Pelvic Abscess


Article Author:
Khalida Khaliq
Noor Nama
Heba Mahdy


Article Editor:
Abdul Waheed


Editors In Chief:
Kranthi Sitammagari
Mayank Singhal


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
8/5/2019 10:08:45 AM

Introduction

A pelvic abscess is a life-threatening collection of infected fluid in the pouch of Douglas, fallopian tube, ovary, or parametric tissue.[1] Usually, a pelvic abscess occurs as a complication after operative procedures. It starts as pelvic cellulitis or hematoma spreads to parametrial tissue.[2] It can also present as a result of the complexity of certain medical conditions like sexually transmitted disease, pelvic inflammatory disease, appendicitis, diverticulitis, inflammatory bowel disease[3]. Also, patients with pelvic abscess present with high-grade fever, leukocytosis, palpable pelvic mass, vaginal bleeding or discharge, and lower abdominal pain often associated with elevated sedimentation rate or C-reactive protein.[4] Pelvic abscess responds well to adequate antibiotic treatment and hydration.[5] Due to its variable presentation, it requires early recognition, diagnosis, immediate hospitalization, and treatment regardless of the size of the abscess.[3] The current activity aims to explain the pathophysiology of pelvic abscess, elaborates the importance of imaging techniques in diagnosing a pelvic abscess, and also illustrates the necessary information that leads to the identification of high-risk patients requiring immediate surgical intervention.

Etiology

The pelvic abscess is a frequent complication of an infection of the lower genital tract, including pelvic inflammatory disease. Other causes subsumed in the etiology of pelvic abscess are operative procedures like hysterectomy, laparotomies, caesarian sections, and induced abortion. Cancers of pelvic organs, trauma to the genital tract, Crohn disease complications, and diverticulitis are other significant causes.[6] In Crohn disease, the pelvic abscess may occur spontaneously and secondary to the surgery.[7] In females, it usually lies between the uterus, posterior fornix, and the rectum which sometimes drains automatically into the rectum.

The risk factor for the pelvic abscess is the same as of pelvic inflammatory disease like multiple sexual partners, sexually transmitted disease intrauterine device diabetes, low immune system.  Other recognizable risk factors that have studied in developing post-surgical abscess classify as preoperative, intraoperative, and postoperative causes.

The preoperative risk factors involved in pelvic abscess formation are untreated pelvic inflammatory disease, hydrosalpinx, endometrioma, uncontrolled blood sugar with HbA1c greater than 6.5, renal comorbidities, obesity with BMI over 30, congenital anomalies of the genital tract. Asymptomatic bacterial vaginosis is also a known documented risk factor for postsurgical vaginal cuff cellulitis and abscess formation.[8]

The perioperative risk factors include intraoperative blood loss of over 500ml, prolonged surgical procedure exceeding 140 minutes, patients undergoing extensive surgeries like para-aortic lymphadenectomy, pelvic lymphadenectomy, pelvic exenteration for pelvic malignancies.

The postoperative risk factors include uncontrolled blood sugar over 200 mg in the first 48 hours, and prolonged preoperative hospital stay also increases the incidences of surgical site infections and pelvic abscess formation. Postoperative hematoma is also one of the critical causes of pelvic abscess.

Epidemiology

In reproductive age women, pelvic abscess most frequently present as the progression of the end-stage of pelvic inflammatory disease, involving Fallopian tube, ovary, and adjacent pelvic organs.[5][9] One-third of the women who have hospitalized with pelvic inflammatory disease found to have a tubo-ovarian abscess. Notice that all the cases of abscess are not associated with the pelvic inflammatory disease. The incidence of the pelvic abscess is less than 1% in a patient undergoing obstetric and gynecological surgeries.

Pathophysiology

The pelvic abscess is a circumscribed collection of infected exudate. It formed by liquefaction necrosis. It develops as a result of an imbalance between host defense mechanism and insufficient antibiotic coverage in the setting of bacterial inoculum of high virulence. The necrotic tissues are built up around the infective exudate which formed a thick fibrous wall. If the pus does not drain, it will localize the microbes as well as toxins which could be detrimental to the host and make it more difficult for antimicrobial agents to penetrate the fibrous inflammatory capsule and act on it. The enzymatic degradation of immunoglobulins and local release of complements occurs, which results in persistent pus formation.

In young women, pelvic abscess occurs as one of the complications of pelvic inflammatory disease. It starts as an ascending infection from the vagina, cervix and spreads to the uterus, fallopian tube, ovary, and peritoneum.  It causes the endothelial damage and edema of the fallopian tube and consequently leads to tubal blockage. Notably, it generally occurs in the follicular phase of the menstrual cycle. Likewise, high estrogen and cervical ectopy help in the linkage of Neisseria Gonorrhea and chlamydia to the genital tract, which is one of the most common causes of Pelvic inflammatory disease and its complication.

In postoperative patients, the theory is that blood loss, serous fluid, lymphatic debris, necrotic tissue, and fibrillar hemostats cumulates in the lower pelvic area and vaginal vault and results in the formation of a simple collection of fluid. The fluid accumulation eventually becomes infected via skin contamination and vaginal opening and results in pelvic abscess formation. The pathogenic organism ascends from the vagina, endocervix and via skin to the surgical site, including vaginal vault and abdominal incision.

Compound and dynamic mixture of pathogenic and nonpathogenic bacteria ascend from the vagina comprises anaerobic facultative gram-negative and gram-positive bacteria. As a result of an imbalance of the pathogenic and nonpathogenic bacteria, the sterile tissue gets infected and evolves in a pelvic abscess. Infection is usually polymicrobial with the predominance of anaerobic bacteria. The bacteria involved are Escherichia coli, Bacteroides fragilis, Bacteroides, Peptostreptococcus,  aerobic Streptococcus, and Peptococcus.[10]

History and Physical

The clinical presentation of the pelvic abscess is highly variable. Patients may present with a high-grade fever, general malaise, nausea, vomiting, tachycardia, lower abdominal pain, vaginal discharge, vaginal bleeding, retention of urine, and change in bowel habit. Leukocytosis with a left shift along with elevated erythrocyte sedimentation rate and high C-reactive protein is present in blood workup.[4] Ectopic pregnancy should always be ruled out on a urine pregnancy test. A diagnosis is conventionally made based on the presence of fever and palpable mass or fullness. In 1983 a study conducted by Landers and Sweet demonstrated that 35% of women with abscess present afebrile, while 23% had normal leucocyte count. In the same study, they reported that 50% of the patients with tubo-ovarian abscess present with fever, 28% with nausea, and 21% with vaginal bleeding.[10]

The complete physical exam includes a thorough abdominal, vaginal, and rectal examination. Superficial or deep abdominal tenderness on abdominal palpation may be indicative of peritonitis. The comprehensive vaginal examination consists of the bimanual and speculum exam. The bimanual vaginal exam should assess the size of the uterus, mobility, consistency, and adnexa. Usually, the cervical motion tender is present, the uterus is tender, boggy, and most likely pushed anteriorly.[9] An abscess can be unilocular or multilocular. It can be palpable as a well-defined fluctuant mass, and it can also be less distinct and presents as a fullness on the bimanual vaginal exam. On the rectal exam, tenderness and bulging of the anterior rectal wall may be present.

Evaluation

Different imaging techniques are the most effective way to determine the size and location of an abscess. Pelvic ultrasound is the first method of choice to evaluate a pelvic mass in the women of reproductive age group. It can help in differentiating between the fluid-filled lesion and solid lesion. It is a relatively easy and inexpensive method of imaging with no ionizing radiation. On ultrasound, an abscess appears a collection of pus with different sizes of delicate internal echoes. Transvaginal ultrasound is always superior to transabdominal ultrasound.[11] Multilocular abscess on imaging is likely represents as a multiple inflamed tissue adherent to each other along with a small collection of pus, mostly seen in a tubo-ovarian abscess. Unilocular abscess probably appears as an actual localized mass on imaging.

Ultrasound is still the safe and first method of choice in women of reproductive age group and tubo-ovarian abscess. In a study conducted by Hiller et al. demonstrates that the majority of cases are multilocular 85%, and 73% had internal fluid echos, 95% has thick enhancing uniform abscess wall. Other common findings demonstrated were mesosalpinx 91%, and infiltration into fat. Less common finding on CT was bowel thickening and infiltrated of the uterosacral ligament.[12]

Other radiological techniques used in diagnosis include computed tomography and magnetic resonance. Computed tomography (CT) and magnetic resonance imaging (MRI) are cross-sectional imaging methods often used in the postoperative patient with suspected abscess. In postoperative patients, the ultrasound is less likely to locate the pelvic abscess because of the collection of postoperative air, open surgical wounds, and abundant gas [13]. CT scan with oral and intravenous (IV) contrast enhances the diagnostic accuracy. Oral contrast opacify the bowel loop while the use of IV contrast enhances the vascularity of the mass and opacify the urinary tract in the contrast CT scan. The pelvic abscess exhibits as a hypodense collection with peripheral round or oval intensification on CT scan. CT scan has slightly better sensitivity and specificity than ultrasound.  In the review of a few studies in the past, it has demonstrated that sensitivity to detect abscess was 78 to 100 % as compared to ultrasound has the sensitivity of 75 to 82% and CT scan with the specificity of 100 vs. 92 % for an ultrasound.[14][15][16] Furthermore, the MRI is usually recommended to clarify or supplement ultrasound findings as it does not determine the origin of the mass and the extent of the disease. It does not provide any additional information.[17]

Moreover, other investigations include complete blood count, blood culture, exudate culture and sensitivity, wet mount test of vaginal discharge, and a urine pregnancy test to rule out an intrauterine and ectopic pregnancy.

Treatment / Management

All the patients with suspicious of pelvic abscess and diagnosis should be admitted to the hospital regardless of the size of the pelvic abscess. All patients should be monitored closely for sepsis and rupture. The initial approach to the treatment is Broad-spectrum antibiotics. A multilocular abscess usually represents tubo-ovarian abscess and substantially respond well to Antibiotic treatment alone.

CONSERVATIVE MANAGEMENT

The ideal candidates for conservative management alone are women with no sign of sepsis and rupture, hemodynamically stable and, pelvic abscess greater than 8 cm on imaging. In a study by Granberg et al. in 2009 stated that 25% of the patient fails to respond to conservative treatment.[5] A localized unilocular abscess more likely referred to postsurgical complications and generally requires surgical drainage.

Once diagnosed, a combination of parental antibiotic should be started to treat the mixed aerobic and anaerobic microbes. The gold standard antibiotics regimen is the combination of clindamycin or metronidazole with an aminoglycoside, penicillin, or third-generation cephalosporins. Aztreonam is a substitute for aminoglycoside in patients with renal impairment. Other antibiotics with high therapeutic efficacy which may be options as a single agent include extended-spectrum antibiotics (cefoxitin, cefotetan, cefotaxime, ceftizoxime), beta-lactamase inhibitors (ticarcillin-clavulanate and carbapenems, meropenem, ertapenem,)extended-spectrum penicillin (piperacillin-tazobactam).[4][18][19] Parental antibiotics should continue for 24 to 48 hours after the patient becomes afebrile and subsequently be switch to oral antibiotics. Vaginal cuff abscess is a likely complication of a post-hysterectomy infection that satisfactorily responds to dilatation and drainage of the vaginal cuff.

SURGICAL MANAGEMENT AND DRAINAGE OF THE PELVIC ABSCESS

Recent evidence suggests that it is acceptable and beneficial for the patient to perform primary surgical drainage along with appropriate antibiotic coverage. It decreases the length of stay of hospitalization and improves the fertility outcomes. In a study by Perez and medina reported that surgical drainage is needed if the size of the abscess is over 8 cm or failure to respond to adequate antibiotic treatment in 2 to 3 days.[20] The criteria for failure of treatment include; increase in leucocyte count, tense and tender abdomen, despite the antibiotic therapy there is no reduction in the size of the abscess, new onset of fever and increase in the size of the abscess.

Different techniques are available for surgical drainage of the pelvic abscess, but in the past, the preferred approach was laparotomy. Many gynecologists still prefer this surgical route for the removal and the drainage of the surgical abscess. Most of the gynecologist employs vertical incision in need for the proper visualization of abdomen and pelvis. Following steps should be done in the removal and surgical drainage of the abscess

Always confirms the diagnosis first with the appropriate backup.

Cultures are obtained upon entering into the peritoneal cavity and abscess itself.

Surgically remove the abscess as much as possible if the abscess is in the ovary, an adnexectomy is likely necessary.

Always irrigate the peritoneal cavity with normal saline to lessen the burden of infection.

All the tissues removed sent for culture and histopathology.

Leave in the closed suction drain until the output from the drain is minimal, and the patient improves clinically.

Now the laparoscopic approach is being used for the drainage. The laparoscopic approach is being used more successfully in a patient with no exhibition of the rupture of an abscess. The choice between laparotomy and laparoscopy depends upon the determination and skill of the surgeon.  However, the CT, MRI, or U/S guided drainage with antibiotics is the procedure of choice and has a success rate of 80 to 90%.[21][22] In a study conducted by Perez and medina, states that these techniques have several advantages over laparoscopy, it requires no anesthesia, less morbidity, decreases the length of stay in hospital.[23][24] CT guided transgluteal percutaneous drainage is a safe procedure, especially for deep abscess of postsurgical type. It is a successful procedure where the anterior approach to the pus collection is not feasible.[25] Endoscopic ultrasound (ESU)-guided drainage is another safe and effective method of draining in the pelvic abscess, which is not manageable to percutaneous drainage.[6][26] Some of the recent studies have shown the effectiveness and safe use of intracavitary tissue plasminogen activator (tPA) for refractory and complicated abscess.[27][28] Rupture of the pelvic abscess is always a life-threatening emergency in such patients immediate fluid resuscitation, and surgery required with antibiotics therapy.

Differential Diagnosis

Differentials diagnosis of the pelvic abscess includes:

  • Pelvic inflammatory disease
  • Ectopic pregnancy
  • Sepsis following miscarriage 
  • Appendicitis
  • Renal colic
  • Bowel obstruction
  • Obturator hernia

Prognosis

The prognosis for the patients with a localized abscess is good; it usually depends on the timely diagnosis, prompt management, and etiology of the collection of pus. The prognosis is poor with regards to infertility in women of the reproductive age group who have had a pelvic abscess.[9]

Complications

The complication of a pelvic abscess includes ectopic pregnancy, the scar tissue from the previous inflammation and infection prevents the fertilized ovum to implant in the uterus and results in ectopic pregnancy.

Infertility is another prevalent complication, adhesion as a result of abscess and inflammation causes severe damages the fallopian tube and ciliary epithelium and ovary and results in infertility.[29] Chronic pelvic pain has seen in one-third of the patients, and pain is related to scarring and adhesions from the previous abscess and infection.[9][30]

Postoperative and Rehabilitation Care

Postoperative care is critical in the patient with surgical abscess removal and drainage. The patient must be monitored closely in the first 24 hours for any worsening of the condition. They are at a high risk of clinical deterioration. 

All patients require strict observation for any sign and symptoms of sepsis, hemorrhage, and shock.

Every patient's vital signs should be monitored and recorded periodically. It includes systolic blood pressure, pulse, temperature, and oxygen saturation.

The patient's intake and output should be maintained and recorded, including the drain. Drain can be removed in a few days after the drainage become minimal, and the patient improves clinically.

Appropriate analgesia should be given to control post-operative pain.

Nausea control should be with an anti-nausea medicine as per needed basis.

Woundcare will involve by keeping the dressing dry and clean.

The parenteral antibiotic should be given for the first 24 hours or until the patient becomes afebrile and then subsequently be changed to oral antibiotics to complete the course.

Deterrence and Patient Education

The most common cause of pelvic abscess in the women of reproductive age group is a pelvic inflammatory disease. It is the duty of the provider either nurse, primary physician or ob-gyn to provide education to the patient about safe sex, regular use of condoms and limiting the number of sexual partners especially in adolescents and teenagers.

Enhancing Healthcare Team Outcomes

The diagnosis and treatment of a pelvic abscess are very challenging. In a clinical setting, the presentation of the pelvic abscess is sometimes vague with high-grade fever, prostration, and vague lower abdominal pain. It requires prompt diagnosis and hospitalization. To avoid high morbidity, managing the condition is best when by an interprofessional team. It is coherent that the role of a gynecologist is dominant in the diagnosis and management of the patient. The integrated care includes primary care providers, The ED physician, nurses, pharmacists, and radiologists. Generally, the patient first presents to either the primary care physician, nurse practitioner, or to the ED with their chief complaints. The attending physician has to consider pelvic abscess in their differentials. The involvement of radiologists is essential in establishing the diagnosis, causes, and further treatment if imaging-guided drainage is needed.[31]

Close monitoring of these patients by nurses is vital because multiple complications can develop, including stress ulcers, sepsis, DVT, and pneumonia. Also, the nurses should provide prophylaxis against pressure sores and encourage incentive spirometry. Pharmacists should assist in the prophylactic and therapeutic dosing and administration of antimicrobial therapy, and consult with the physician staff if there are any concerns regarding therapy, which in many cases will be administered by the nursing staff.

A dietary consult is necessary since many patients will have ileus and require short term IV nutrition.  Bedside physical therapy is vital to prevent muscle contractures and wasting. Only with close interprofessional team collaboration and open communication can the outcomes be improved. [Level V]

Outcomes

The outcome of the patients with a pelvic abscess depends on the extent of the disease, prompt diagnosis, and response to the initial medical treatment. Sometimes the pelvic abscess drains spontaneously into the rectum. The rupture of the pelvic abscess is a life-threatening emergency and requires immediate surgery and frequent monitoring. The rupture of pelvic abscess can present as sepsis, peritonitis, but fortunately, early recognition and expeditious treatment with appropriate antibiotics and surgical interventional can lead to successful treatment.


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Pelvic Abscess - Questions

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Which of the following is the most common cause of pelvic abscesses in children?



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A 68-year-old woman living in a rural area presents to the clinic with a fever of 38 C, continuous pain in the left lumbosacral region and antalgic gait with limited hip movement. The patient has a history of severe sacroiliitis in the past, anterior resection for rectal cancer, radiation treatment, and chemotherapy. She is taking insulin and oral hypoglycemics for diabetes. Her blood tests showed raised inflammatory markers. CT scan of the pelvis showed left sacroiliac joint erosions. Bone scintigraphy exhibited increased radioisotope uptake at the left sacroiliac joint. MR scan revealed a mass in the left iliac fossa. What is the most likely diagnosis in this patient?



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A 33-year-old female presents to the emergency department with abdominal pain and fever. The pain began four days ago along with the fever. Initially, the pain was mild and limited to the lower abdomen. The patient had a history of laparotomy for fibroid uterus 20 days ago. For the last 10 hours, the pain has worsened and is accompanied by nausea and vomiting. She has vomited several times in the last 6 hours. She has no chronic medical condition but smokes half pack per day for the last 15 years. Her temperature is 39.4 C, blood pressure 110/60mmhg, pulse 110/min, and oxygen saturation on room air 97%. Abdominal examination shows tenderness and guarding. On pelvic exam, there is pelvic tenderness, and a left adnexal mass is palpable. Speculum examination shows yellowish purulent vaginal discharge from vaginal vault. Doppler ultrasound shows a pelvic mass measuring 5x4 cm in the left adnexa with fine internal echoes and a thick wall. Which of the following is the next best step in the management of this patient?



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A 33-year-old female presents to the emergency department with abdominal pain and fever. The pain began four days ago, along with the fever. Initially, the pain was mild and limited to the lower abdomen. The patient had a laparotomy for uterine fibroids 20 days ago. Initially, the pain was mild but has worsened significantly over the last 10 hours. The patient has vomited several times over the previous 6 hours. Pain is 9/10 in intensity constant and not relieved ibuprofen or acetaminophen. She has no chronic medical conditions but smokes half pack per day. She denies any recreational drug use. Her temperature is 102.2 F, blood pressure 110/60 mmHg, pulse 110/min, and oxygen saturation 97%. Abdominal examination shows tenderness and guarding. Pelvic examination shows pelvic tenderness, and a left adnexal mass is present. Speculum examination shows yellowish purulent vaginal discharge. An ultrasound shows a pelvic mass measuring 5x4 cm in the left adnexa with fine internal echoes. The patient is admitted, and antibiotics are initiated. Two days later, the patient is still febrile, and a repeat pelvic ultrasound shows an increase in the size of the abscess from 5 cm to 8 cm. Which of the following is the next best step in the management of this patient?



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A 24-year-old G1P1 female presents to the emergency department with lower abdominal pain, green vomiting, and diarrhea with recurrent fevers. She had a cesarian section 8 days ago for fetal stress. On examination, the patient is febrile with temperature 39.3 C, pulse 110/min, respiratory rate 20/min. On examination, the abdomen is soft with tender uterus and adnexa on palpation but with no guarding or rebound. The uterine fundus is 1 cm below the umbilicus. Foul-smelling discharge is noted when a swab is taken for gram stain, and culture and sensitivity. On transvaginal ultrasound, free fluid is seen in the pouch of Douglas. She is diagnosed with postoperative endometritis. The patient is admitted, and intravenous co-amoxiclav therapy is initiated. After 48 hours, the patient is still febrile. Repeat ultrasound shows normal endometrium, but an inhomogenous mass in a pouch of Douglas. A CT scan is performed, which shows four abscesses involving the right adnexa. Vaginal swab shows Gardnerella vaginalis. Ultrasound-guided drainage is performed, and the patient improves. She is discharged on oral co-amoxiclav, clindamycin, and metronidazole. Which of the following is the most concerning the late sequela of pelvic abscess in this patient?



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A 60-year-old female presents to the emergency department with complaints of nausea, vomiting, and abdominal pain for the last 24 hours. She had a history of total abdominal hysterectomy with bilateral salpingo-oophorectomy with dissection of lymph nodes 15 days ago for endometrial cancer. The surgery was uneventful with the operative time of fewer than 110 mins. Her past history is not significant, and she denies any use of tobacco, alcohol, and recreational drug use. Her BMI is 40. The abdominal pain had started one week ago. In the beginning, it was intermittent and 5/10 in intensity, in the last 24 hours, it got worse, constant, and 9/10 in severity: her temperature 103 F, pulse 110/min, and blood pressure 130/70 mmHg. Her examination is remarkable with abdominal tenderness without guarding or rebound. There is no drainage from the incision line, and sutures are intact. A tender mass is noted on pelvic examination. The transvaginal sonogram demonstrates a mass of 6x5 cm with a thick wall and internal echoes, suggestive of a pelvic mass. The total leucocyte count is 14,000/mm3 with the left shift. What is the most important factor contributing to the risk of pelvic abscess formation in this patient?



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A 24-year-old female G1P1 presents to the emergency department with lower abdominal pain, green color vomiting, and diarrhea with recurrent fevers. She had a cesarian section 8 days ago for failure to progress in labor. The patient is febrile with a temperature of 39.3 C, pulse 110/min, respiratory rate 20/min. On examination, the abdomen is soft and tender with no guarding or rebound. The uterine fundus is 1 cm below the umbilicus. There is no discharge seen from the incision line, and sutures are intact. On pelvic exam the uterus is tender, foul-smelling discharge is present, a vaginal swab is taken and sent for gram stain, and culture and sensitivity. The transvaginal ultrasound, free fluid is seen in the pouch of Douglas. The total leucocyte count is 14,000/mm3 with the left shift. She is diagnosed with postoperative endometritis. The patient is admitted, and intravenous ampicillin-clavulanate therapy is initiated. After 48 hours, the patient is still febrile. Repeat ultrasound shows normal endometrium, but an inhomogenous mass in a pouch of Douglas. A CT scan is performed, which shows four abscesses involving the right adnexa. Vaginal swab shows Gardnerella vaginalis. CT guided drainage is being planned. Which of the following is the most appropriate antibiotic regimen to cover this procedure?



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Pelvic Abscess - References

References

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