Michael Nevill Director of Nursing BPAS NICE Guideline Committee Member The views expressed in this presentation are those of the authors and not necessarily those of NICE Guideline is available from ID: 920451
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Slide1
Antibiotic Prophylaxis for Abortion
Michael Nevill
Director of Nursing, BPAS
NICE Guideline Committee Member
Slide2The views expressed in this presentation are those of the authors and not necessarily those of NICE
Guideline is available from:
https://www.nice.org.uk/guidance/NG140
Slide3What is the optimal antibiotic prophylaxis regimen (including no antibiotic prophylaxis as an option) for women who are having medical abortion?
Slide4Search Strategy (1)
Population
Women who are having medical termination of pregnancy
Intervention
Antibiotic prophylaxis (any dose) using:
Oral azithromycin
Oral doxycycline
Oral or rectal metronidazole
Comparison
Antibiotic prophylaxis (single agent or combination) vs placebo/ no treatment
Antibiotic prophylaxis A (single agent or combination) vs antibiotic prophylaxis B (single agent or combination)
Slide5Search Strategy (2)
Critical Outcomes
Sever
e infection (defined as sepsis, requiring hospitalisation, requiring intravenous antibiotics, or infection as cause of death) within 1 month of termination
Post-
abortal
pelvic inflammatory diseases (including
endometritis
, upper genital tract infection) within 1 month of termination
Adherence to antibiotics
Important Outcomes
Gastro-intestinal
side-effects:
Nausea
Vomiting
Diarrhoea
Patient acceptability
Slide6Search Results
Slide7Included Studies
Study and setting
Population
Intervention
Comparison
Outcomes
Fjerstad
2009
Retrospective cohort study
USA
n=227,823
whole study
n=
115,562 cohorts of interest for review
Women undergoing medical abortion
Period 4
:
Buccal misoprostol
and
doxycycline 100mg twice a day for 7-days
through
63 days of gestation
Period 1
:
Vaginal misoprostol
and standard antiseptic measures through
63 days
of gestation
Severe infection within 2 weeks of termination
Frye 2015
Prospective cohort study
USA
n=581
Women
presenting for medical abortion in the study clinics who could read English or Spanish
Doxycycline 7-day course (dose not specified)
No antibiotic prophylaxis
Nausea
Vomiting
Diarrhoea
*Patient adherence reported in doxycycline arm only
Slide8Results
Slide9Antibiotic prophylaxis with doxycycline versus no antibiotic prophylaxis
Slide10Antibiotic prophylaxis with doxycycline versus no antibiotic prophylaxis
Outcome: Severe infection within 1 month of termination
Slide11Antibiotic prophylaxis with doxycycline versus no antibiotic prophylaxis
Outcome: Nausea
NNT= 1 in 91
Slide12Antibiotic prophylaxis with doxycycline versus no antibiotic prophylaxis
Outcome: Vomiting
NNT= 1 in 4
Slide13Antibiotic prophylaxis with doxycycline versus no antibiotic prophylaxis
Outcome: Diarrhoea
Slide14Summary: Antibiotic prophylaxis with doxycycline vs no antibiotics
Outcome
Favours
Severe
infection
Antibiotic
prophylaxis with doxycycline
Nausea
Overall: No difference
Severe: Antibiotic prophylaxis with doxycycline
>1 day
duration: No difference
Vomiting
Overall: antibiotic prophylaxis with doxycycline
Severe: Antibiotic prophylaxis with doxycycline
>1 day
duration:
Antibiotic prophylaxis with doxycycline
Diarrhoea
Overall: No difference
Severe:
No difference
>1 day
duration: No difference
Slide15Making recommendations
The evidence did show lower rates of severe infection with antibiotics than without, but the quality of the evidence was poor and the risk of severe infection was extremely low.
The committee had to consider
Antibiotic resistance
Adherence
Relative risk
Side effects
Slide16Medical abortion prophylaxis –
The recommendations
1.4.2 Do not routinely offer antibiotic prophylaxis to women who are having a medical abortion.
However consider the risk and screening recommendations for STIs.
Slide17What is the optimal antibiotic prophylaxis regimen for women who are having surgical abortion?
Slide18Evidence Search Strategy
Population
Women who are having
surgical
termination of pregnancy (using
vacuum aspiration or dilation and evacuation, but NOT sharp curettage)
Intervention
Any oral or rectal antibiotic prophylaxis (any dose)
Comparison
Antibiotic prophylaxis A (single agent or combination) vs antibiotic prophylaxis B (single agent or combination)
Antibiotic prophylaxis A (oral doxycycline or metronidazole only) – duration A vs antibiotic prophylaxis A (oral doxycycline or metronidazole only) – duration B
Slide19Evidence Search Strategy (2)
Critical Outcomes
Sever
e infection (defined as sepsis, requiring hospitalisation, requiring intravenous antibiotics, or infection as cause of death) within 1 month of termination
Post-
abortal
pelvic inflammatory diseases (including
endometritis
, upper genital tract infection) within 1 month of termination
Adherence to antibiotics
Important Outcomes
Gastro-intestinal
side-effects:
Nausea
Vomiting
Diarrhoea
Patient acceptability
Slide20Search results
Slide21Included Studies
Study and setting
Population
Intervention
Comparison
Outcomes
Litchenberg
2003
RCT
USA
n=800
Women no more than 13
+0
weeks pregnant presenting for surgical termination of pregnancy
Postoperative doxycycline 100mg twice
a day for 3 days
Postoperative doxycycline 100mg twice a day for 7 days
Post-
abortal
pelvic inflammatory disease at 2-week follow-up
Adherence to
antibiotcs
Vomiting
Diarrhoea
Miller 2004
RCT
USA
n=393 whole population
Women
presenting for 1
ST
or 2
nd
trimester surgical termination of pregnancy with elevated vaginal pH and amines detected in their vaginal discharge
n=236 positive gram stain for bacterial
vaginosis
Metronidazole
1g orally prior to procedure, followed by 400mg twice a day for 7-days + postoperative doxycycline 100mg twice a day for 7-days
Postoperative doxycycline 100mg twice a day for 7 days
Post-
abortal
complication score of
>
3 at 7-10 days*
Post-
abortal
complication score of
>
5
at 7-10 days*
*Women returning
to clinic because of suspected infection were asked the same standardised questions
Slide22Results from the studies
Slide231. Antibiotic prophylaxis with metronidazole and doxycycline versus doxycycline
Slide24Antibiotic prophylaxis with metronidazole and doxycycline versus doxycycline
Outcome: Post-
abortal
pelvic inflammatory disease
Slide25Antibiotic prophylaxis with doxycycline 3-days versus doxycycline 7-days
Slide26Antibiotic prophylaxis with doxycycline 3-days vs doxycycline 7-days
Outcome: Post-
abortal
pelvic inflammatory disease
Slide27Antibiotic prophylaxis with doxycycline 3-days vs doxycycline 7-days
Outcome: Adherence to antibiotics
Slide28Antibiotic prophylaxis with doxycycline 3-days vs doxycycline 7-days
Outcome: Vomiting
Slide29Antibiotic prophylaxis with doxycycline 3-days vs doxycycline 7-days
Outcome: Diarrhoea
Slide30Summary
Outcome
Metronidazole
+ doxycycline vs doxycycline
Doxycycline
3-days vs 7-days
Post-
abortal
pelvic inflammatory disease
No
difference
No difference
Adherence
to antibiotics
No difference
Vomiting
No difference
Diarrhoea
No difference
Slide31Making recommendations
It was never considered that we would be making a recommendation for no antibiotics for surgical abortion prophylaxis.
The evidence did not identify which regimen is most effective
No difference in 3 vs 7 days doxycycline
No apparent benefit to the addition of metronidazole
Slide32Surgical abortion prophylaxis –
The recommendations
1.4.3 Offer antibiotic prophylaxis to women who are having a surgical abortion
1.4.4 When using doxycycline for antibiotic prophylaxis…consider oral doxycycline 100mg twice a day for 3 days
1.4.5 When using metronidazole for antibiotic prophylaxis…do not routinely offer it in combination with another broad spectrum antibiotic such as doxycycline
Again consider the risk and screening recommendations for STIs.
Slide33Thank you
With thanks to Mia Schmidt-Hansen
MSchmidtHansen@rcog.org.uk
and Laura O’Shea
LOShea@rcog.org.uk