Antibiotic prophylaxis for intrauterine contraceptive device insertion

Prophylactic use of antibiotics to reduce of the risk of upper genital infection after IUD insertion yields no benefit with respect to pelvic inflammatory disease or IUD continuation rates.

RHL Commentary by Faúndes A

1. EVIDENCE SUMMARY

This review concludes that at the present time there is no scientific basis for recommending the routine use of prophylactic antibiotics to reduce of the risk of upper genital infection after insertion of an intrauterine device (IUD).

The methodology appears to be appropriate.

2. RELEVANCE TO UNDER-RESOURCED SETTINGS

2.1. Magnitude of the problem

Pelvic inflammatory disease (PID) among IUD users is not frequent in Brazil. The cumulative rate of IUD removals for infection is below 1% after one year of use in an environment in which the prevalence of Neisseria gonorrhoea infection is low and of Chlamydia infection moderate (1, 2). Data from other Latin-American countries are not different.

2.2. Feasibility of the intervention

The routine use of prophylactic antibiotics in family planning clinics would more than double the cost of consumables, if azithromycin was used. As other costs of IUD insertion are low in developing countries, the imposition of the use of antibiotics may have a significant impact on the availability of the method. More importantly, if international organizations dealing with contraception were to recommend prophylactic antibiotics before every IUD insertion, it would be interpreted as a confirmation of a strong association between IUD and PID - a wrong concept that has been difficult to dispell.

2.3. Applicability of the results of the Cochrane Review

As the Cochrane Review includes countries with prevalence rates of pelvic infection which are both higher and lower than in Latin America, the results should be applicable to the region.

2.4. Implementation of the intervention

The use of prophylactic antibiotics at IUD insertion should not be implemented in our region for the reasons given above (2.2), and also because the use of antibiotics could give a false sense of safety from infection, which in turn could lead to relaxation of the precautions that need to be taken before and at the time of insertion. The evidence presented in the Cochrane Review will help to prevent possible initiatives to introduce such an intervention and to stop the practice where prophylactic antibiotics are routinely used at the time of IUD insertion.

2.5. Research

The studies included in the review indicate that fewer than 20 % of the women with Chlamydia trachomatis or Neisseria gonorrhoea in the cervix develop PID after IUD insertion. However, it is not clear if cases of PID were observed among women without pre-existing colonisation. A recent study found two cases of PID after IUD insertion among 19 women with Chlamydia in the cervix but no case among 308 women free from this pathogen who had an IUD inserted during the same period in the same clinic (3). Research directed towards understanding why some of these women develop pelvic infection while others do not will help to design new strategies to decrease the risk of PID after IUD insertion. Research should be directed at methods of detecting pre-existing cervical contamination, and preventing the spread of the infection in these women after IUD insertion.

References

  • Díaz J, Díaz MM, Pastene L, Araki R, Faúndes Al. Randomized clinical study of the T-Cu 380A and the Lippes Loop C, in Campinas, Brazil. Contraception 1982;26:221-228.
  • Shaffer N et al. UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction IUD Research Group. The Tcu 380A IUD and the frameless IUD "the FlexiGard": interim three-year data from an international multicenter trial. Contraception 1995;52:77-83.
  • Faúndes A, Telles E, Cristofoletti ML, Faúndes D, Castro S, Hardy E. The risk of inadvertent intrauterine insertion in women carriers of endocervical Chlamydia trachomatis. Contraception 1998;56:105-109.

This document should be cited as: Faúndes A. Administration of prophylactic antibiotics at IUD insertion : RHL commentary (last revised: 1 December 2001). The WHO Reproductive Health Library; Geneva: World Health Organization.