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Factors associated with failed medical management of tubo-ovarian abscesses include fever at admission, high inflammatory markers, and larger abscess diameter.

Tubo-ovarian abscesses (TOAs) are associated with considerable morbidity. Broad-spectrum IV antibiotics are the first-line management for these inflammatory masses. However, if antibiotic treatment is unsuccessful, surgical intervention is necessary.

“As antibiotics alone are often unsuccessful at treating TOAs, being able to predict who is most likely to benefit from additional therapies would be useful for triaging care,” Anna Marshall and colleagues wrote in the International Journal of Gynecology & Obstetrics.

They conducted a single-center, retrospective cohort study to determine the clinical characteristics associated with treatment failure in patients admitted to a tertiary-level teaching hospital with a radiologically or surgically proven TOA. Failed medical treatment was defined as surgical intervention required beyond 24 hours of antibiotics. Multivariable analyses using logistic regression determined predictors of failed medical management. Risk scores for predicting the failure of conservative treatment were calculated using the score system developed by Fouks et al.

The researchers identified 522 admissions with TOA for 425 patients between January 1, 2012, and December 31, 2018. Of the cohort, 84% of patients had one admission, 10% had two admissions, 4% had three admissions, 1% had four admissions, and less than 1% were admitted five times with new, recurrent, or persistent TOA. The majority (96.4%) had a diagnosis of TOA based on radiological findings, and most of those diagnosed by surgery were in the early intervention group (89.5%).

Use of Surgery & Other Interventions

In the first 24 hours, 14% of admissions were treated with a surgical intervention in addition to IV antibiotics, while 86% were treated with only IV antibiotics. Medical treatment was successful in 65.1% of patients treated with IV antibiotic monotherapy, with 35% requiring additional surgical or radiological intervention prior to discharge.

Among variables independently associated with failed medical treatment, they found that fever at admission (adjusted OR, 1.72; 95% CI, 1.11-2-67), higher inflammatory markers (C-reactive protein, 1% higher odds for every unit increase), and larger mean diameter of TOA (2% higher odds for every 1-mm increase in abscess size) were predictive of requiring surgery. However, the Fouks et al prediction model using these variables indicated poor discriminatory ability (area under the curve, 0.63; 95% CI, 0.58-0.68).

“Prospective studies are needed to determine whether earlier recourse to surgery can improve outcomes,” concluded the investigators. “Long-term follow-up should also be looked at, to support both short- and long-term benefits from intervention.”