an important, life-threatening disease, and it has become more common in recent years, posing a major health risk to women. Broad-spectrum antimicrobial agents are necessary to cover the most likely pathogens because the pathogens that cause TOA are polymicrobial. However, the response rate of antibiotic treatment is about 70%, whereas one-third of patients have poor clinical consequences and they require drainage or surgery. Rising antimicrobial resistance serves as a significant reason for the unsatisfactory medical outcomes. It is important to study the antibiotic resistance mechanism of TOA pathogens in solving the problems of multi-drug resistant strains. This paper focuses on the most common pathogenic bacteria isolated from TOA specimens and discusses the emerging trends and epidemiology of resistant Escherichia coli, Bacteroides fragilis, and gram-positive anaerobic cocci. Besides that, new methods that aim to solve the antibiotic resistance of related pathogens are discussed, such as CRISPR, nanoparticles, bacteriophages, antimicrobial peptides, and pathogen-specific monoclonal antibodies. Through this review, we hope to reveal the current situation of antibiotic resistance of common TOA pathogens, relevant mechanisms, and possible antibacterial strategies, providing references for the clinical treatment of drug-resistant pathogens.

The role of systemic inflammatory markers in prediction of medical treatment failure in patients with tubo-ovarian abscess

Aim: Aimed to evaluate the role of systemic inflammatory markers and Aspartate aminotransferase to Platelet Ratio Index (APRI) sore in predicting medical treatment failure in patients with Tubo-ovarian abscess (TOA). Materials and Methods: Patients (n=240) hospitalized with a diagnosis of TOA between August 2016 - October 2020 were included in the study. Patients' demographic and clinical characteristics and mean C-Reactive protein (CRP) level, neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR) and APRI score measured on admission were also recorded. The role of these parameters was investigated in predicting medical treatment failure in patients who only received medical treatment or who needed surgical treatment. Results: The mean age (40.95 ± 6.96 vs. 38.09 ± 7.69), abscess size (67.57 ± 19.86 mm vs. 52.78 ± 16.63 mm), CRP level, (140.61 ± 110.88 vs. 75.24 ± 36.64 mg/L), white blood cell count (13818.86 ± 5445.80 and 11845.31 ± 4424.39 μL), neutrophil count (11146.81 ± 5284.83 and 9242.03 ± 4278.60 μL) and NLR (9.52 ± 6.88 and 6.64 ± 6.30) of patients who received surgical treatment were significantly higher than those who received only medical treatment. In receiver operating characteristics (ROC) analysis area under the curve (AUC) 0.607 was statistically significant for CRP with a cut-off value of 11.57 to predict medical treatment failure (95% 0.531-0.682, sensitivity 63.3%, specificity 55.4%). Conclusion: NLR, PLR and APRI score are ineffective in predicting the need for surgical treatment. CRP could be used as a marker in predicting the need for surgical treatment in patients with TOA.

Pelvic inflammatory disease in the adolescent and young adult: An update

Pelvic inflammatory disease (PID) is an infection of the female upper genital tract that is typically polymicrobial with classic core involvement of Neisseria gonorrhoeae and/or Chlamydia trachomatis, though other endogenous flora from the vagino-cervical areas can be involved as well. It is often a sexually transmitted disease but other etiologic routes are also noted. A variety of risk factors have been identified including adolescence, young adulthood, adolescent cervical ectropion, multiple sexual partners, immature immune system, history of previous PID, risky contraceptive practices and others. An early diagnosis and prompt treatment are necessary to reduce risks of PID complications such as chronic pelvic pain, ectopic pregnancy and infertility. Current management principles of PID are also reviewed. It is important for clinicians to screen sexually active females for common sexually transmitted infections such as Chlamydia trachomatis and provide safer sex education to their adolescent and young adult patients. Clinicians should provide comprehensive management to persons with PID and utilize established guidelines such as those from the US Centers for Disease Control and Prevention (CDC).

Minimally invasive approach to the management of tubo-ovarian abscesses

PURPOSE OF REVIEW

The purpose of this publication is to review the most up-to-date literature regarding the pathogenesis, diagnosis and management of tubo-ovarian abscesses.

RECENT FINDINGS

Prior to the advent of broad-spectrum antibiotics, tubo-ovarian abscesses necessitated total abdominal hysterectomy and bilateral salpingo-oophorectomy. Although it carries a risk of treatment failure, antibiotic therapy enabled fertility-sparing treatment for many women. Recent studies have identified key predictors for antibiotic treatment failure, including age, BMI and abscess diameter. C-reactive protein was also found to be a strong predictor of antibiotic treatment response. Given the growing evidence of treatment failure with antibiotic therapy alone, along with increased availability and access to interventional radiology, image-guided drainage with or without catheter placement, combined with broad-spectrum antibiotics, is now considered first-line therapy.

SUMMARY

Tubo-ovarian abscess is a diagnostic challenge, as presentation can vary. Inadequate treatment is associated with severe morbidity and mortality. Despite adequate conservative treatment, recurrence risk is high and clinical sequelae can have devastating effects on reproductive health. Recent evidence-based developments, including a risk score system to predict antibiotic failure, serve to provide appropriately directed risk-based care. However, large-scale randomized controlled trials are needed to clarify the most appropriate treatment modalities.