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Antibiotic regimens prior to procedures for pregnancy loss or termination

Antibiotic regimens prior to procedures for pregnancy loss or termination
When osmotic dilators* are NOT used:
  • Doxycycline 200 mg orally administered as a single dose within 60 minutes prior to uterine evacuation[1-3] or
  • Metronidazole 500 mg orally administered as a single dose within 60 minutes prior to uterine evacuation[1] or
  • Azithromycin 500 mg orally administered as a single dose within 60 minutes prior to uterine evacuation¶[1,3]
When osmotic dilators* are used:
  • Azithromycin 500 mg orally administered as a single dose at time of dilator placement¶Δ[1] or
  • Azithromycin 500 mg orally administered at time of dilator placement plus ceftriaxone 500 mg IV (1 g in patients ≥150 kg) at time of uterine evacuation¶◊§[4] or
  • Doxycycline 200 mg orally administered as a single dose within 60 minutes prior to uterine evacuation◊¥[5]
Antimicrobial prophylaxis is given prior to uterine aspiration or D&E procedures for pregnancy loss or termination. The choice of regimen is guided by susceptibility patterns of likely pathogens, bioavailability of antimicrobials, clinical experience, and use of osmotic dilators. The use of dilators is determined by the size of the pregnancy and other clinical factors. These concepts are discussed in related UpToDate content.

D&E: dilation and evacuation; IgE: immunoglobulin E; IV: intravenously.

* Types of osmotic dilators include laminaria japonica and Dilapan-S.

¶ Azithromycin may have a lower side effect profile (eg, less nausea) compared with regimens that include doxycycline.

Δ Because of its long half-life, a second dose of azithromycin is only given if the surgical abortion is performed >24 hours after the initial dose of antibiotics.

◊ This regimen is based on institutional protocol and is not included in expert guidelines.

§ Ceftriaxone provides additional coverage for gonococcal infection; however, other cephalosporins (eg, cefazolin) may be used depending on several factors, including local availability. Most patients with a reported mild penicillin allergy can use cephalosporins safely (excluding those with features of IgE-mediated allergy such anaphylaxis, angioedema, or urticaria).

¥ In this regimen, antibiotics are not administered at the time of dilator placement.
References:
  1. Manual of medical standards and guidelines, Planned Parenthood Federation of America, Washington, DC 2016.
  2. American College of Obstetricians and Gynecologists' Committee on Practice Bulletins—Gynecology. ACOG Practice Bulletin No. 195: Prevention of infection after gynecologic procedures. Obstet Gynecol 2018; 131:e172.
  3. Best practice in comprehensive abortion care. Royal College of Obstetricians and Gynaecologists. https://www.rcog.org.uk/globalassets/documents/guidelines/best-practice-papers/best-practice-paper-2.pdf (Accessed on July 22, 2020).
  4. Institutional protocol; DuPont Clinic, Washington, DC.
  5. Institutional protocol; Northwestern Memorial Hospital, Chicago, IL.
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