Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal pain
Treatment: Inpatient admission
The inpatient admission was medically necessary.

A tubo-ovarian abscess (TOA) is an inflammatory mass involving the fallopian tube, ovary and, occasionally, other adjacent pelvic organs (eg, bowel, bladder). These abscesses are found most commonly in reproductive age women and typically result from upper genital tract infection. TOA is a serious and potentially life-threatening condition. Aggressive medical and/or surgical therapy is required and rupture of an abscess may result in sepsis. Prior to the advent of broad-spectrum antibiotics and modern surgical practice, the mortality rate associated with TOA was approximately 50 percent or higher. The mortality rate approaches zero for abscesses that are not ruptured. For patients with ruptured abscesses, current mortality rates have not been reported, but data from the 1960s suggest the rate may be as high as 1.7 to 3.7 percent.

Treatment modalities for TOA include intensive antibiotic therapy, minimally-invasive drainage procedures, invasive surgery, or a combination of these interventions. The large majority of small abscesses (less than [<] nine centimeters [cm] in diameter) resolves with antibiotic therapy alone. Most women are candidates for medical management, which allows the avoidance of surgery. Antimicrobial agents alone are effective in approximately 70 percent of all cases, based upon data from large case series. Antibiotic therapy alone for women with the following characteristics is recommended:

1) Hemodynamically stable with no signs of a ruptured TOA (acute abdomen, sepsis)
2) Abscess < nine cm in diameter  
3) Adequate response to antibiotic therapy
4) Premenopausal 

Experts agree that women with a TOA should be treated as an inpatient with intravenous antibiotics, at least initially. This is consistent with the recommendation by the United States Centers for Disease Control (CDC).

Antibiotic therapy for TOA is similar to treatment for pelvic inflammatory disease (PID). Although TOA and PID are related conditions caused by similar pathogens, their pathophysiology is not identical. For PID (and for many with TOA), first-line therapy typically uses a second generation cephalosporin with anti-anaerobic activity and it is still inconclusive whether additional anti-anaerobic coverage is needed above and beyond the second-generation cephalosporin. For this reason, the CDC guidelines for treatment of PID advise only selected use of metronidazole.

Patients require close observation for at least 48 to 72 hours due to the serious nature of the infection, the potential for abscess rupture and ensuing sepsis, and occasional diagnostic uncertainty. The duration of antibiotic therapy required for treatment of a TOA is not well-established. When antibiotics alone are the chosen therapy, a minimum of two weeks is most commonly used. This is consistent with the CDC guidelines on the treatment for pelvic inflammatory disease. Most experts recommend continuation of antibiotic therapy until the abscess has resolved on follow-up imaging studies. This can sometimes require four to six weeks of total antibiotic therapy. In cases in which the patient is improving on antibiotics alone, but the abscess has not completely resolved, longer courses of outpatient antibiotics may be given. Cases that do not resolve with routine therapy are best managed in collaboration with an expert in infectious diseases.

No data are available to formally guide length of therapy when imaging-guided drainage procedures and/or extirpative surgery are used in combination with antimicrobial therapy. In experience, ten to 14 days of total antibiotic therapy is usually effective. The overall clinical scenario of each individual patient must also be taken into consideration in these decisions.

Finishing the course of therapy with oral antibiotics as an outpatient is reasonable in select patients. Ideal candidates for outpatient therapy should meet the following criteria: demonstrate clear clinical improvement, tolerate oral medications, and be able to comply with follow-up communication and appointments. 

In review of the medical record and the literature, the patient meets the criteria for an acute inpatient admission given that her results revealed the diagnosis of a tubo ovarian abscess requiring treatment with IV antibiotics. She also had leukocytosis, fever, and an elevated lactic acid level which is concerning for sepsis. Therefore the acute inpatient level of care was medically necessary as this was the most appropriate and necessary level of care.