Antibiotic regimens for tubo-ovarian abscess

Regimens	Dose (adult)
Recommended parenteral regimens*^[1]
Ceftriaxone plus	1 g IV every 24 hours
Doxycycline plus	100 mg orally or IV every 12 hours
Metronidazole	500 mg orally or IV every 12 hours
or
Cefotetan plus	2 g IV every 12 hours
Doxycycline	100 mg orally or IV every 12 hours
or
Cefoxitin plus	2 g IV every 6 hours
Doxycycline	100 mg orally or IV every 12 hours
Alternative parenteral regimens*^[1]
Ampicillin-sulbactam plus	3 g IV every 6 hours
Doxycycline	100 mg orally or IV every 12 hours
or
Clindamycin plus	900 mg IV every 8 hours
Gentamicin	2 mg/kg loading dose then 1.5 mg/kg every 8 hours IV or IM Alternatively, may administer gentamicin 3 to 5 mg/kg IV once daily
Additional parenteral regimens^¶
Ampicillin plus	2 g IV every 6 hours
Clindamycin plus	900 mg IV every 8 hours
Gentamicin	2 mg/kg loading dose then 1.5 mg/kg every 8 hours IV or IM Alternatively, may administer gentamicin 3 to 5 mg/kg IV once daily
or
Levofloxacin^§ plus	500 mg IV once daily
Metronidazole	500 mg IV every 12 hours
or
Imipenem-cilastatin	500 mg IV every 6 hours
Oral regimens (Use only as continuation of parenteral therapy and in select patients)^◊
Metronidazole plus	500 mg orally twice daily
Doxycycline	100 mg orally twice daily
or
Clindamycin plus	450 mg orally four times daily
Doxycycline	100 mg orally twice daily
or
Levofloxacin^§ plus	500 mg orally once daily
Metronidazole	500 mg orally twice daily
or
Moxifloxacin^§ plus	400 mg orally once daily
Metronidazole	500 mg orally twice daily
or
Azithromycin plus	500mg orally once on day 1, followed by 250 mg orally once daily on subsequent days
Metronidazole	500 mg orally twice daily
or
Ofloxacin^§ plus	400 mg orally twice daily
Metronidazole	500 mg orally twice daily
or
Amoxicillin-clavulanate XR	Extended release: 2 g orally twice daily

The duration of antibiotic therapy is not well established. When antibiotics are used alone (without drainage or surgery) a minimum of 14 days is common practice. If the patient is improving on antibiotics but the abscess has not completely resolved, longer courses of antibiotics may be given. When a drainage procedure or surgery is performed, 10 to 14 days of total antibiotic therapy is usually effective.

IV: intravenously; IM: intramuscularly; XR: extended release; CDC: Centers for Disease Control and Prevention.
* These antibiotic regimens are recommended by the CDC for treatment of pelvic inflammatory disease and extrapolated to treat tubo-ovarian abscesses. There may be other reasonable antimicrobial regimens.
¶ These regimens also provide appropriate antibiotic coverage but are not listed by the CDC as "Recommended" or "Alternative" regimens.
◊ In select patients in whom clinical improvement has been clearly documented, transition to oral therapy may be appropriate. Direct communication with the patient and a plan for follow-up must also be confirmed prior to hospital discharge. This is discussed in detail separately.
§ The CDC recommends against fluoroquinolone-containing regimens due to emergence of fluoroquinolone-resistant gonorrhea. However, this may be a reasonable alternative in select patients (eg, in the setting of drug allergies) if community prevalence and individual risk for gonorrhea are low.

Reference:

Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021; 70:1.

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Antibiotic regimens for tubo-ovarian abscess