Antibiotic prophylaxis for intrauterine contraceptive device insertion

Cochrane Review by Grimes DA, Schulz FK

This record should be cited as: Grimes DA, Schulz FK. Antibiotic prophylaxis for intrauterine contraceptive device insertion. Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD001327. DOI: 10.1002/14651858.CD001327.

 

 


ABSTRACT

Title

Antibiotic prophylaxis for intrauterine contraceptive device insertion

Background

Concern about the risk of upper genital tract infection (pelvic inflammatory disease (PID)) often limits use of the intrauterine device (IUD), a highly effective contraceptive. Prophylactic antibiotic administration around the time of induced abortion significantly reduces the risk of postoperative endometritis (Sawaya 1996). Since the risk of IUD-related infection is limited to the first few weeks to months after insertion (Lee 1983; Farley 1992) contamination of the endometrial cavity at the time of insertion (Mishell 1966) appears to be the mechanism, rather than the IUD or string itself. Thus, antibiotic administration before IUD insertion might reduce the risk of upper genital tract infection from passive introduction of bacteria at insertion.

Objectives

To assess the effectiveness of prophylactic antibiotic administration before IUD insertion in reducing IUD-related complications (pelvic inflammatory disease; complaints leading to an unscheduled visit) and discontinuations within three months of insertion.

Search strategy

We used computer searches of MEDLINE, POPLINE, and EMBASE. We also reviewed references lists in original research and review articles. We wrote to experts on several continents to identify unpublished trials.

Selection criteria

We included randomized controlled trials using any antibiotic compared with a placebo.

Data collection and analysis

Two independent reviewers abstracted data. We made telephone calls to investigators to obtain additional information. We assessed the validity of each study using methods suggested in the Cochrane Handbook. We generated 2x2 tables for the principal outcome measures. The Peto modified Mantel-Haenszel technique was used to calculate odds ratios and assessed statistical heterogeneity between studies.

Main results

The odds ratio (OR) for pelvic inflammatory disease was 0.89 (95% Confidence Interval (CI) 0.53 to 1.51) for use of prophylactic doxycycline or azithromycin compared with placebo or no treatment. Use of prophylaxis was associated with a small reduction in unscheduled visits to the provider (OR 0.82; 95% CI 0.70 to 0.98). Use of doxycycline or azithromycin had little effect on the likelihood of removal of the IUD within 90 days of insertion (OR 1.05; 95% CI 0.68 to 1.63). No statistically significant heterogeneity between study results was detected.

Authors' conclusions

Use of either doxycycline 200 mg or azithromycin 500 mg by mouth before IUD insertion confers little benefit. While the reduction in unscheduled visits to the provider was marginally significant, the cost-effectiveness of routine prophylaxis remains questionable. A uniform finding in these trials was the low risk of IUD-associated infection, with or without use of antibiotic prophylaxis.

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