A 29-year-old woman is evaluated in the hospital prior to discharge. Three days ago, she w… — USMLE Step 2 CK

A 29-year-old woman is evaluated in the hospital prior to discharge. Three days ago, she was admitted with severe lower abdominal pain, a temperature of $38.6^\circ\text{C}$ ( $101.5^\circ\text{F}$ ), a blood pressure of $110/70\text{ mmHg}$ , and a heart rate of $112\text{/min}$ . Pelvic examination at that time revealed purulent cervical discharge, pronounced cervical motion tenderness, and a palpable, tender left adnexal mass. A copper intrauterine device string was visible at the cervical os. Pelvic ultrasonography confirmed a $6\text{-cm}$ left tubo-ovarian abscess. She was admitted and started on intravenous cefoxitin and oral doxycycline. Over the past 72 hours, she has become afebrile, her heart rate has decreased to $78\text{/min}$ , and her pelvic pain has significantly improved. Her leukocyte count has normalized to $7,500/\text{mm}^3$ . She is currently tolerating a regular diet. Endocervical nucleic acid amplification testing from admission returned positive for *Chlamydia trachomatis* and negative for *Neisseria gonorrhoeae*. Blood cultures show no growth. She will be discharged to complete a 14-day total course of therapy. Which of the following is the most appropriate next step in management?

Retain the intrauterine device; prescribe oral doxycycline and oral metronidazoleAnswer
B
Retain the intrauterine device; prescribe oral doxycycline alone
C
Retain the intrauterine device; prescribe outpatient intravenous piperacillin-tazobactam
D
Remove the intrauterine device; prescribe oral doxycycline and oral metronidazole
E
Remove the intrauterine device; prescribe oral doxycycline alone

Answer

The most appropriate management is to retain the intrauterine device and prescribe oral doxycycline combined with oral metronidazole.

The correct management involves retaining the intrauterine device (IUD) and prescribing oral doxycycline and oral metronidazole. For patients with pelvic inflammatory disease (PID) and a tubo-ovarian abscess (TOA) who have an IUD in place, the device does not need to be removed if the patient demonstrates clinical improvement (e.g., defervescence, decreased pain, normalizing leukocytosis) within 48 to 72 hours of starting parenteral antibiotics. Because this patient has responded well to intravenous cefoxitin and oral doxycycline, the IUD should be left in situ. Regarding step-down therapy, patients with a TOA require a full 14-day course of antimicrobials that includes robust anaerobic coverage. Because TOAs are polymicrobial and involve vaginal and gastrointestinal flora (including strict anaerobes like Bacteroides species), targeted therapy against Chlamydia trachomatis (doxycycline) is insufficient on its own. Metronidazole must be added to the oral doxycycline regimen to ensure eradication of the abscess cavity flora and prevent recurrence.

Step-by-Step Solution

Assess the clinical response to initial inpatient therapy.

The patient has become afebrile, hemodynamically stable, and her pain has improved over 72 hours.

Determines if conservative medical management is successful or if surgical intervention (e.g., abscess drainage, device removal) is required.

Determine the appropriate management of the intrauterine device (IUD).

Retain the IUD.

Guidelines recommend retaining the IUD during acute pelvic inflammatory disease unless the patient fails to improve clinically after 48-72 hours of appropriate therapy.

Select the optimal oral step-down antibiotic regimen.

Prescribe oral doxycycline and oral metronidazole.

Doxycycline covers the identified C. trachomatis, while metronidazole is mandatory to cover the polymicrobial anaerobic flora inherent to tubo-ovarian abscesses.

Key Concept

Management of tubo-ovarian abscess requires 14 days of broad-spectrum antimicrobial therapy including anaerobic coverage, and an intrauterine device can be retained if the patient demonstrates clinical improvement within 48-72 hours.

Estimated Time:1m 30s

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