**4. Treatment**

Gynecological surgical site infections are polymicrobial with a mix of both anaerobic and aerobic infections. Common pathogens contain gram-negative bacilli, enterococci, streptococci, and anaerobes**—**that is, *Staphylococcus aureus*, coagulase-negative staphylococci, and Streptococcus and Enterococcus species. When SSI is suspected, the wound should be thoroughly inspected. Surgical site infections are characterized as superficial, deep incisional, or organ/space. Involvement of the fascia and/or muscle with infection is the hallmark of a deep incisional SSI, whereas patients with organ/space SSI typically present with generalized malaise, fever, and pain. It becomes important to note that early recognition of necrotizing soft tissue infection is crucial. These infections can manifest rapidly after surgery with Group A streptococcus and clostridia as the primary pathogens.

Wound exploration and debridement are pillars in the management of superficial and deep-incisional SSIs. This includes not only opening the wound, debridement of necrotic and devitalized tissue, but also involves the culture of the wound to allow for speciation of potential pathogens to assist in antibiotic therapy.

The mortality and morbidity of organ/space SSI tend to be higher than superficial or deep SSI. The primary objective in management is to achieve source control. Computed tomography and ultrasound are employed to guide placement of closed suction percutaneous drains into abscess collections when feasible. The initial approach in treatment of post-hysterectomy pelvic abscess depends on three factors: (1) hemodynamic stability, (2) abscess size, and (3) abscess location. Hemodynamically unstable patients require prompt surgical intervention and intensive care monitoring.

Patients who are hemodynamically stable with a post-hysterectomy pelvic abscess should be treated empirically with parenteral broad-spectrum antibiotics. Initial antimicrobial regimens can be tailored to subsequent culture and sensitivity results. If the patient does not respond within 48–72 hours, percutaneous drainage or infectious disease consultation may be warranted. An argument can be made for earlier percutaneous drainage. In fact, a systematic review comparing the success rates of 3 modalities of minimally invasive management of tubo-ovarian abscesses—laparoscopy, ultrasound-guided drainage and computed tomographyguided drainage**—**reported that better outcomes were achieved by the minimally invasive approach when compared with conservative management. Of these techniques, image-guided drainage provided the highest success rates, fewest complications, and shortest hospital stay compared to laparoscopy [33].

Treatment failure is defined as persistent fever, leukocytosis, pain or lack of abscess resolution. Risk factors include residual fluid collection after drainage and increasing patient age. Surgical management is recommended at this time.
