Antibiotics for treating septic abortion: Cochrane systematic review
Assessed as up to date: 2016/04/19
A septic abortion refers to any abortion (spontaneous or induced) complicated by upper genital tract infection including endometritis or parametritis. The mainstay of treatment of septic abortion is antibiotic therapy alone or in combination with evacuation of retained products of conception. Regimens including broad-spectrum antibiotics are routinely recommended for treatment. However, there is no consensus on the most effective antibiotics alone or in combination to treat septic abortion. This review aimed to bridge this gap in knowledge to inform policy and practice.Objectives
To review the effectiveness of various individual antibiotics or antibiotic regimens in the treatment of septic abortion.Search methods
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, LILACS, and POPLINE using the following keywords: 'Abortion', 'septic abortion', 'Antibiotics', 'Infected abortion', 'postabortion infection'. We also searched the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov for ongoing trials on 19 April, 2016.Selection criteria
We considered for inclusion randomised controlled trials (RCTs) and non-RCTs that compared antibiotic(s) to another antibiotic(s), irrespective of route of administration, dosage, and duration as well as studies comparing antibiotics alone with antibiotics in combination with other interventions such as dilation and curettage (D&C).Data collection and analysis
Two review authors independently extracted data from included trials. We resolved disagreements through consultation with a third author. One review author entered extracted data into Review Manager 5.3, and a second review author cross-checked the entry for accuracy.Main results
We included 3 small RCTs involving 233 women that were conducted over 3 decades ago.
Clindamycin did not differ significantly from penicillin plus chloramphenicol in reducing fever in all women (mean difference (MD) -12.30, 95% confidence interval (CI) -25.12 to 0.52; women = 77; studies = 1). The evidence for this was of moderate quality. "Response to treatment was evaluated by the patient's 'fever index' expressed in degree-hour and defined as the total quantity of fever under the daily temperature curve with 99°F (37.2°C) as the baseline".
There was no difference in duration of hospitalisation between clindamycin and penicillin plus chloramphenicol. The mean duration of hospital stay for women in each group was 5 days (MD 0.00, 95% CI -0.54 to 0.54; women = 77; studies = 1).
One study evaluated the effect of penicillin plus chloramphenicol versus cephalothin plus kanamycin before and after D&C. Response to therapy was evaluated by "the time from start of antibiotics until fever lysis and time from D&C until patients become afebrile". Low-quality evidence suggested that the effect of penicillin plus chloramphenicol on fever did not differ from that of cephalothin plus kanamycin (MD -2.30, 95% CI -17.31 to 12.71; women = 56; studies = 1). There was no significant difference between penicillin plus chloramphenicol versus cephalothin plus kanamycin when D&C was performed during antibiotic therapy (MD -1.00, 95% CI -13.84 to 11.84; women = 56; studies = 1). The quality of evidence was low.
A study with unclear risk of bias showed that the time for fever resolution (MD -5.03, 95% CI -5.77 to -4.29; women = 100; studies = 1) as well as time for resolution of leukocytosis (MD -4.88, 95% CI -5.98 to -3.78; women = 100; studies = 1) was significantly lower with tetracycline plus enzymes compared with intravenous penicillin G.
Treatment failure and adverse events occurred infrequently, and the difference between groups was not statistically significant.Authors' conclusions
We found no strong evidence that intravenous clindamycin alone was better than penicillin plus chloramphenicol for treating women with septic abortion. Similarly, available evidence did not suggest that penicillin plus chloramphenicol was better than cephalothin plus kanamycin for the treatment of women with septic abortion. Tetracyline enzyme antibiotic appeared to be more effective than intravenous penicillin G in reducing the time to fever defervescence, but this evidence was provided by only one study at low risk of bias.
There is a need for high-quality RCTs providing reliable evidence for treatments of septic abortion with antibiotics that are currently in use. The three included studies were carried out over 30 years ago. There is also a need to include institutions in low-resource settings, such as sub-Saharan Africa, Latin America and the Caribbean, and South Asia, with a high burden of abortion and health systems challenges.
Udoh Atim, Effa Emmanuel E, Oduwole Olabisi, Okusanya Babasola O, Okafo Obiamaka
Antibiotics for treating septic abortion
A septic abortion is any abortion with infection after a miscarriage or intentional pregnancy termination. One of the signs of septic abortion is fever. Antibiotic treatment is very important for the treatment of septic abortion. The recommended treatments include antibiotics that have effects on different types of bacteria. However, there is no agreement on the most effective antibiotics to be used either alone or in combination to treat septic abortion.
This review included 3 small studies of 233 women with septic abortion. One study compared clindamycin alone to penicillin plus chloramphenicol; the second study compared penicillin plus chloramphenicol to cephalothin plus kanamycin; and the third study compared tetracycline enzyme-based antibiotic with intravenous penicillin G.
We found no strong evidence that clindamycin alone is better than penicillin plus chloramphenicol for treating women with septic abortion. Similarly, the available evidence did not suggest that penicillin plus chloramphenicol is better than cephalothin plus kanamycin for the treatment of women with septic abortion. Furthermore, performing D&C before starting antibiotic treatment was not better than performing D&C after antibiotic treatment has begun. The use of tetracycline-enzyme antibiotic brought women's fever down faster than intravenous penicillin G.
The available evidence from three small trials, which involved some antibiotics not currently in use, is insufficient to advocate for a change in existing treatment recommendations for septic abortion. In spite of this, combinations of antibiotics may be administered to women with septic abortion because they are more likely to reduce fever faster, including in women with bacteria in the blood, than single antibiotic treatment. Only one study reported harm experienced by women: two women given clindamycin had treatment failure, and one woman had an adverse drug reaction. In addition, two women in the clindamycin group had pelvic abscess compared to one in the penicillin plus chloramphenicol group, although the difference was not significant. The limitation of this review is the inclusion of three small studies conducted over 30 years ago.
Implications for practice
The available data and quality of the evidence from 3 small trials conducted over 30 years ago using antibiotics some of which are no longer in use in clinical practice is insufficient to advocate for a change in the existing treatment regimen for septic abortion. Furthermore, the emergence of new and antibiotic-resistant strains of organisms suggests practice needs to be based on these realities.
Currently, combination antibiotic regimens such as intravenous gentamicin and clindamycin; ampicillin, gentamicin, and metronidazole; and levofloxacin and metronidazole or single broad-spectrum agents such as imipenem, piperacillin-tazobactam, and ticarcillin-clavulanate have been recommended to target gram-positive, gram-negative, and anaerobic organisms. These should be started promptly prior to, during, and continued after evacuation of the uterus. Given this review's paucity of effectiveness data, we have no reason not to recommend this strategy. However, prompt and early diagnosis as well as cultures of appropriate specimen are imperative. The need for other adjunctive measures in the management of sepsis such as resuscitation with fluids, blood transfusion, oxygen therapy, surgical removal of uterus or tubes, and intensive care should be borne in mind. It seems reasonable to stress the importance of focusing on strategies to prevent the occurrence of unsafe abortions. In this regard, advocacy for health policy change, removal of appropriate legal restrictions, and the scaling up of public health measures to lessen the stigma associated with abortion are necessary. In addition, utilising preventative interventions such as testing for and treating sexually transmitted infections, routine use of perioperative antibiotics, training of caregivers in the use of sterile techniques, and improved access to effective contraception should be of great benefit.
Implications for research
The findings of this review cannot confidently address the question of which policy of antibiotic treatment should be adopted for treating septic abortion. Well-powered, multisetting, high-quality RCTs that can provide reliable evidence as to whether or not the more commonly used antibiotics such as metronidazole for anaerobic bacteria, quinolones like ciprofloxacin, third-generation cephalosporins like ceftriaxone, and other antibiotics like imipenem are effective either alone or in combination for treating septic abortion are needed.
Newer trials on this subject should focus on important endpoints like treatment failure, microbiological cure, fever resolution time, duration of bacteraemia, adverse events of the medications used, as well as long-term morbidities such as chronic pelvic pain and subfertility. It is also important to consider antibiotic resistance patterns during the design of the studies. The challenge of poor antibiotic stewardship in resource-poor settings such as sub-Saharan Africa, Latin America and the Caribbean, and Southeast Asia with high burden of septic abortion and health systems challenges should also be borne in mind.Get full text at The Cochrane Library
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