Pelvic infection complicates up to 12% of induced abortions and has an adverse effect on future reproductive outcome. The presence in the lower genital tract of Neisseria gonorrhoeae, Chlamydia trachomatis or the anaerobic organisms characterizing bacterial vaginosis is associated with an increased risk of post-abortion infective morbidity. Meta-analysis of randomized trials has shown that prophylaxis with antibiotics effective against either C. trachomatis or bacterial vaginosis reduces the risk of post-abortion infective morbidity by around a half. Other strategies which have been advocated for minimizing the risk of infective morbidity are screening for lower genital tract infections, with treatment of positive cases only, and a combined strategy where women are screened for sexually transmitted infections as well as receiving prophylaxis. These strategies provide the opportunity for appropriate follow-up and partner notification of those women found to have sexually transmitted infections. A multicentre study designed to determine the prevalence of genital tract infections among Scottish women seeking induced abortion, and to compare strategies of 'universal prophylaxis' and 'screen and treat' for minimizing infective morbidity in such women has been undertaken. A total of 1672 women were recruited. Prevalence rates of lower genital tract gonorrhoea, chlamydia and bacterial vaginosis were found to be similar to those reported in other UK studies. Women managed by the 'screen and treat' strategy (particularly those whose genital tract swabs were reported negative) had slightly higher rates of infective morbidity in the 8 weeks after abortion than those managed by 'prophylaxis'. Using currently available screening tests and genitourinary medicine services, 'prophylaxis' appears to be the more cost effective of the two strategies studied.
PIP: Reported rates of post-abortion pelvic inflammatory disease (PID) range from 5-29%. The risk of infection has been associated with the presence of Neisseria gonorrhoeae, Chlamydia trachomatis, and anaerobic organisms in the lower genital tract. The present study analyzed the prevalence of genital tract infections in 1672 women undergoing induced abortion at 3 centers in Scotland and evaluated the efficacy of two preventive interventions. Prevalence rates of lower genital tract gonorrhea, chlamydia, and bacterial vaginosis before abortion were similar to those identified in other UK studies. Women were randomly allocated to receive either prophylactic metronidazole (immediately before abortion) and doxycycline (for 7 days after abortion) or received antibiotics only if pre-abortion genital tract swabs were positive for any of the 3 infections. During the 8-week post-abortion follow-up period, women managed by the screen-and-treat protocol had slightly less favorable outcomes in terms of hospital readmissions, general practitioner consultations, antibiotic prescriptions, time off work, and limitations on domestic activities than women who received prophylactic treatment. Differences were statistically significant, however, only for women whose swabs were negative for all 3 infections. The rate of post-abortion PID/endometritis in this groups was 3% among women who received prophylactic antibiotics and 6% in those who were screened and not treated. These findings suggest that universal antibiotic prophylaxis may represent the most cost-effective approach to minimizing the risk of infective morbidity. Advocated for consideration is a third strategy involving prophylaxis at the time of abortion followed by screening for gonorrhea and chlamydia to ensure adequate follow-up of treatment results and partner notification.