Question 1

A 21 yo female presents with abdominal pain and fever. Exam notable for cervical motion tenderness and purulent vaginal discharge. She receives IM ceftriaxone and oral doxycycline. She returns 3 days later and has persistent symptoms. A CT shows a 4 cm complex multiloculated mass involving the ovaries and fallopian tubes. What is the best next step in management?

Answer Choices:

IM cefoxitin and oral probenecid

Add metronidazole to the current regimen

Admit to the hospital for IV antibiotics

Consult with IR for drainage of the mass

Proceed with laparoscopy

Correct Answer:

Admit to the hospital for IV antibiotics

Explanation:

  • PID treatment can be done outpatient or inpatient with no differences in outcomes. Admission should be considered in the presence of a tubo-ovarian abscess (TOA), pregnancy, severe illness, inability to tolerate an oral antibiotic regimen or lack of clinical response to antibiotics

  • This patient did not respond to outpatient treatment and developed a TOA

  • A ruptured TOA is a surgical emergency

  • Usually abscesses 4 cm or less in size respond to IV antibiotics. TOAs greater than 10 cm in size are less responsive to antibiotics.

  • Recommend admission for TOA with IV antibiotics (including anaerobic coverage- metronidazole)

  • If no improvement after 48 hours, may need further intervention like IR or surgical drainage.