A 25-year-old sexually active woman presents with lower abdominal pain, fever 38.5°C, and cervical motion tenderness on examination. Right adnexal tenderness is present. A transvaginal ultrasound shows a 4 cm right tubo-ovarian complex without complete liquefaction. She has no signs of peritonitis. Her WBC count is 15,000/µL. The MOST appropriate initial management is:
- A IV cefoxitin + doxycycline for 14 days, then reassess ✓
- B Immediate laparoscopy and drainage
- C Oral azithromycin + metronidazole for 14 days
- D Ultrasound-guided percutaneous drainage under CT guidance
Correct answer: A. IV cefoxitin + doxycycline for 14 days, then reassess
Explanation
CDC 2021 PID guidelines recommend in-patient IV antibiotics for tubo-ovarian complex (TOC)/abscess. The standard IV regimen is cefoxitin 2g IV q6h (or cefotetan) + doxycycline 100 mg IV/PO q12h, transitioned to oral doxycycline + metronidazole after clinical improvement, for a total of 14 days. A TOC without frank abscess and without peritonitis should initially be managed medically. Laparoscopy is reserved for ruptured TOA, failure of medical management at 72 hours, or diagnostic uncertainty. Oral-only therapy is inadequate for TOC.
Reference: Shaw's Textbook of Gynaecology, 17th ed.
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Written and medically reviewed by the StethoPrep medical team.