Prophylactic antibiotics in women with a history of pelvic inflammatory disease undergoing first-trimester abortion. Comparison of preventive use of metronidazole and ampicillin in women with a history of pelvic inflammatory disease undergoing first-trimester abortion. Prophylactic antibiotics for suction curettage abortion: results of a clinical controlled trial. Incidence of pelvic inflammatory disease after first-trimester legal abortion in women with bacterial vaginosis after treatment with metronidazole: a double-blind, randomized study. A clinical double-blind study on the effect of prophylactically administered single dose tinidazole on the occurrence of endometritis after first trimester legal abortion. Investigation of the prophylactic effect of tinidazole on the postoperative infection rate of patients undergoing vacuum aspiration. Antibiotic prophylaxis to prevent post-abortal upper genital tract infection in women with bacterial vaginosis: randomised controlled trial. Prophylactic antibiotics in first-trimester abortions: a clinical, controlled trial. [Antibiotic prophylaxis with prulifloxacin in women undergoing induced abortion: a randomized controlled trial]. A double-blind randomized study of the effect of erythromycin in preventing pelvic inflammatory disease after first trimester abortion. Treatment with 2% clindamycin vaginal cream prior to first trimester surgical abortion to reduce signs of postoperative infection: a prospective, double-blinded, placebo-controlled, multicenter study. Metronidazole prophylaxis in elective first trimester abortion. Prophylaxis with lymecycline in induced first-trimester abortion: a clinical, controlled trial assessing the role of Chlamydia trachomatis and Mycoplasma hominis. No effect of single dose ofloxacin on postoperative infection rate after first-trimester abortion. A clinical, controlled trial. The prophylactic effect of doxycycline on postoperative infection rate after first-trimester abortion. Preventive lymecycline therapy in women with a history of pelvic inflammatory disease undergoing first-trimester abortion: a clinical, controlled trial. A randomised comparison of strategies for reducing infective complications of induced abortion. A randomized clinical trial of prophylaxis for vacuum abortion: 3 versus 7 days of doxycycline.
In a double-blind controlled trial the effect of prophylactic metronidazole on postabortal infection in women with a history of pelvic inflammatory disease (PID) was assessed. One hundred and thirty-five women were eligible for randomization, of whom 17 were excluded. The regimen consisted of oral metronidazole 400 mg 1 h before the abortion and again 4 and 8 h after, or else placebo. In the placebo group the rate of postabortal PID was 13.0% (7/54) and in the metronidazole group 10.9% (7/64), a nonsignificant difference (p greater than 0.7). Women in gestational weeks 11-12 had a significantly increased rate of postabortal PID compared with women in weeks 6-10 (p less than 0.005), but this rate was not influenced by the treatment (p greater than 0.2). Women with parity 1 had a significantly increased rate of postabortal PID compared with women with parity 0 (p less than 0.05), but again the treatment did not influence this rate significantly (p greater than 0.2). The number of hospital days for women in the metronidazole group did not differ significantly from that in the placebo group (p less than 0.1). The amount of metronidazole administered for prophylactic and postabortal treatment was significantly greater in the metronidazole group (p less than 0.001). The amounts of other antibiotics prescribed showed non-significant differences between the two groups (all p-values greater than 0.3). In a double-blind controlled trial the efficacy of prophylactic metronidazole and pivampicillin to women with a history of pelvic inflammatory disease (PID) undergoing first-trimester abortion was assessed. Thirty-eight women received pivampicillin tablets 350 mg and 43 women metronidazole tablets 400 mg, given 1 h before and 4 and 8 h after the abortion. In the pivampicillin group 5 women (13.1%) and in the metronidazole group 8 women (18.6%) developed post-abortal PID, a non-significant difference (P greater than 0.05). The number of hospital days and amounts of antibiotics were not significantly different in the two treatment groups (all P-values greater than 0.05). Women with a history of PID were found to be at risk of contracting postabortal PID. The prophylactic use of 300 mg doxycycline at the time of an abortion was evaluated in a randomized controlled trial. In the group with negative chlamydia screening results, only two (0.4%) of 502 patients who received prophylactic treatment developed pelvic infection, compared with 15 (3.0%) of 497 patients who received placebos (p = 0.001). The same effectiveness was found in women with positive chlamydia screening results. Vomiting was the major side effect of the medication and could limit its use. A simulation of selective prophylaxis in women with negative chlamydia screening results showed that its selective use in patients with a history of gonorrhea or in nulliparous women with multiple sex partners could be nearly two thirds as effective as general prophylaxis. The purpose of this study was to evaluate the effect of metronidazole treatment on the incidence of postoperative pelvic inflammatory disease after first-trimester abortion in women with bacterial vaginosis.
                A double-blind, randomized, multicenter study was conducted on 231 women undergoing first-trimester legal abortion and fulfilling the criteria for bacterial vaginosis. The women were randomized to either metronidazole 500 mg three times daily for 10 days or placebo. Treatment was started at the outpatient visit the week before the operation.
                Among the 174 women who could be evaluated, pelvic inflammatory disease developed in 14 after the abortion. In the treatment group there were three infections (3.8%) compared with 11 (12.2%) in the placebo group (p less than 0.05).
                These data suggest that patients with bacterial vaginosis should be treated in conjunction with first-trimester abortion because treatment with metronidazole reduces the postoperative infection rate more than three times. In a clinical double-blind study, 212 women were administered either a placebo or 2 g of tinidazole 8-15 h before being subjected to a first trimester legal abortion using vacuum aspiration. After the operation, the rectal temperature was recorded twice daily for 5 days. Screening for gonorrhoea was performed before the operation. A total of 27 women (12.7%) had febrile reactions with rectal temperatures greater than 38.0 degrees C after the operation. In 13 women with, and 2 women without a febrile reaction, endometrial specimens were obtained using a protected technique at the time of the febrile reaction. The specimens were cultured for aerobic and anaerobic bacteria, yeast, fungi, chlamydiae, mycoplasmas, and ureaplasmas. Specific culture methods for the detection of gonococci, group B streptococci, Listeria monocytogenes, and Campylobacter foetus were employed. In 8 of the 13 women with a febrile reaction and in one of the 2 women without such a reaction all cultures were sterile. M. hominis was recovered from the uterine contents of 2 women who had febrile reactions. In 4 of the women bacteria and fungi belonging to the endogenous vaginal flora were isolated from the endometrial specimen. In 5 women, who did not consult because of the elevated temperature, the febrile reactions were transient and self-limiting without treatment. No differences were observed between the women administered tinidazole and those given a placebo with respect to the rate of febrile postoperative reactions and isolation of micro-organisms from the intra-uterine specimens. In a double-blind randomized trial the effect of a single oral tinidazole dose of 2 g, given pre-operatively, on the infection rate was assessed in 210 patients undergoing first trimester abortion by vacuum aspiration (VA) and compared to placebo medication. Anaerobic and facultative anaerobic bacteria were the predominant organisms isolated from the cervix. Six patients in the tinidazole group and 11 from the control group developed a postoperative pelvic infection necessitating antibiotic therapy. In 2 patients, one in each group, hospitalization was necessary. This study indicated that identification of the bacteria present in the cervix before VA does not make it possible to predict the likelihood of the postoperative pelvic infection. Tinidazole administration preoperatively seems to reduce the postoperative pelvic infection rate after VA. To determine the prevalence of bacterial vaginosis in women undergoing first trimester suction termination of pregnancy and to evaluate the efficacy of metronidazole in reducing the risk of post abortal pelvic infection in women with bacterial vaginosis.
                Randomised double-blind placebo-controlled trial.
                Two teaching hospitals and one district general hospital.
                Two hundred and seventy-three women with bacterial vaginosis undergoing termination of pregnancy.
                Women with bacterial vaginosis, diagnosed using modified Spiegel's criteria, were individually randomised to receive either a 2 g metronidazole suppository or identical placebo per-operatively. Participants, doctors and investigators were blinded to treatment allocation. Participants were asked to complete a questionnaire about post-operative symptoms, visits to the general practitioner, antibiotic treatment, readmission to hospital, contraception and emotional response after one month.
                The prevalence of bacterial vaginosis was 29.3% (326/1,111). Intention-to-treat analysis showed that post-operative upper genital tract infection developed in 12/142 (8.5%) women allocated to metronidazole and 21/131 (16.0%) women randomised to placebo, a difference of 7.6% (95% confidence intervals -15.4 to +0.2%; relative risk 0.53. 0.27 to 1.03, P = 0.055). The effect of prophylaxis was similar when the analysis was restricted to women receiving the allocated treatment and with complete follow up. There was no difference in the risk of readmission to hospital and the frequencies of self reported symptoms in the two groups were similar.
                This randomised placebo-controlled trial among women with bacterial vaginosis provides weak evidence that metronidazole decreases the risk of upper genital tract infection after first trimester suction termination of pregnancy but a chance finding could not confidently be excluded. Large well-conducted randomised trials with long term outcome measures are now needed to determine the most effective antibiotic combinations and strategy for prevention of post-abortal pelvic infection. The efficacy of prophylactic antibiotic therapy in induced first-trimester abortions was investigated in a double-blind study. Of the 493 women in the study, 254 received doses of 2 million IU of penicillin G intramuscularly one-half hour before and 3 hours after the procedure, followed by 350 mg of pivampicillin three times daily for 4 days, and 239 women received corresponding doses of placebo. The incidence of pelvic infectious complications was 5.5% in the treated group and 10.9% in the control group (p = 0.05). The difference could be attributed to a selective prophylactic effect in women who had earlier suffered from pelvic inflammatory disease (N = 105). The rate of infection in this group was 22.4% among those receiving placebo and 2.1% among those receiving antibiotics (p = 0.006). Prophylactic administration of antibiotics for first-trimester abortions should be used in women who have earlier had pelvic inflammatory disease. To verify the efficacy of prulifloxacin in prevention of infective morbidity in women undergoing first trimester induced abortion. The aim of the study was to observe the incidence of infection during four weeks following abortion by monitoring the symptoms which require general practitioner prescription or hospitalization.
                Randomized controlled trial carried on by the Research Group for Sexology, Familiar Planning Service of the Department of Microbiological and Gynecological Science, University of Catania from September 2005 to March 2007. The study included 466 women, ranging in age from 14 to 44 years (mean age 26.7), who were randomized in three groups: group A (153 subjects) treated with 600 mg daily of prulifloxacin for 5 days after abortion; group B (155 subjects) treated with 600 mg daily of prulifloxacin for 3 days after abortion; group C (158 subjects) treated with 600 mg daily of prulifloxacin one day before and 2 days after abortion.
                Two hundred sixteen were nulliparous (47%), 96 were pluriparous (38.5%). Thirty-two nulliparous (15%) were under eighteen. Among pluriparous, 96 (38.5%) have had previous surgery delivery and 154 (61.5%) spontaneous delivery; moreover, 56 women have had previous surgical interruption during the first-trimester of pregnancy. Surgical abortion was practiced in a range of gestational age between 6th and 11th week of amenorrhea (average week 8.2). The percentage of pelvic inflammatory disease symptoms (pain, fever, leucoxantorrhea ) were about 10.5 in group A, 7.1 in group B and 2.5 in group C. Group C protocol was statistically more effective than group A protocol (P<0.05), but not than group B, even if prevalence of adverse events were less.
                Antibiotic prophylaxis before surgical abortion and shortening supplies after abortion is more effective than post abortion treatment alone. To assess the prophylactic use of erythromycin in prevention of post-abortal pelvic inflammation disease (PID) in first trimester abortion.
                Double-blind, randomized controlled trial.
                Department of Surgery, County Hospital, Denmark.
                Four hundred and thirty two women who were to undergo induced abortion before 12 weeks gestation were randomized to be treated either with prophylactic erythromycin or a placebo.
                The women were randomized to receive a placebo or erythromycin, 500 mg twice a day for 7 1/2 days starting the evening before the abortion. All the women were investigated for Chlamydia trachomatis and Neisseria gonorrhoea before the abortion.
                Frequency of cervical C. trachomatis and N. gonorrhoea and frequency of PID after abortion.
                Fifty four women were excluded after randomization. The frequency of PID was 11% (20/189) in the erythromycin group and 16% (30/189) in the placebo group (P = 0.13, chi 2-test). The prevalence of C. trachomatis was 19% (15/78) in women less than or equal to 20 years of age, 13% (14/109) in women between 21 and 25 years and 2% (5/241) in women greater than or equal to 26 years of age. In women positive for C. trachomatis erythromycin prophylaxis significantly reduced the frequency of PID to 8% (1/13) compared with 43% (6/14) in the placebo group (P = 0.051, logistic regression analysis). Erythromycin had no effect on other potential high risk groups (first pregnancy, nulliparous, less than 20 years of age, and women with previous PID).
                Prophylactic erythromycin is not warranted for all women having an abortion. Cervical C. trachomatis is a risk factor for postabortal PID, and prophylaxis with erythromycin significantly reduces the frequency of PID. However, only a few women with PID had cervical C. trachomatis, and the prevention of post-abortal PID remains a major challenge requiring further studies. Bacterial vaginosis (BV) and intermediate flora is known risk-factor for postoperative infection after surgical termination of pregnancy. Vaginal application of 2% clindamycin cream is an efficacious treatment for BV, but it is not known whether preoperative administration of clindamycin cream might reduce the signs of post-abortion infection after surgical termination of pregnancy.
                To evaluate whether preoperative treatment with clindamycin cream might reduce the signs of post-abortion infection after legal abortion.
                Prospective, double-blinded, placebo-controlled, multicenter study.
                Consecutive women attending for surgical termination prior to 11+4 gestational weeks were approached. We randomized participants to preoperative vaginal treatment with 2% clindamycin cream or placebo cream in a double-blinded fashion. At all visits vaginal smears were air dried on microscopy slides to be stored. The rate of postoperative pelvic infection according to our definition was the main outcome variable, the cure rates of BV and of intermediate flora were secondary outcome variables.
                Of 1655 enrolled women, 1102 were evaluable for analyses. Fifty-eight women developed signs of post-abortion infection. Preoperative treatment with clindamycin cream significantly (RR: 4.2, 95% C.I. 1.2-15.9) reduced the risk of post-abortion infection among women with abnormal vaginal flora (BV and intermediate flora). Treatment with clindamycin cream in women with normal lactobacilli flora did not demonstrate any difference compared to the non-treatment group.
                Preoperative treatment for at least three days with clindamycin cream significantly reduced the risk for developing signs of post-abortion infection only among women with preoperative abnormal vaginal flora (BV and intermediate flora). In a double-blind controlled trial, the efficacy of prophylactic metronidazole in elective first trimester abortions was assessed. Of 119 randomized women, 100 followed the protocol. Fifty-one women received 400 mg metronidazole one hour before and again four and eight hours after abortion; 49 women received a placebo. In the placebo group 20.4% contracted postabortal genital infection compared with 3.9% in the metronidazole group (P less than .025). Of 25 women with a positive history of pelvic inflammatory disease, six contracted postabortal infection, which was a significantly increased frequency compared with women without previous episodes of pelvic inflammatory disease (P less than .05). The administration of prophylaxis, however, did not significantly influence the frequency. The number of hospital days was not significantly lower in the prophylaxis group (P greater than .05). The total amount of metronidazole prescribed in the study group was significantly larger than in the placebo group (P less than .05), whereas the amount of ampicillin/pivampicillin prescribed in the placebo group was significantly larger (P less than .05). The difference between the penicillin doses given in the treatment and placebo groups was not significant (P greater than .1). A clinical, controlled trial was performed to study the effect of prophylaxis with lymecycline and the role of Chlamydia trachomatis and Mycoplasma hominis in postabortal genital infection. Of 532 women who were to undergo first-trimester abortion, 269 were randomized to treatment with oral lymecycline (300 mg bid) starting 2 days before the abortion and continuing for a total of 7 days, and 263 were randomized to placebo treatment. The rate of postabortal infection was 9.3% in the antibiotic group and 9.5% in the placebo group, an insignificant difference (P greater than .8). The presence of C. trachomatis in the cervix/urethra at the time of abortion showed a significant association with the occurrence of postabortal infection (P less than .005), but there was no correlation between the effect of treatment and the presence of infection (P greater than .4). The presence of M. hominis, a history of pelvic inflammatory disease, maternal age, gestational age, the number of births, spontaneous and induced abortion, and the Hegar number showed no significant association with postabortal infection (all P values greater than .05). It is recommended that women who are to undergo induced abortion be examined for the presence of C. trachomatis and treated, as they constitute a risk group. In a double-blind stratificated, placebo controlled study the efficacy and safety of a single oral dose of ofloxanin (Tarivid) (400 mg) in preventing postabortal pelvic inflammatory disease (P-PID) in women with induced first-trimester abortions were assessed. The tablets were given 1 1/2-2 h before the abortion, and the women were followed one month after the operation. Group I consisted of 308 with previous PID. Ofloxacin tablets were given to 149 women and 159 women received placebo tablets. In the ofloxacin group 20 women (13.4%) and in the placebo group 27 women (17%) developed P-PID, a non-significant difference (p = 0.39). Group II consisted of 765 women without a history of PID. Ofloxacin tablets were given to 376 women and 389 women received placebo tablets. Thirty-five women (9.3%) in the ofloxacin group and 46 women (11.9%) in the placebo group developed P-PID, a non-significant difference (p = 0.26). A single oral dose of ofloxacin (400 mg) did not reduce the incidence of P-PID either among women with previous PID or among women without previous PID. A prospective double-blind study was performed to evaluate the effect of prophylactic antibiotic treatment before induced abortion. Eight hundred consecutive women admitted for first-trimester abortion, without signs of genital infection or antibiotic use in the last three weeks, were included in the study. Doxycycline 400 mg or placebo was given as a single oral dose ten to 12 hours before vacuum aspiration. Ninety-one women (11.8%) returned to the hospital with suspected complications. Thirty-two of these women were diagnosed as having pelvic inflammatory disease, eight of whom (2.1%) had received doxycycline before the abortion and 24 of whom (6.2%) had received placebo, a statistically significant difference (P less than .01). A history of pelvic inflammatory disease increased the risk of developing it again after an abortion. In a clinical, controlled trial 55 women with a history of pelvic inflammatory disease (PID) undergoing first-trimester abortion were randomized to either lymecycline therapy or placebo. Twenty-four women received lymecycline capsules 300 mg b.i.d. for 14 days starting on the morning of the abortion and 31 received similar placebo medication. In the lymecycline group 2 women (8.3%) and in the placebo group 7 (22.6%) contracted postabortal PID, a non-significant difference (p greater than 0.2). The variables age, gestational age, number of spontaneous abortions, births and episodes of PID, and Hegar size were not associated with the rate of postabortal PID. Women without previous induced abortions had a significantly increased rate of postabortal infection (p = 0.02), but the treatment did not influence this rate. Three women had a positive culture for Chlamydia trachomatis at the time of abortion and two of these had postabortal PID. None of 7 women with postabortal PID had significant increases in IgA, IgG or IgM chlamydia antibody titers, but two women with uncomplicated abortions had serological evidence of infection. The number of hospital days and amounts of antibiotics prescribed to women with postabortal PID were not significantly different between the two treatment groups (p greater than 0.05). Women with a history of PID had an elevated risk of postabortal PID warranting the use of some sort of prophylaxis, and screening for C. trachomatis in an abortion population is recommended. To determine lower genital tract carriage rates of C. trachomatis, N. gonorrhoeae and bacterial vaginosis among women seeking termination of pregnancy. To compare two clinical management strategies for minimising the risks of infective morbidity after induced abortion.
                Prevalence of infections was assessed by screening women undergoing abortion. Clinical management strategies were compared by a randomised trial.
                The gynaecology departments of four hospitals in Scotland.
                1672 women undergoing induced abortion.
                Women randomised to prophylaxis received metronidazole 1 g rectally before abortion plus doxycycline 100 mg twice daily for seven days. Women randomised to screen-and-treat received appropriate antibiotics only if screening proved positive for one or more infection.
                Prevalences of infections; morbidity in the eight weeks following abortion as assessed by reported symptoms, general practitioner consultation and prescription rates and hospital re-attendances; costs to the NHS of alternative managements.
                Prevalence rates: C. trachomatis 5.6%; N gonorrhoeae 0.19%; bacterial vaginosis 17.5%. Overall, women allocated to receive prophylaxis had lower rates of measures of short term infective morbidity than those allocated to screen-and-treat. These differences only reached statistical significance for women who were reported negative on screening. The direct costs to the NHS of prophylaxis and screen-and-treat were calculated to be 8.17 and 18.34 per woman, respectively.
                Prevalences of lower genital tract infections which have been implicated in increased rates of infective morbidity after abortion are similar to those reported elsewhere. Universal antibiotic prophylaxis is at least as effective as a policy of screen-and-treat in minimising the risk of short term infective morbidity and is far more cost efficient. To estimate prospectively whether reducing oral doxycycline prophylaxis from 7 to 3 days increases the incidence of endometritis after elective first-trimester vacuum abortion.
                We randomized 800 women requesting first-trimester abortion to two study groups: 1) 100 mg of doxycycline administered orally twice a day for 7 days or 2) 100 mg of doxycycline orally twice a day for 3 days followed by an oral placebo twice daily for the last 4 days. Doxycycline was prescribed immediately after surgery.
                There were no statistically significant differences in age, race, gravidity, parity, number of previous abortions, current gestational age, and history of previous pelvic infection, chlamydia, or intrauterine device use. Women in the doxycycline plus placebo group were more likely to have had a history of gonorrhea (3.3% versus 0.8%, P =.42) or chlamydia (7.0% versus 4.3%, P =.18). The 66.3% of enrollees returning for 2-week examinations were distributed similarly between study groups and were similarly compliant in self-reported pill taking (mean 97.5%). The study groups did not differ in the incidence of postoperative symptoms or examination findings suggesting infection. One patient in the doxycycline-only group developed endometritis and was treated as an outpatient.
                Shortening oral doxycycline prophylaxis from 7 to 3 days had no adverse effect on the incidence of postabortion infection.
Antibiotic prophylaxis at the time of first trimester surgical abortion is effective in preventing post-abortal upper genital tract infection. Evidence of between trial heterogeneity suggests that the effect might not apply to all settings, population groups or interventions.
This review did not determine the most effective antibiotic prophylaxis regimen. Antibiotic choice should take into account the local epidemiology of genital tract infections, including sexually transmitted infections.
Further RCTs comparing different antibiotics or combinations of antibiotics with each other would be useful. Such trials could be done in low and middle income countries and where the prevalence of genital tract infections in women presenting for abortion is high.