Clinical Updates in Reproductive Health

Prophylactic antibiotics for vacuum aspiration and dilatation and evacuation

Last reviewed: December 2, 2019

Recommendation:

  • Administer prophylactic antibiotics prior to vacuum aspiration and dilatation and evacuation (D&E).
  • Where antibiotics are unavailable, uterine evacuation procedures should still be offered.
  • Administer treatment doses of antibiotics to those with signs or symptoms of sexually transmitted infection; partners of individuals with sexually transmitted infections also require treatment. Treatment should not delay uterine evacuation.

Strength of recommendation: Strong

Quality of evidence:

  • Vacuum aspiration: High
  • D&E: Very low
  • Incomplete or missed abortion: Moderate

Risk of infection

When objective measures are used to diagnose postabortion infection following vacuum aspiration performed before 13 weeks gestation, the infection rate ranges from 0.01-2.44% (Achilles & Reeves, 2011). In studies performed in the United States before routine use of antibiotic prophylaxis, reported rates of infection following D&E ranged from 0.8-1.6% (Achilles & Reeves, 2011).

Evidence for antibiotic prophylaxis

A Cochrane meta-analysis of 19 randomized controlled clinical trials showed that administration of prophylactic antibiotics at the time of vacuum aspiration for induced abortion before 13 weeks gestation significantly reduces the risk of infection (Low, Mueller, Van Vliet, & Kapp, 2012). Evidence to support use of prophylactic antibiotics before D&E is limited; however, because of the demonstrated benefit of prophylactic antibiotics before vacuum aspiration, the World Health Organization (WHO, 2014), Society of Family Planning (Achilles & Reeves, 2011), American College of Obstetricians and Gynecologists (ACOG, 2018) and Royal College of Obstetricians and Gynaecologists (RCOG, 2015) recommend prophylactic antibiotics for all women undergoing vacuum aspiration or D&E.

Five randomized trials have examined the use of prophylactic antibiotics before vacuum aspiration or curettage for incomplete or missed abortion (postabortion care) (Lissauer et al., 2019; Prieto, Eriksen, & Blanco, 1995; Ramin et al., 1995; Seeras, 1989; Titipant & Cherdchoogieat, 2012). One large, multicountry randomized trial that examined currently recommended prophylactic antibiotics found that fewer women in the prophylactic antibiotic group developed postabortion infection than those in the placebo group when strict, international diagnostic criteria for pelvic infection were used (Lissauer et al., 2019; Serwadda, 2019). A secondary analysis of this study found that antibiotic prophylaxis is cost-effective, estimating that routine prophylaxis could save $8.5 million across the two regions of sub-Saharan Africa and South Asia (Goranitis et al., 2019). The four other studies found no statistically significant difference in postabortion infection rates between the groups that received antibiotic prophylaxis and those that received placebo or no treatment; however, these studies all suffered from serious methodologic flaws including small size, inadequate antibiotic dose or poor adherence to study protocol (Prieto, Eriksen, & Blanco, 1995; Ramin et al., 1995; Seeras, 1989; Titipant & Cherdchoogieat, 2012).

Giving prophylactic antibiotics is more effective than screening all women and treating only those with evidence of infection (Levallois & Rioux, 1988). The inability to provide antibiotics should not limit access to abortion (WHO, 2014), as the overall risk of infection with abortion procedures is very low.

Regimen

Many studies have examined antibiotic regimens for prophylaxis before abortion, but the ideal antibiotic, dose and timing has not been established (Achilles & Reeves, 2011; Low et al., 2012). Tetracyclines (doxycycline) and nitroimidazoles (metronidazole and tinidazole) are commonly used because of their efficacy, ease of oral administration, low cost and low risk of allergic reactions (Achilles & Reeves, 2011; O’Connell, Jones, Lichtenberg, & Paul, 2008). Although studies of abortion are limited (Caruso et al., 2008), evidence from the obstetric (Costantine et al., 2008), gynecologic (Mittendorf et al., 1993) and general surgery (Classen et al., 1992) literature supports the practice of giving antibiotics before the procedure to decrease the risk of infection. Antibiotic regimens do not need to be continued after the abortion procedure (Achilles & Reeves, 2011; Caruso, et al., 2008; Levallois & Rioux, 1988; Lichtenberg & Shott, 2003).

The following table lists regimens recommended by professional organizations based on clinical evidence and expert opinion.

Common regimens Recommender
Doxycycline 200mg orally before the procedure
or
Azithromycin 500mg orally before the procedure
or
Metronidazole 500mg orally before the procedure
​Planned Parenthood Federation of America (PPFA, 2016)
Doxycycline 200mg orally no more than 2 hours before the procedure
or
Azithromycin 500mg orally no more than 2 hours before the procedure
Royal College of Obstetricians and Gynaecologists (RCOG, 2015)
Doxycycline 200mg orally within 1 hour before procedure American College of Obstetricians and Gynecologists
(ACOG, 2018)

Antibiotics with osmotic dilators

Although not well studied, cervical preparation with osmotic dilators does not appear to increase the risk of infection (Fox & Krajewski, 2014; Jonasson, Larsson, Bygdeman, & Forsum, 1989). Some providers start antibiotics at the time of osmotic dilator placement, but there are no studies evaluating the benefit of this practice (White et al., 2018).

Therapeutic antibiotics

Women at high risk should be screened for sexually transmitted infections in addition to receiving prophylactic antibiotics. Women who have signs and symptoms of sexually transmitted infection should receive abortion services without delay and appropriate antibiotic treatment according to evidence-based regimens (WHO, 2014; WHO, 2005). Partners of women with sexually transmitted infections also require treatment (WHO, 2016).

Resources

Recommendations for use of prophylactic antibiotics in safe abortion care (card)

References

Achilles, S. L., & Reeves, M. F. (2011). Society of Family Planning Clinical Guideline 20102: Prevention of infection after induced abortion. Contraception83(4), 295-309.

American College of Obstetrics and Gynecology. (2018). Practice Bulletin No. 195: Prevention of infection after gynecologic procedures. Obstetrics & Gynecology, 131(6), e172-e189.

Caruso, S., Di Mari, L., Cacciatore, A., Mammana, G., Agnello, C., & Cianci, A. (2008). [Antibiotic prophylaxis with prulifloxacin in women undergoing induced abortion: A randomized controlled trial]. Minerva Ginecologica60(1), 1-5.

Classen, D. C., Evans, R. S., Pestotnik, S. L., Horn, S. D., Menlove, R. L., & Burke, J. P. (1992). The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. The New England Journal of Medicine326(5), 281-286.

Costantine, M. M., Rahman, M., Ghulmiyah, L., Byers, B. D., Longo, M., Wen, T., & Saade, G. R. (2008). Timing of perioperative antibiotics for cesarean delivery: A metaanalysis. American Journal of Obstetrics & Gynecology199(3), 301-306.

Fox, M. C., & Krajewski, C. M. (2014). Society of Family Planning Clinical Guideline 20134: Cervical preparation for second-trimester surgical abortion prior to 20 weeks’ gestation. Contraception, 89(2), 75-82.

Goranitis, I., Lissauer, D. M., Coomarasamy, A., Wilson, A., Daniels, J., Middleton, L., … & Roberts, T. E. (2019). Antibiotic prophylaxis in the surgical management of miscarriage in low-income countries: a cost-effectiveness analysis of the AIMS trial. The Lancet Global Health, 7(9), e1280-e1286.

Jonasson, A., Larsson, B., Bygdeman, S., & Forsum, U. (1989). The influence of cervical dilatation by laminaria tent and with Hegar dilators on the intrauterine microflora and the rate of postabortal pelvic inflammatory disease. Acta Obstetricia et Gynecologica Scandinavica68(5), 405-410.

Levallois, P., & Rioux, J. E. (1988). Prophylactic antibiotics for suction curettage abortion: Results of a clinical controlled trial. American Journal of Obstetrics & Gynecology158(1), 100-105.

Lichtenberg, E. S., & Shott, S. (2003). A randomized clinical trial of prophylaxis for vacuum abortion: 3 versus 7 days of doxycycline. Obstetrics & Gynecology101(4), 726-731.

Lissauer, D., Wilson, A., Hewitt, C.A., Middleton, L., Bishop, J.R.B., Daniels, J., … Coomarasamy, A. (2019). A randomized trial of prophylactic antibiotics for miscarriage surgery. The New England Journal of Medicine, 380(11), 1012-1021.

Low, N., Mueller, M., Van Vliet, H., & Kapp, N. (2012). Perioperative antibiotics to prevent infection after first‐trimester abortion. The Cochrane Database of Systematic Reviews, (3), CD005217.

Mittendorf, R., Aronson, M. P., Berry, R. E., Williams, M. A., Kupelnick, B., Klickstein, A., & Chalmers, T. C. (1993). Avoiding serious infections associated with abdominal hysterectomy: A meta-analysis of antibiotic prophylaxis. American Journal of Obstetrics & Gynecology169(5), 1119-1124.

Planned Parenthood Federation of America. (2016). Manual of Medical Standards and Guidelines. Washington, D.C.: Planned Parenthood Federation of America.

Prieto, J. A., Eriksen, N. L., & Blanco, J. D. (1995). A randomized trial of prophylactic doxycycline for curettage in incomplete abortion. Obstetrics & Gynecology85(5), 692-696.

Ramin, K. D., Ramin, S. M., Hemsell, P. G., Nobles, B. J., Heard, M. C., Johnson, V. B., & Hemsell, D. L. (1995). Prophylactic antibiotics for suction curettage in incomplete abortion. Infectious Diseases in Obstetrics and Gynecology2(5), 213-217.

Royal College of Obstetricians and Gynaecologists. (2015). Best Practice Paper No. 2: Best practice in comprehensive abortion care. London: Royal College of Obstetricians and Gynaecologists Press.

Seeras, R. (1989). Evaluation of prophylactic use of tetracycline after evacuation in abortion in Harare Central Hospital. East African Medical Journal66(9), 607-610.

Serwadda, D. M. (2019). To give or not to give prophylactic antibiotics for miscarriage surgery? The New England Journal of Medicine, 380(11), 1075-1076.

Titapant, V., & Cherdchoogieat, P. (2012). Effectiveness of cefoxitin on preventing endometritis after uterine curettage for spontaneous incomplete abortion: A randomized controlled trial study. Journal of the Medical Association of Thailand, 95(11), 1372-1377.

White, K. O., Jones, H. E., Shorter, J., Norman, W. V., Guilbert, E., Lichtenberg, E. S., & Paul, M. (2018). Second-trimester surgical abortion practices in the United States. Contraception, 98, 95-99.

World Health Organization. (2014). Clinical practice handbook for safe abortion. Geneva: World Health Organization Press.

World Health Organization. (2016). Global health sector strategy on sexually transmitted infections 2016-2021. Geneva: World Health Organization Press.

World Health Organization. (2005). Sexually transmitted and other reproductive tract infections: A guide to essential practice. Geneva: World Health Organization Press.