Clinical questions and recommendations
1 What is the risk of infection following induced abortion?
|Study||Number of abortions||Years||Diagnostic criteria for infection||Number of infections||Infection rate (%)||Gestational age (weeks)||Facility type, location||Antibiotic prophylaxis||Ascertainment method|
|170000||1971–1987||Physician concern, tenderness, fever not required||784||0.46%||≤14||3 free-standing clinics,||None||Retrospective|
|≥2 days of fever ≥40°C||6||0.00%||New York City|
|20248||1972–1973||Bleeding, fever, and/or pain, with or without re-aspiration||135||0.67%||≤12||free-standing clinic,||“As indicated”||Prospective|
|Bleeding, fever, and/or pain, without re-aspiration||45||0.22%||Washington, DC, USA|
|Wulff and Freiman |
|16410||1973–1976||Infection, JPSA criteria||16||0.10%||≤14||Free-standing clinic, St. Louis, MO, USA||All patients||Retrospective|
|351789||1975–1980||“Infection”||633||0.18%||≤15||all facilities, Canada (national data)||Uncertain||Retrospective|
|Joint study of RCGP and RCOG |
|PID||100||1.60%||Great Britain (national data)|
|Heisterberg and Kringelbach |
|5851||1980–1985||Re-admission, fever ≥38°C||143||2.40%||≤12||Hospital,||None||Retrospective|
|Re-admission, antibiotic therapy||190||3.20%||Copenhagen, Denmark|
|Fried et al. |
|1000||1987||Infection||47||4.70%||≤15||Hospital,||Doxycycline if Chlamydia (+)||Prospective|
|Fever ≥38°C||16||1.60%||Stockholm, Sweden|
|Infection risk <8% in placebo group||Author||Year||Antibiotic||Dosing Method||Total N||Antibiotic group||Placebo group||Relative Risk|
|Pre-procedure||Post-procedure||Total Days||Infxn||No Infxn||Rate||Infxn||No Infxn||Rate|
|Levallois||1988||Doxycycline||100 mg||200 mg||1||1074||3||532||0.60%||26||513||4.80%||0.12|
|1994||Ceftriaxone||1 gram i.v.||–||1||549||2||273||0.70%||10||264||3.60%||0.2|
|Infection risk >8% in placebo group||Author||Year||Antibiotic||Dosing Method||Total N||Antibiotic group||Placebo group||Relative Risk|
|Pre-procedure||Post-procedure||Total Days||Infxn||No Infxn||Rate||Infxn||No Infxn||Rate|
|1981||Penicillin G and pivampicillin||PcnG 2 mil IU||Pcn G 2 mil IU; then Piva. 350 mg tid×4 days||5||493||14||240||5.50%||26||213||10.90%||0.51|
|1985||Lymecycline||300 mg||300 mg bid×7 days||8||532||25||244||9.30%||25||238||9.50%||0.98|
|1985||Metronidazole||400 mg||400 mg at 4 and 8 h||1||100||2||49||3.90%||10||39||20.40%||0.19|
|1987||Metronidazole||400 mg||400 mg at 4 and 8 h||1||118||7||57||10.90%||7||47||13.00%||0.84|
|1988||Lymecycline||300 mg||300 mg bid×14 days||15||55||2||22||8.30%||7||24||22.60%||0.37|
|1992||Erythromycin||500 mg||500 mg bid×7 days||8||378||20||169||10.60%||30||159||15.90%||0.67|
|1992||Metronidazole||500 mg tid×7 days||500 mg tid×3 days||10||174||3||81||3.60%||11||79||12.20%||0.29|
Early medical abortion
|Study Population||Prostalgandin, route|
|Infection Risk||95% Confidence Interval|
|2||2115||gemeprost, p.v., or sulprostone, i.m.||0.09%||0.01%||0.34%|
|43||16173||gemeprost, p.v. or i.m.||0.27%||0.19%||0.36%|
2 What are risk factors for postabortal infection?
- Larsson P.G.
- Platz-Christensen J.J.
- Dalaker K.
- et al.
3 What are the sequelae of postabortal infection?
|Sequelae||Post-abortal PID||No Post-abortal PID||p|
|Chronic pelvic pain||29||4||25||13.80%||323||7||316||2.20%||0.01||6.4||2||20.5|
4 Does antibiotic prophylaxis lower the risk of infection following surgical abortion?
|Infection risk without antibiotics||Relative risk||Infection risk with antibiotic prophylaxis||NNT|
5 Does antibiotic prophylaxis lower the risk of infection following medical abortion?
6 Which antibiotic is best for prevention of postabortal infection?
7 When should antibiotics be given to prevent infection with surgical abortion?
8 What are the disadvantages of antibiotic prophylaxis for abortion?
9 What means other than antibiotics have been studied to prevent postabortal infection?
10 Does the risk of infection change with immediate insertion of an intrauterine device?
Conclusions and recommendations
- •Antibiotic prophylaxis lowers the risk of infection following surgical abortion and therefore should be provided to all patients undergoing surgically induced abortion.
- •Prophylactic antibiotics should be given pre-operatively for maximal effect and the lowest risk of adverse reactions.
- •The shortest possible course of antibiotics should be used to minimize the risks of adverse reactions and bacterial development of antibiotic resistance. In most cases, a single dose given preoperatively would be optimal.
- •Preoperative doxycycline is a safe and effective prophylactic antibiotic for surgically induced abortion, whether used as a single dose or short perioperative course.
- •When doxycycline is taken with dinner the night preceding the abortion procedure, nausea, a common side effect, may be reduced.
- •The presence of N. gonorrhoeae and C. trachomatis at the time of induced abortion increases the risk of infection. Universal prophylaxis with a variety of regimens, including those not recommended by the United States Centers for Disease Control for the treatment of gonorrhea or Chlamydia have proven effective in significantly reducing postabortal infection among asymptomatic women who screen positive for gonorrhea, Chlamydia, or both. In addition to provision of universal antibiotic prophylaxis, when possible, appropriate screening for gonorrhea and Chlamydia should be performed so that those testing positive may be treated.
- •Immediate insertion of intrauterine contraception does not increase the risk of infection following induced surgical abortion.
- •Nitroimidazoles, such as metronidazole and tinidazole, are appropriate alternative choices of antibiotic prophylaxis for induced abortion. The lack of studies in low-risk populations limits generalizability.
- •A 1-week course of doxycycline begun at the time of medical abortion may lower the risk of serious infection at the time of early medical abortion.
- •Chlorhexidine may be more effective than povidone iodine at reducing bacteria within the vagina, although neither alters the risk of post-procedure infection.
- •The addition of metronidazole is unlikely to further reduce the risk of infection in women with bacterial vaginosis already receiving prophylactic antibiotics.
- •Initiation of antibiotics after induced abortion is unlikely to be beneficial. This practice has not been shown to lower infection risk in placebo-controlled studies.
- •The same infection-reducing antibiotic prophylaxis regimens used in first-trimester induced abortion are probably effective in second-trimester induced abortion, but these regimens have not yet been subject to comparison studies specifically for second-trimester procedures.
- 1.What is the best regimen for antibiotic prophylaxis? No trials could be identified which directly compared regimens of different antibiotics (e.g., doxycycline versus metronidazole). Thus far, only two published trials could be identified that compare regimens of the same antibiotic.
- 2.Is antibiotic prophylaxis warranted for early medical abortion? No randomized controlled trials of antibiotic prophylaxis at medical abortion have been performed. Although the risk of serious infection is low, recent data indicate that there may be significant reduction in the risk of serious infection by providing treatment doses of Doxycycline starting at the time the medical abortion treatment is initiated.
- 3.Is there a role for antibiotic prophylaxis in the setting of second-trimester induction of labor abortion?
- 4.Would initiation of antibiotic prophylaxis at the time of dilator placement prior to D&E be beneficial in reducing infectious morbidity?
- 5.At what prevalence of Chlamydia infection does global treatment become more cost-effective than prophylaxis?
- 6.Is there a benefit in providing antibiotic prophylaxis before suction aspiration in the setting of incomplete or missed abortion? This question warrants further study as the only published trial was underpowered.
- 7.Does use of vaginal misoprostol to induce abortion in women with BV confer additional infectious risk? Currently there are no data available that address this question.
Conflict Of Interest
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