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. 2000;1999(2):CD001327.
doi: 10.1002/14651858.CD001327.

Antibiotic prophylaxis for intrauterine contraceptive device insertion

D A Grimes  1 , K F Schulz
Affiliations

Antibiotic prophylaxis for intrauterine contraceptive device insertion

D A Grimes et al. Cochrane Database Syst Rev. 2000.

Update in

Abstract

Background: Concern about the risk of upper genital tract infection (pelvic inflammatory disease) often limits use of the 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 and discontinuations within three months of insertion. The primary outcome was pelvic inflammatory disease (four reports) or early removals of the device (two reports).

Search strategy: We searched both MEDLINE and EMBASE, handsearches of journals through CENTRAL, and lists of references. We also wrote to international experts in the field to identify unpublished studies.

Selection criteria: We included randomized controlled trials using any antibiotic compared with a placebo. We found four such trials; two had pilot study data available.

Data extraction: We used searches of MEDLINE, EMBASE, and handsearches of journals available through CENTRAL. We also reviewed lists of references in original research and in review articles. We wrote to experts to identify unpublished trials and made telephone calls to authors to supply missing information. Two independent reviewers abstracted data. We assessed the validity of each study using methods suggested in the Cochrane Handbook.

Data synthesis: We generated 2x2 tables for the principal outcome measures. We used the Peto modified Mantel-Haenszel technique to calculate odds ratios and assessed statistical heterogeneity between studies.

Main results: The odds ratios for pelvic inflammatory disease associated with use of prophylactic doxycycline or azithromycin compared with placebo or no treatment was 0.89 (95%CI 0.53-1.51). Use of prophylaxis was associated with a small reduction in unscheduled vists to the provider (OR 0.82; 95% CI 0.70-0.98). 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 0.68-1.63). Significant heterogeneity did not exist between studies.

Reviewer's 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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Conflict of interest statement

Drs. Grimes and Schulz were investigators in the Kenya trial (Sinei 1985; Sinei 1990) and Dr. Grimes in the Los Angeles trial (Walsh 1994; Walsh 1998) included in this review.

Dr. Grimes has consulted with the pharmaceutical companies Bayer Healthcare Pharmaceuticals and Merck & Co, Inc.

Figures

1.1
1.1. Analysis
Comparison 1 Antibiotic versus placebo or no treatment, Outcome 1 Pelvic inflammatory disease (OR).
1.2
1.2. Analysis
Comparison 1 Antibiotic versus placebo or no treatment, Outcome 2 Pelvic inflammatory disease (RR).
1.3
1.3. Analysis
Comparison 1 Antibiotic versus placebo or no treatment, Outcome 3 Unscheduled visits to the clinic (OR).
1.4
1.4. Analysis
Comparison 1 Antibiotic versus placebo or no treatment, Outcome 4 Unscheduled visits to the clinic (RR).
1.5
1.5. Analysis
Comparison 1 Antibiotic versus placebo or no treatment, Outcome 5 Removal of the IUD within 90 days (OR).
1.6
1.6. Analysis
Comparison 1 Antibiotic versus placebo or no treatment, Outcome 6 Removal of the IUD within 90 days (RR).
1.7
1.7. Analysis
Comparison 1 Antibiotic versus placebo or no treatment, Outcome 7 Fever without PID diagnosis.
See this image and copyright information in PMC

References

References to studies included in this review

Ladipo 1991 {published data only}
    1. Ladipo OA, Farr G, Otolorin E, Konje JC, Sturgen K, Cox P, et al. Prevention of IUD‐related pelvic infection: the efficacy of prophylactic doxycycline at IUD insertion. Advances in Contraception 1991;7:43‐54. [MEDLINE: ] - PubMed
Sinei 1985 {unpublished data only}
    1. Sinei SKA, Schulz KF, Lamptey PR, Grimes DA, Mati JKG, Rosenthal SM, et al. Kenya, January 14, 1985 ‐ February 7, 1985. Consultation regarding the analysis of the pilot phase and the initiation of the full‐scale phase of the randomized clinical trial of prophylactic doxycycline at the time of IUCD insertion to prevent pelvic inflammatory disease. Schulz KF: Foreign trip report (AID/RSSA); 1985 Feb.
Sinei 1990 {published data only}
    1. Sinei SKA, Schulz KF, Lamptey PR, Grimes DA, Mati JKG, Rosenthal SM, et al. Preventing IUCD‐related pelvic infection: the efficacy of prophylactic doxycycline at insertion. British Journal of Obstetrics and Gynaecology 1990;97:412‐9. [MEDLINE: ] - PubMed
Walsh 1994 {published data only}
    1. Walsh TL, Bernstein GS, Grimes DA, Frezieres R, Bernstein L, Coulson AH. Effect of prophylactic antibiotics on morbidity associated with IUD insertion: results of a pilot randomized controlled trial. IUD Study Group. Contraception 1994;50:319‐27. [MEDLINE: ] - PubMed
Walsh 1998 {published and unpublished data}
    1. Walsh T, Grimes D, Frezieres R, Nelson A, Bernstein L, Coulson A, et al. Randomised controlled trial of prophylactic antibiotics before insertion of intrauterine devices. Lancet 1998;351:1005‐8. [MEDLINE: ] - PubMed
Zorlu 1993 {published data only}
    1. Zorlu CG, Aral K, Cobanoglu O, Gurler S, Gokmen O. Pelvic inflammatory disease and intrauterine devices: prophylactic antibiotics to reduce febrile complications. Advances in Contraception 1993;9:299‐302. [MEDLINE: ] - PubMed

References to studies excluded from this review

Jovanovic 1988 {published data only}
    1. Jovanovic R, Barone CM, Natta FC, Congema E. Preventing infection related to insertion of an intrauterine device. Journal of Reproductive Medicine 1988;33:347‐52. - PubMed
Rogovskaya 1998 {unpublished data only}
    1. Rogovskaya SI. Prophylaxis of complications connected with intrauterine contraception [dissertation]. Moscow (Russia): Research Centre of Ob/Gyn and Perinatology, 1998.

Additional references

Farley 1992
    1. Farley TMM, Rosenberg MJ, Rowe P, Chen J‐H, Meirik O. Intrauterine devices and pelvic inflammatory disease: an international perspective. Lancet 1992;339:785‐8. [MEDLINE: ] - PubMed
Hager 1983
    1. Hager WD, Eschenbach DA, Spence MR, Sweet RL. Criteria for diagnosis and grading of salpingitis. Obstetrics and Gynecology 1983;61:113‐4. [MEDLINE: ] - PubMed
Lee 1983
    1. Lee NC, Rubin GL, Ory HW, Burkman RT. Type of intrauterine device and the risk of pelvic inflammatory disease. Obstetrics and Gynecology 1983;62:1‐6. [MEDLINE: ] - PubMed
Mishell 1966
    1. Mishell DR Jr, Bell JH, Good RG, Moyer DL. The intrauterine device: a bacteriologic study of the endometrial cavity. American Journal of Obstetrics and Gynecology 1966;96:119‐26. [MEDLINE: ] - PubMed
Sawaya 1996
    1. Sawaya GF, Grady D, Kerlikowske K, Grimes DA. Antibiotics at the time of induced abortion: the case for universal prophylaxis based on a meta‐analysis. Obstetrics and Gynecology 1996;87:884‐90. [MEDLINE: ] - PubMed

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