Analgesia and supportive care
›Symptom control and monitoring
›Analgesia
›Acetaminophen 1000 mg PO or IV every 6 hours as needed
›Ibuprofen 400 to 600 mg PO every 6 hours as needed if no contraindication
›Hydromorphone 0.2 to 0.5 mg IV every 2 to 3 hours as needed
›Antiemetic
›Ondansetron 4 mg IV or PO every 6 to 8 hours as needed
›Fluids
›Crystalloid bolus 20 to 30 ml/kg if hypotension or lactate elevation
›Reassess after each bolus with MAP and urine output
›VTE prophylaxis if admitted
›Mechanical prophylaxis
›Pharmacologic prophylaxis per bleeding risk
›Broad spectrum pelvic infection coverage
›Coverage targets
›Gonorrhea and chlamydia
›Anaerobes including BV associated flora
›Gram negative enterics
›Streptococci
›Preferred inpatient regimens
›Ceftriaxone based regimen
›Ceftriaxone 1 g IV every 24 hours
›Dose 2 g IV every 24 hours if severe sepsis or high BMI per local protocol
›Doxycycline 100 mg IV or PO every 12 hours
›Switch to PO when tolerating
›Metronidazole 500 mg IV or PO every 12 hours
›Continue anaerobic coverage for TOA
›Cefoxitin based regimen
›Cefoxitin 2 g IV every 6 hours
›Alternative if ceftriaxone unavailable
›Doxycycline 100 mg IV or PO every 12 hours
›Switch to PO when tolerating
›Metronidazole 500 mg IV or PO every 12 hours
›Continue for TOA
›Clindamycin gentamicin regimen
›Clindamycin 900 mg IV every 8 hours
›Anaerobe coverage strong
›Gentamicin IV once daily dosing
›5 to 7 mg/kg actual body weight IV every 24 hours
›Dose adjust for renal function
›Beta lactam allergy considerations
›Clindamycin gentamicin regimen
›Clindamycin 900 mg IV every 8 hours
›Monitor for C difficile risk
›Gentamicin 5 to 7 mg/kg IV every 24 hours
›Trough monitoring per local policy
›If anaphylaxis history and gentamicin unsuitable then ID consult
›Alternative regimens based on local resistance
›Transition to oral therapy
›Clinical improvement and afebrile at least 24 hours
›Doxycycline 100 mg PO every 12 hours
›Continue to complete 14 days total
›Metronidazole 500 mg PO every 12 hours
›Continue to complete 14 days total
Source control and procedures
›Abscess management strategy
›Medical therapy first
›Hemodynamically stable
›No peritonitis
›Drainage indications
›No improvement after 48 to 72 hours IV antibiotics
›Large abscess size
›Persistent fever
›Persistent leukocytosis
›Surgical indications
›Rupture suspicion
›Generalized peritonitis
›Septic shock with uncontrolled source
›Concern for malignancy or torsion
›Drainage approaches
›Transvaginal ultrasound guided drainage
›Preferred when accessible
›CT guided percutaneous drainage
›Consider if transvaginal not feasible
›Intraoperative options
›Laparoscopy washout
›Tube and ovary preservation if feasible
›Salpingo oophorectomy
›If necrosis or rupture and unstable
›IUD management
›Do not remove immediately if improving on antibiotics
›Reassess at 48 to 72 hours
›If no improvement then consider removal
›Shared decision making with gynecology
Sepsis and shock therapies
›Hemodynamic support
›Vasopressor
›Initiate norepinephrine if MAP < 65 after fluids
›Start 0.05 to 0.1 mcg/kg/min
›Titrate every 2 to 5 minutes to MAP goal
›Second line vasopressor
›Add vasopressin 0.03 units/min if escalating norepinephrine
›Avoid titration above 0.03 units/min per typical protocol
›Steroid consideration
›If refractory shock then hydrocortisone 50 mg IV every 6 hours
›Class IIa recommendation based on sepsis guideline consensus
›Early reassessment
›Repeat lactate mmol/l
›Bedside ultrasound for volume status
›Urine output monitoring