Prophylactic antibiotics in first-trimester abortions: a clinical, controlled trial. Antibiotic prophylaxis to prevent post-abortal upper genital tract infection in women with bacterial vaginosis: randomised controlled trial. Prophylactic antibiotics in women with a history of pelvic inflammatory disease undergoing first-trimester abortion. Metronidazole prophylaxis in elective first trimester abortion. Randomized trial of prophylactic antibiotic therapy after preterm amnion rupture. Prophylactic antibiotics for suction curettage abortion: results of a clinical controlled trial. A randomised controlled trial of a tailored multifaceted strategy to promote implementation of a clinical guideline on induced abortion care. [Antibiotic prophylaxis in a priori cesarean sections without a high risk of infection. Experiences of a Tunisian maternity department]. A randomised comparison of strategies for reducing infective complications of induced abortion. [Antibiotic prophylaxis with prulifloxacin in women undergoing induced abortion: a randomized controlled trial]. Randomized trial of antibiotics in addition to tocolytic therapy to treat preterm labor. Prophylaxis with lymecycline in induced first-trimester abortion: a clinical, controlled trial assessing the role of Chlamydia trachomatis and Mycoplasma hominis. Choice of antibiotics for infection prophylaxis in emergency cesarean sections in low-income countries: a cost-benefit study in Mozambique. A double-blind randomized study of the effect of erythromycin in preventing pelvic inflammatory disease after first trimester abortion. The prophylactic effect of doxycycline on postoperative infection rate after first-trimester abortion. Prophylactic antibiotics in Caesarean section: effect of a short preoperative course of benzyl penicillin or clindamycin plus gentamicin on postoperative infectious morbidity. Antibiotic treatment of preterm labor with intact membranes: a multicenter, randomized, double-blinded, placebo-controlled trial. A double-blind randomized controlled trial on the use of prophylactic antibiotics in patients undergoing elective caesarean section.
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 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. 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 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). Our purpose was to determine whether maternal administration of prophylactic ampicillin or erythromycin after preterm amnion rupture is associated with maternal or neonatal benefits.
                Women with singleton pregnancies between 24 and 33 weeks 6 days of gestation were eligible if they had no immediate indication for delivery. After giving informed consent, patients were randomized either to receive ampicillin (erythromycin if penicillin allergic) until delivery or to enter a control group. Women whose cervical cultures were positive for either group B streptococci or Neisseria gonorrhoeae received treatment. Tocolytics and corticosteroids were not used.
                From January 1990 to February 1992 117 patients (antibiotics 59, control 58) were recruited and analyzed. Prophylactic antibiotics were associated with a longer latent phase (mean 12 vs 7.0 days, p = 0.004) and fewer maternal infectious complications (29% vs 60%, p = 0.001). A higher incidence of neonatal necrotizing enterocolitis was observed in the treatment group (14% vs 3.5%, p = 0.05). Other neonatal complications, including death, were lower in the treatment group, but none attained statistical significance (p = 0.09 to 0.33).
                The use of prophylactic antibiotics in selected patients after preterm amnion rupture appears to have a demonstrable maternal benefit. Large, multicenter trials may demonstrate a significant neonatal benefit or confirm any adverse outcomes. 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. To evaluate the effectiveness and efficiency of a tailored multifaceted strategy, delivered by a national clinical effectiveness programme, to implement a guideline on induced abortion.
                Cluster randomised controlled trial.
                All 26 hospital gynaecology units in Scotland providing induced abortion care.
                Following the identification of barriers to guideline implementation, intervention units received a package comprising audit and feedback, unit educational meetings, dissemination of structured case records and promotion of a patient information booklet. Control units received printed guideline summaries alone.
                Compliance with five key guideline recommendations (primary outcomes) and compliance with other recommendations, patient satisfaction and costs of the implementation strategy (secondary outcomes).
                No effect was observed for any key recommendation: appointment with a gynaecologist within five days of referral (odds ratio 0.89; 95% confidence interval 0.50 to 1.58); ascertainment of cervical cytology history (0.93; 0.36 to 2.40); antibiotic prophylaxis or screening for lower genital tract infection (1.70; 0.71 to 5.99); use of misoprostol as an alternative to gemeprost (1.00; 0.27 to 1.77); and offer of contraceptive supplies at discharge (1.11; 0.48 to 2.53). Median pre-intervention compliance was near optimal for antibiotic prophylaxis and misoprostol use. No intervention benefit was observed for any secondary outcome. The intervention costs an average of pound 2607 per gynaecology unit.
                The tailored multifaceted strategy was ineffective. This was possibly attributable to high pre-intervention compliance and the limited impact of the strategy on factors outside the perceived control of clinical staff. This study was conducted to evaluate the effect of antibiotic prophylaxy on decreasing the frequency of postoperative infections after cesarean sections performed in cases with no prior indication of a high risk of infection.
                A prospective randomized study included 269 cesarean sections without a high risk of infection performed in the Maternity and Neonatology Ward of the Sousse Hospital from February 1991 to July 1991. The patients were randomly divided into two groups. One group received an antibiotic prophylactic treatment including cephapirine, gentamicin and metronidazole) and the second group was given no treatment.
                Antibiotic prophylactic therapy led to a reduction of infectious morbidity after cesarean section in patients without high risk o infection from 33% to 11%. A 66% rate of efficacy was observed. In addition, antibiotics given in this context led to substantial cost reduction both by reducing the cost of antibiotics prescribed in the postoperative period and by reducing the number of days of hospitalization, and thus total cost.
                This study demonstrated the effectiveness of antibiotic prophylaxy for cesarean sections in patients without a high risk of infection. Nevertheless, a reevaluation of the antibiotic protocols and a rigorous operative procedure are essential. 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 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. The objective of this study was to assess whether antibiotic therapy plus tocolysis given to women in preterm labor would prolong pregnancy compared with tocolysis alone.
                A randomized, double-blind trial of intravenous mezlocillin and oral erythromycin therapy vs. placebo was used in addition to tocolysis among women in preterm labor < or =34 weeks gestation with intact membranes. Amniocentesis was performed, and chorioamnionic membranes were examined histologically and cultured for microorganisms after delivery.
                Clinical characteristics including gestational age at enrollment, frequency of contractions, cervical Bishop's score, and white blood cell count on admission were similar in the 2 groups. Antibiotic therapy was well tolerated. No significant differences in the interval to delivery, birth weight, and neonatal outcomes were observed between the 2 groups. Women in the antibiotic group had a significantly lower incidence of postpartum infections compared with women in the placebo group. Patients with evidence of upper genital tract infection in either group had a significantly shorter interval to delivery, lower gestational age at delivery, lower mean birth weight, and increased neonatal hospitalization time.
                Lack of an antibiotic effect on the gestational age at delivery may be due to the low prevalence of upper genital tract infection among unselected women in preterm labor, to advanced preterm labor unresponsive to antibiotic therapy, or to an inability of antibiotics given alone to inhibit the cytokine response. Further work is needed to identify markers of upper genital tract infection among women in preterm labor and to evaluate other potential therapeutic interventions. 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. There is a need to assess the cost-benefit of different models of antibiotic administration for the prevention of post cesarean infection, particularly in resource-scarce settings.
                Randomized, nonblinded comparative study of a single combined preoperative dose of gentamicin and metronidazole vs. a post cesarean scheme for infection prophylaxis.
                Pregnant women (n = 288) with indication for emergency cesarean section were randomly allotted to two groups. Group 1 (n = 143) received the single, combined dose of prophylactic antibiotics and group 2 (n = 145) received, over 7 days, the postoperative standard scheme of antibiotics followed in the department. Both groups were followed up during 7 days for detection of signs of wound infection, endometritis, peritonitis and urinary tract infection.
                Prevalence of postoperative infection, mean hospital stay and costs of antibiotics used.
                Women completing the study (n = 241) were distributed into group 1 (n = 116) and group 2 (n = 125). No significant difference was found neither in the prevalence of postoperative infection nor in the mean hospital stay. No death occurred. The cost of the single dose of prophylactic antibiotics was less than one-tenth of the cost of the standard postoperative scheme.
                In our setting, the administration of a single dose of 160 mg of gentamicin in combination with 500 mg of metronidazole before emergency cesarean section for prevention of infection is clinically equivalent to existing conventional week-long postoperative therapy, but at approximately one-tenth of the cost. 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. 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. The efficacy of a narrow-spectrum (benzyl penicillin) versus broad-spectrum (clindamycin + gentamicin) preoperative antimicrobial prophylaxis was studied in a series of 147 consecutive patients undergoing Caesarean section at the State Maternity Hospital, Helsinki, Finland. Both regimens proved effective in reducing postoperative endometritis: from 33% (19/57 cases) to 6.5% (3/46 cases) in the penicillin treated group, and to 9.5% (4/42 cases) in the clindamycin + gentamicin treated group. The reduction in the incidence of endometritis was not reflected in the duration of hospital stay, which was 7.7 days in the untreated group, 7.8 days in the penicillin treated group, and 7.6 days in the clindamycin + gentamicin treated group. No significant differences between the groups were detected in the incidence of wound infections. Although an association between subclinical intrauterine infection and preterm birth is well established, there is conflicting evidence regarding the benefits of antibiotic administration to women in preterm labor with intact membranes. We attempted to determine the effect of ampicillin-amoxicillin and erythromycin treatment on prolongation of pregnancy, the rate of preterm birth, and neonatal morbidity in patients with preterm labor and intact membranes.
                A multicenter, randomized, double-blinded, placebo-controlled trial was designed and implemented by the Maternal-Fetal Medicine Units Network of the National Institute of Child Health and Human Development. Two hundred seventy-seven women with singleton pregnancies and preterm labor with intact membranes (24 to 34 weeks) were randomly allocated to receive either antibiotics or placebos.
                Of the 2373 patients screened for participation in this study in six medical centers, 277 women were enrolled (n = 133 for antibiotics group vs n = 144 for placebo group). In each study group, 60% of patients completed all the study medications. The overall prevalence of microbial invasion of the amniotic cavity was 5.8% (14/239). No significant difference between the antibiotic group and the placebo group was found in maternal outcomes, including duration of randomization-to-delivery interval, frequency of preterm delivery (< 37 weeks), frequency of preterm premature rupture of membranes, clinical chorioamnionitis, endometritis, and number of subsequent admissions for preterm labor. Similarly, no significant difference in neonatal outcomes could be detected between the two groups including respiratory distress syndrome, bronchopulmonary dysplasia, intraventricular hemorrhage, sepsis, and admission and duration of newborn intensive special care unit hospitalization.
                The results of this study do not support the routine use of antibiotic administration to women in preterm labor with intact membranes. In a double-blind randomized controlled study 232 patients undergoing elective lower segment caesarean section were randomly allocated to receive a pre-operative prophylactic dose of a combination of crystalline penicillin and chloramphenicol or a placebo. The two groups were comparable in terms of patient characteristics and operation variables. The group receiving antibiotics had significantly fewer febrile and infectious morbid events and thus spent fewer days in hospital than the group receiving the placebo.
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.