Prophylactic antibiotics for transcervical intrauterine procedures

  • Review
  • Intervention

Authors

  • Jadsada Thinkhamrop,

    Corresponding author
    1. Khon Kaen University, Department of Obstetrics and Gynaecology, Faculty of Medicine, Khon Kaen, Thailand
    • Jadsada Thinkhamrop, Department of Obstetrics and Gynaecology, Faculty of Medicine, Khon Kaen University, Faculty of Medicine, 123 Mittraparb Highway, Khon Kaen, 40002, Thailand. jadsada@kku.ac.th.

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  • Malinee Laopaiboon,

    1. Khon Kaen University, Department of Biostatistics and Demography, Faculty of Public Health, Khon Kaen, Thailand
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  • Pisake Lumbiganon

    1. Khon Kaen University, Department of Obstetrics and Gynaecology, Faculty of Medicine, Khon Kaen, Thailand
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Abstract

Background

The transcervical intrauterine route is commonly used for operative gynaecological procedures in women. The vagina is an area of the body that is abundant with normal bacterial flora. An operative procedure through the vagina may, therefore, be considered to have added potential for post-procedure infection. Prophylactic antibiotics may play a role in the prevention of post-procedure transcervical intrauterine infections.

Objectives

To assess the effectiveness and safety of antibiotic prophylaxis compared to placebo or no treatment in women undergoing transcervical intrauterine procedures.

Search methods

The search strategy was based on the Cochrane Menstrual Disorders and Subfertility Group (MDSG) search strategy. We searched the following databases: the Cochrane MDSG Specialised Register; Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (to August 2012); MEDLINE (1946 to August 2012); EMBASE (1980 to August 2012); PsycINFO (to August 2012); CINAHL (to August 2012), Biological Abstracts (1966 to August 2012) and AMED (1966 to August 2012).

Selection criteria

We planned to include only truly randomised controlled trials that compared antibiotic prophylaxis with placebo or no treatment in order to prevent infectious complications after transcervical intrauterine procedures. Controlled clinical trials without randomisation and pseudo-randomised trials were excluded.

Data collection and analysis

No data collection or analysis was done because no trials were eligible for inclusion in the review.

Main results

The search did not identify any randomised controlled trials investigating the effect of antibiotic prophylaxis compared to placebo or no treatment in women undergoing transcervical intrauterine procedures.

Authors' conclusions

At this time, there are no randomised controlled trials that assess the effects of prophylactic antibiotics on infectious complications following transcervical intrauterine procedures. It is, therefore, not possible to draw any conclusions regarding the use of prophylactic antibiotics for the prevention of post-procedure transcervical intrauterine infections.

Plain language summary

Prophylactic antibiotics for transcervical intrauterine procedures

The administration of antibiotics before or following transcervical intrauterine procedures may prevent infection. The lower genital tract is an area which is abundant with normal flora (resident bacteria) so that operative procedures which pass through it may increase the risk of infection. The operative procedure may cause contamination of the uterine cavity with vaginal or cervical flora, or both. In addition, the associated trauma may compromise the ability of the uterus to combat infection. The prophylactic administration of antibiotics (giving antibiotics before the development of any infection) in women undergoing transcervical intrauterine procedures may prevent infection post-procedure. There have been no randomised controlled trials evaluating the usefulness of antibiotics for the prevention of infection after these procedures. Therefore we could not draw any conclusions regarding the use of prophylactic antibiotics for the prevention of post-procedure transcervical intrauterine infections

Background

Antibiotic prophylaxis is the use of antibiotics for the prevention of infection. There are special considerations regarding the use of antibiotic prophylaxis in obstetric and gynaecological procedures. Because the lower genital tract is abundant with normal vaginal flora, operation through or adjacent to this area can lead to a moderate to high incidence of infection. There are established recommendations for using antibiotic prophylaxis in many major procedures, for example, vaginal hysterectomy (ACOG 2001), abdominal hysterectomy (ACOG 2001; Mittendorf 1993) and caesarean section (ACOG 2003; Chelmow 2001; Smaill 2010). There are no clear recommendations for minor operative procedures such as dilatation and curettage for evacuation of conceptive products, fractional curettage for abnormal uterine bleeding, hysterosalpingography for infertility evaluation, and hysteroscopy for intrauterine cavity diagnosis and treatment.

Description of the condition

Transcervical intrauterine procedures involve the passage of an instrument through the endocervical canal into the uterine cavity. The procedures include the collection of endometrial tissue to assess the cause of abnormal uterine bleeding, hysterosalpingography for infertility evaluation, hysteroscopy for intrauterine cavity diagnosis and treatment, and the evacuation of conceptive products. These are minor procedures. Women who undergo these procedures are at risk of infection due to exposure to the abundant genital bacteria. Infectious morbidities after these procedures include endometritis and pelvic inflammatory diseases, which need antibiotic treatment or surgical drainage, and may cause prolonged hospitalisation.

The incidence of infectious morbidity from transcervical intrauterine procedures varies widely according to the background prevalence for the study population and the procedure involved. A study of pelvic inflammatory diseases (PID) after dilatation and curettage in women with metrorrhagia found that 4 of 33 women who received doxycycline for one week, and 3 of 34 women who did not receive any antibiotic regimen after the procedure, had PID (Makris 2000). The incidence of infectious morbidity after hysterosalpingography has been reported as 3.1% in 448 women (Stumpf 1980) and 44% in 150 women (Lema 1993).

Description of the intervention

The intervention of interest in this review is the administration of antibiotics to women without documented infection, prior to a transcervical intrauterine procedure, with the aim of preventing postoperative infection.

How the intervention might work

Using prophylactic antibiotics for surgical procedures through or adjacent to the vagina, such as caesarean section, vaginal hysterectomy and abdominal hysterectomy, is recommended for reducing postoperative febrile morbidity (ACOG 2001; Chelmow 2001; Mittendorf 1993; Smaill 2010).

Transcervical intrauterine procedures also entail a risk of contamination by vaginal flora and might result in infection. However, there is no consensus on whether it is necessary to use prophylactic antibiotics to prevent postoperative infection for this type of surgery. There are no recommendations for these minor operative procedures, probably because they cause relatively small areas of raw surface and tissue trauma. It is questionable as to whether or not antibiotic prophylaxis for these minor procedures is associated with more benefit than harm. However, these procedures may cause ascending infection from the lower genital tract to the upper genital tract, especially those procedures that pass through the endocervical canal into the uterine cavity. Therefore, antibiotic prophylaxis might have a role in the prevention of infection.

A randomised controlled trial to assess the effect of prophylactic antibiotics on the incidence of bacteraemia following hysteroscopic surgery found the incidence to be 16% of 61 women in the non-antibiotic group and 2% of 55 women in the antibiotic group (Bhattacharya 1995). A study of metronidazole in prostaglandin-induced abortion reported pyrexia in 24% of 142 women without prophylactic antibiotics and 4.1% of 145 women with prophylactic antibiotics. A study of PID after hysterosalpingography in 116 women, which was associated with Chlamydia trachomatis and Mycoplasma hominis, reported that two of the four cases who developed PID were positive for C. trachomatis before the procedure. The authors concluded that C. trachomatis should be identified in women before hysterosalpingography and, if detected, an appropriate antibiotic should be given before the procedure (Moller 1984). Another study of tubo-ovarian abscess after operative hysteroscopy found that the women who did not receive antibiotic prophylaxis had a higher incidence of infection following the procedure than the group who had antibiotic prophylaxis. These findings were in a high-risk group with a history of PID (McCausland 1993).

Why it is important to do this review

Transcervical intrauterine procedures are common in obstetric and gynaecological practices. These procedures are considered to be clean-contaminated or contaminated surgery, with a high possibility of infectious complications. It is not clear from the literature whether antibiotic prophylaxis protects against infection following transcervical intrauterine procedures and so we undertook this systematic review. There are already reviews of antibiotic prophylaxis for intrauterine contraceptive device insertion, medical or surgical first trimester induced abortion, and antibiotics for incomplete abortion (Grimes 1999; May 1999; Snieders 2005). We have adjusted the published protocol, which initially included women undergoing intrauterine insemination or instillation and embryo transfer (Kroon 2012), to exclude these women since they are now the topic of other Cochrane systematic reviews.

Objectives

To assess the effectiveness and safety of antibiotic prophylaxis compared to placebo or no treatment in women undergoing transcervical intrauterine procedures.

Methods

Criteria for considering studies for this review

Types of studies

The review authors included only truly randomised controlled trials (RCTs) that compared antibiotic prophylaxis with placebo or no treatment in the prevention of infectious complications after transcervical intrauterine procedures. Controlled clinical trials without randomisation and pseudo-randomised trials were excluded. Cluster-randomised and cross-over trials are not feasible in this review context.

Types of participants

Inclusion criteria

Non-pregnant women undergoing diagnostic or therapeutic intrauterine manipulation, or both, where the instrument was passed through the uterine cervical canal. Procedures included:

  • fractional curettage for evacuation of the whole endometrial lining tissue;

  • endometrial sampling for removal of some part of the endometrial lining tissue;

  • hysterosalpingography;

  • hysteroscopy;

  • hysteroscopic surgery, including endometrial ablation and endometrial resection.

Exclusion criteria
  • Women using antibiotics for any indication

  • Women undergoing embryo transfer

  • Women undergoing intrauterine insemination (IUI)

  • Women undergoing intrauterine device insertion

Types of interventions

Antibiotics by oral or parenteral administration versus placebo or no treatment to prevent infection in women undergoing transcervical intrauterine procedures.

Types of outcome measures

We planned to assess the effect of antibiotic prophylaxis on postoperative infectious complications as the primary outcome and the adverse effects of the intervention as the secondary outcome.

Primary outcomes
  1. Postoperative complications.

    1. Postoperative febrile morbidity (defined as a postoperative body temperature greater than 38 degrees Celsius after the operation, within 10 days but not the first 24 hours).

    2. Postoperative infectious complications (defined as any documented sites of infection identified by cultivation or clinical symptoms and signs, or both) including:

      1. endometritis;

      2. pelvic inflammatory disease;

      3. pelvic abscess.

    3. Postoperative treatment needed for infection including:

      1. antibiotic treatment;

      2. hospitalisation needed for longer duration than usual;

      3. surgical treatment, for example exploratory laparotomy for abscess evacuation or drainage.

Secondary outcomes
  1. Adverse effects.

    1. Antibiotic side effects including:

      1. nausea;

      2. vomiting;

      3. diarrhoea;

      4. allergic reaction;

      5. anaphylactic reaction.

  2. Antibiotic resistance.

  3. Alteration of bacterial flora resulting in:

    1. pseudomembranous enterocolitis.

Studies were required to report as an outcome at least one infectious complication or adverse effect.

Search methods for identification of studies

We searched for all published and unpublished RCTs that compared antibiotic prophylaxis with placebo or no treatment to prevent infectious complications after transcervical intrauterine procedures, without language restriction and in consultation with the Cochrane Menstrual Disorders and Subfertility Group (MDSG) Trials Search Co-ordinator.

Electronic searches

We searched the following electronic databases, trial registers and websites: the Cochrane MDSG Specialised Register of Controlled Trials, the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library) (to August 2012), MEDLINE (1946 to August 2012), EMBASE (1980 to August 2012), CINAHL (to August 2012), and PsycINFO (to August 2012).

Other electronic sources of trials included:

Searching other resources

We handsearched reference lists of articles retrieved by the search and planned to contact experts in the field to obtain additional data. We also handsearched relevant journals and conference abstracts that are not covered in the MDSG Register, in liaison with the Trials Search Co-ordinator.

The search strategy is described in detail in Appendix 1.

Data collection and analysis

The following methods for conducting the review were planned at the protocol stage. As no randomised controlled trials were relevant to the review, despite extensive searching, we did not use these methods but they are included here for the purpose of future updating of the review. These were the criteria for considering whether studies were relevant.

We planned to extract the following information from the included studies and to present it in a table entitled 'Characteristics of included studies'.

Trial characteristics

  • Type of transcervical intrauterine procedure

  • Allocation concealment

  • Number of women randomised, excluded and analysed

  • Follow-up rate

  • Duration, timing and location of the trial

  • Existing underlying diseases in the participants, e.g. HIV infection, history of sexually transmitted infection

Intervention

  • Detailed description of the antibiotic regimen used (including type of drug, dose, frequency and timing)

  • Type of control (placebo or no treatment)

Outcomes

  • Outcomes reported as specified above

  • How are outcomes defined?

  • How are outcomes measured (blinding of assessors)?

  • Timing of outcome measurement

  • Summary measures of the outcomes and their variation

Selection of studies  

We planned to select trials in which the administration of antibiotics was done before or immediately after the procedure and without any documentation of an existing infection at that time. Study selection was to be undertaken by two review authors (JT and PL). The titles and abstracts of articles found in the search would be screened by JT, who would discard studies that were clearly ineligible but would aim to be overly inclusive rather than risk losing relevant studies. JT would obtain copies of the full-text articles and would make copies for PL; details of the authors and institutions would have been struck out and the results section removed. Both review authors would independently assess whether the studies met the inclusion criteria, with disagreements resolved by discussion. Further information would be sought from the authors where papers contained insufficient information to make a decision about eligibility.

Selection of studies

We planned to select trials in which the administration of antibiotics was done before or immediately after the procedure and without any documentation of an existing infection at that time. Study selection was to be undertaken by two review authors (JT and PL). The titles and abstracts of articles found in the search would be screened by JT, who would discard studies that were clearly ineligible but would aim to be overly inclusive rather than risk losing relevant studies. JT would obtain copies of the full-text articles and would make copies for PL; details of the authors and institutions would have been struck out and the results section removed. Both review authors would independently assess whether the studies met the inclusion criteria, with disagreements resolved by discussion. Further information would be sought from the authors where papers contained insufficient information to make a decision about eligibility.

Data extraction and management

JT planned to provide PL with the results sections of the included studies and both review authors were to independently extract information. Discrepancies were to be resolved by discussion. Where possible, missing data would be sought from the authors.

All trials that met, or appeared to meet, the inclusion criteria but were then excluded from the review were to be described with the reason why the trials had been excluded listed in the table 'Characteristics of excluded studies'.

Assessment of risk of bias in included studies

Two review authors (JT and ML) were to independently assess risk of bias using the guidelines in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). We planned to resolve any disagreement by discussion. We intended to extract the following data.

(1) Sequence generation

We planned to assess methods as:

  • low risk of bias (any truly random process, e.g. random number table; computer random number generator);

  • high risk of bias (any non-random process, e.g. odd or even date of birth; hospital or clinic record number); or

  • unclear (insufficient information to allow judgement).

(2) Allocation concealment

We planned to assess methods as:

  • low risk of bias (e.g. telephone or central randomisation; consecutively numbered, sealed, opaque envelopes);

  • high risk of bias (open random allocation; unsealed or non-opaque envelopes; alternation; date of birth);

  • unclear (insufficient information to allow judgement).

(3) Blinding

We planned to assess as:

  • low risk, high risk or unclear for participants;

  • low risk, high risk or unclear for personnel;

  • low risk, high risk or unclear for outcome assessors.

(4) Incomplete outcome data

We intended to describe for each included study, and for each outcome or class of outcomes, the completeness of data including attrition and exclusions from the analysis. We would state whether attrition and exclusions were reported; the numbers included in the analysis at each stage (compared with the total randomised participants); reasons for attrition or exclusion where reported; and whether missing data were balanced across groups or were related to outcomes. We planned to assess methods as:

  • low risk of bias (analysis by intention-to-treat including all or nearly all randomised participants);

  • high risk of bias (more than 20% missing data);

  • unclear risk of bias (20% or less missing data).

We would discuss whether missing data greater than 20% might (a) be reasonably expected (acknowledging that with long-term follow-up complete data are difficult to attain) and (b) likely impact on outcomes.

(5) Selective outcome reporting

We planned to describe for each included study how we investigated the possibility of selective outcome reporting bias and what we found.

We planned to assess the methods as:

  • low risk of bias (where it was clear that all of the study's prespecified outcomes and all expected outcomes of interest to the review had been reported);

  • high risk of bias (where not all the study's pre-specified outcomes had been reported; one or more reported primary outcomes were not pre-specified; outcomes of interest were reported incompletely and so could not be used; study fails to include results of a key outcome that would had been expected to have been reported);

  • unclear risk of bias.

(6) Other sources of bias

We planned to describe for each included study any important concerns we have about other possible sources of bias. We assessed whether each study was free of other problems that could put it at risk of bias:

  • low risk of bias;

  • high risk of bias;

  • unclear risk of bias.

Measures of treatment effect

Dichotomous data

We planned to use risk ratio (RR) with 95% confidence intervals (CI) for dichotomous data.

Continuous data

For continuous data, we planned to use the mean difference (MD) if outcomes were measured in the same way between trials. We planned to use the standardised mean difference (SMD) to combine trials that measured the same outcome, but use different methods.

Unit of analysis issues

We decided to include only randomised controlled trials in the review since studies with non-standard designs, such as cross-over trials and cluster-randomised trials, are not appropriate in this context.

Dealing with missing data

We considered the levels of completeness of data collection. We planned to explore the impact of including studies with high levels of missing data in the overall assessment of treatment effect by using sensitivity analysis. We planned to carry out analysis on an intention-to-treat basis, which meant that we had to include all participants randomised to each group in the analyses and all participants were analysed in the group to which they were allocated, regardless of whether or not they received the allocated intervention.

Assessment of heterogeneity

We planned to assess whether the clinical and methodological characteristics of the included studies were sufficiently similar for them to be combined. We planned to assess statistical heterogeneity for each (meta-analysis) primary outcome using the Tau², I² and Chi² statistics. We regarded heterogeneity as substantial if I² was greater than 30% and either Tau² was greater than zero, or there was a low P value (< 0.10) in the Chi² test for heterogeneity (Higgins 2003).

Assessment of reporting biases

We planned to assess review-wide reporting biases (such as publication bias) using funnel plots. We would assess funnel plot asymmetry visually, and use formal tests for funnel plot asymmetry. If asymmetry was detected in any of these tests or was suggested by a visual assessment, we planned to perform exploratory analyses to investigate it.

Data synthesis

We planned to perform meta-analysis in accordance with the guidelines for statistical analysis developed by The Cochrane Collaboration. For binary data, we planned to calculate pooled risk ratios and the corresponding 95% confidence intervals

Subgroup analysis and investigation of heterogeneity

We planned to assess outcomes separately using subgroup analysis of participants with different risks of infection, such as where the procedure was done with or without vaginal cleaning, in an operating theatre versus outpatient clinic, in women with high versus low risk of sexually transmitted infection, and with or without regular steroid use.

If the detected heterogeneity could not be explained by any clinical or methodological variation, we planned to use a random-effects model.

Sensitivity analysis

We planned to perform sensitivity analysis according to methodological quality for the primary outcome to evaluate the robustness of the conclusions.

Results

Description of studies

No studies were identified which met the inclusion criteria for this review.

Results of the search

We searched to 10 August 2012 using the search strategy described. There were 10 studies which initially appeared potentially eligible for the review. However, after checking the detail of these studies, none met the inclusion criteria.

Included studies

No study was included.

Excluded studies

There were 10 excluded studies: three studies reported no outcomes of interest and seven studies were not randomised controlled trials. See Characteristics of excluded studies and Excluded studies.

Risk of bias in included studies

No study was included.

Effects of interventions

No study was included.

Discussion

Antibiotic prophylaxis is recommended for major operative obstetric and gynaecologic procedures, such as hysterectomy and caesarean section (ACOG 2001; Chelmow 2001; Mittendorf 1993; Smaill 2010). For minor operative procedures there is conflicting evidence regarding the use of routine prophylactic antibiotics (Bhattacharya 1995; Lema 1993; Makris 2000; McCausland 1993; Moller 1984; Stumpf 1980). In this review we planned to use randomised controlled trials to assess the effects of antibiotics on prevention of infection as well as the occurrence of adverse events after minor procedures such as fractional curettage for evacuation of the whole endometrial lining tissue, endometrial sampling for some part of the endometrial lining tissue, hysterosalpingography, hysteroscopy, hysteroscopic surgery, endometrial ablation and endometrial resection. While prophylactic antibiotics for transcervical intrauterine procedures may be of value, we have not been able to determine whether there are any benefits or harms of this intervention.

Authors' conclusions

Implications for practice

There is no evidence to either support or discourage the use of antibiotics to prevent infection for transcervical intrauterine procedures. Prophylactic antibiotics may be considered in populations and areas where the incidence of infection after transcervical intrauterine procedures is high.

Implications for research

Transcervical intrauterine procedures may increase the risk of infection after the procedure. However, there is conflicting evidence as to the benefit of routine prophylactic antibiotics. Some observational studies have found prophylaxis useful. Double-blinded randomised trials comparing prophylactic antibiotics to placebo are needed before any conclusions can be made about the role of prophylactic antibiotics for intracervical intrauterine procedures.

Acknowledgements

We are grateful to the Thai Cochrane Network and the Australasian Cochrane Centre for technical and material support; the Menstrual Disorders and Subfertility Group for comments and suggestions on protocol development and the complete review; and the Thailand Research Fund (Senior Research Scholar) for funding support for time protection and expenditure for the review authors' training and development.

Data and analyses

Download statistical data

This review has no analyses.

Appendices

Appendix 1. Search strategies

Keywords:

We prepared the keywords in consultation with the Cochrane MDSG Trials Search Co-ordinator, using terms related to our objective: antibiotic, antibiotics, prophylaxis, transvaginal, transcervical intrauterine, endometrial sample, endometrium sampling, endometrial biopsy, hysterosalpingography, hysteroscope, hysteroscopy, hysteroscopic surgery, endometrial ablation and endometrial resection.

Search strategy:

The review authors (JT and PL) searched for relevant references which described studies that compared antibiotic prophylaxis with placebo or no treatment to prevent infectious complications after transcervical intrauterine procedures. We used the following search strategy.

1. reproductive techniques/
2. reproductive techniques.mp. [mp=title, original title, abstract, MeSH headings, heading words, keyword]
3. fallopian tube patency tests.mp. [mp=title, original title, abstract, MeSH headings, heading words, keyword]
4. insemination, artificial.mp. [mp=title, original title, abstract, MeSH headings, heading words, keyword]
5. reproductive techniques, assisted.mp. [mp=title, original title, abstract, MeSH headings, heading words, keyword]
6. embryo transfer.mp. [mp=title, original title, abstract, MeSH headings, heading words, keyword]
7. zygote intrafallopian transfer.mp. [mp=title, original title, abstract, MeSH headings, heading words, keyword]
8. (embry$ adj5 transf$).tw.
9. hysteroscop$.tw.
10. endometrial sampl$.tw.
11. endometrial biopsy.tw.
12. hysterosalpingograph$.tw.
13. (chorionic villi sampl$ or chorionic villi biopsy).tw.
14. (IUI or intrauterine insemination).tw.
15. Anti-Bacterial Agent$.mp. [mp=title, original title, abstract, MeSH headings, heading words, keyword]
16. antibiotic$.tw.
17. or/1-14
18. or/15-16
19. 17 and 18
20. from 19 keep 1-9

We searched MEDLINE (1966 to August 2012) using the following MeSH terms:

1. randomized controlled trial.pt.
2. controlled clinical trial.pt.
3. Randomized controlled trials/
4. random allocation/
5. double-blind method/
6. single-blind method/
7. or/1-6
8. clinical trial.pt.
9. exp clinical trials/
10. (clin$ adj25 trial$).ti,ab,sh.
11. ((singl$ or doubl$ or tripl$ or trebl$) adj25 (blind$ or mask$)).ti,ab,sh.
12. placebos/
13. placebo$.ti,ab,sh.
14. random$.ti,ab,sh.
15. Research design/
16. or/8-15
17. animal/ not (human/ and animal/)
18. 7 or 16
19. 18 not 17
20. reproductive techniques/ or contraception/ or fallopian tube patency tests/ or insemination, artificial/ or reproductive techniques, assisted/
21. embryo transfer/ or zygote intrafallopian transfer/
22. Intrauterine Devices, Medicated/ or Intrauterine Devices, Copper/ or Intrauterine Devices/
23. (embry$ adj5 transf$).tw.
24. Hysteroscopy/
25. hysteroscop$.tw.
26. "DILATATION AND CURETTAGE"/ or VACUUM CURETTAGE/ or CURETTAGE/
27. endometrial sampl$.tw.
28. endometrial biopsy.tw.
29. hysterosalpingograph$.tw.
30. Hysterosalpingography/
31. (chorionic villi sampl$ or chorionic villi biopsy).tw.
32. (IUI or intrauterine insemination).tw.
33. (IUD insert$ or intrauterine device insert$).tw.
34. curettag$.tw.
35. or/20-34
36. Anti-Bacterial Agents/
37. Antibiotic Prophylaxis/
38. antibiotic$.tw.
39. or/36-38
40. 35 and 39
41. 19 and 40
42. from 41 keep 1-75

We searched EMBASE (1980 to August 2012) using the following MeSH terms:

1. reproductive techniques/ or contraception/ or fallopian tube patency tests/ or insemination, artificial/ or reproductive techniques, assisted/
2. embryo transfer/ or zygote intrafallopian transfer/
3. Intrauterine Devices, Medicated/ or Intrauterine Devices, Copper/ or Intrauterine Devices/
4. (embry$ adj5 transf$).tw.
5. Hysteroscopy/
6. hysteroscop$.tw.
7. "DILATATION AND CURETTAGE"/ or VACUUM CURETTAGE/ or CURETTAGE/
8. endometrial sampl$.tw.
9. endometrial biopsy.tw.
10. hysterosalpingograph$.tw.
11. Hysterosalpingography/
12. (chorionic villi sampl$ or chorionic villi biopsy).tw.
13. (IUI or intrauterine insemination).tw.
14. (IUD insert$ or intrauterine device insert$).tw.
15. curettag$.tw.
16. intrauterine insemination/
17. Anti-Bacterial Agents/
18. Antibiotic Prophylaxis/
19. antibiotic$.tw.
20. antibacter$.tw.
21. anti-bacter$.tw.
22. or/1-16
23. or/17-21
24. 22 and 23
25. Controlled study/ or randomized controlled trial/
26. double blind procedure/
27. single blind procedure/
28. crossover procedure/
29. drug comparison/
30. placebo/
31. random$.ti,ab,hw,tn,mf.
32. latin square.ti,ab,hw,tn,mf.
33. crossover.ti,ab,hw,tn,mf.
34. cross-over.ti,ab,hw,tn,mf.
35. placebo$.ti,ab,hw,tn,mf.
36. ((doubl$ or singl$ or tripl$ or trebl$) adj5 (blind$ or mask$)).ti,ab,hw,tn,mf.
37. (comparative adj5 trial$).ti,ab,hw,tn,mf.
38. (clinical adj5 trial$).ti,ab,hw,tn,mf.
39. or/25-38
40. nonhuman/
41. animal/ not (human/ and animal/)
42. or/40-41
43. 39 not 42
44. 24 and 43
45. from 44 keep 1-149

We searched Biological Abstracts (1966 to August 2012) using the following MeSH terms:

1. (embry$ adj5 transf$).tw.
2. hysteroscop$.tw.
3. endometrial sampl$.tw.
4. endometrial biopsy.tw.
5. hysterosalpingograph$.tw.
6. (chorionic villi sampl$ or chorionic villi biopsy).tw.
7. (IUI or intrauterine insemination).tw.
8. (IUD insert$ or intrauterine device insert$).tw.
9. curettag$.tw.
10. antibiotic$.tw.
11. antibacter$.tw.
12. anti-bacter$.tw.
13. random$.ti,ab,hw,tn,mf.
14. latin square.ti,ab,hw,tn,mf.
15. crossover.ti,ab,hw,tn,mf.
16. cross-over.ti,ab,hw,tn,mf.
17. placebo$.ti,ab,hw,tn,mf.
18. ((doubl$ or singl$ or tripl$ or trebl$) adj5 (blind$ or mask$)).ti,ab,hw,tn,mf.
19. (comparative adj5 trial$).ti,ab,hw,tn,mf.
20. (clinical adj5 trial$).ti,ab,hw,tn,mf.
21. or/1-9
22. or/10-12
23. or/13-20
24. 21 and 22
25. 23 and 24
26. from 25 keep 1-31

We searched AMED (1985 to August 2012) using the following MeSH terms:

1. reproductive techniq$.tw.
2. fallopian tube patency test$.tw. 3. reproduct$.tw.
4. embryo/
5. hysteroscop$.tw.
6. endometrial sampl$.tw.
7. endometrial biopsy.tw.
8. hysterosalpingograph$.tw.
9. (chorionic villi sampl$ or chorionic villi biopsy).tw.
10. (IUI or intrauterine insemination).tw.
11. antibiotic$.tw.
12. Anti-Bacter$.tw.
13. antibacter$.tw.
14. or/1-10
15. or/11-13
16. 14 and 15
17. from 16 keep 1-3

We searched CINAHL (1982 to August 2012) using the following MeSH terms:

1. reproductive techniques/ or contraception/ or fallopian tube patency tests/ or insemination, artificial/ or reproductive techniques, assisted/
2. embryo transfer/ or zygote intrafallopian transfer/
3. Intrauterine Devices, Medicated/ or Intrauterine Devices, Copper/ or Intrauterine Devices/
4. (embry$ adj5 transf$).tw.
5. Hysteroscopy/
6. hysteroscop$.tw.
7. "DILATATION AND CURETTAGE"/ or VACUUM CURETTAGE/ or CURETTAGE/
8. endometrial sampl$.tw.
9. endometrial biopsy.tw.
10. hysterosalpingograph$.tw.
11. Hysterosalpingography/
12. (chorionic villi sampl$ or chorionic villi biopsy).tw.
13. (IUI or intrauterine insemination).tw.
14. (IUD insert$ or intrauterine device insert$).tw.
15. curettag$.tw.
16. Controlled study/ or randomized controlled trial/
17. placebo/
18. random$.ti,ab,hw,tn,mf.
19. latin square.ti,ab,hw,tn,mf.
20. crossover.ti,ab,hw,tn,mf.
21. cross-over.ti,ab,hw,tn,mf.
22. placebo$.ti,ab,hw,tn,mf.
23. ((doubl$ or singl$ or tripl$ or trebl$) adj5 (blind$ or mask$)).ti,ab,hw,tn,mf.
24. (comparative adj5 trial$).ti,ab,hw,tn,mf.
25. (clinical adj5 trial$).ti,ab,hw,tn,mf.
26. exp Antibiotics/
27. Antibiotic Prophylaxis/
28. antibiotic$.tw.
29. antibacter$.tw.
30. anti-bacter$.tw.
31. or/1-15
32. or/26-30
33. or/16-25
34. 31 and 32
35. 33 and 34
36. from 35 keep 1-5

What's new

DateEventDescription
31 May 2013Review declared as stableAs no studies are expected, this review will no longer be updated.

History

DateEventDescription
15 January 2013New citation required but conclusions have not changedNew search, but no studies to include.
15 January 2013New search has been performedContact details updated.
6 November 2008AmendedConverted to new review format.
22 April 2007New citation required and conclusions have changedSubstantive amendment.

Contributions of authors

JT: selecting the topic, searching for and selecting papers, drafting the review.
PL: co-drafting and final approval of the review.
ML: final approval of the review.

Declarations of interest

None known.

Sources of support

Internal sources

  • Khon Kaen University, Thailand.

  • Thai Cochrane Network, Thailand.

External sources

  • Thailand Research Fund, Senior Research Scholar, Thailand.

Differences between protocol and review

The original protocol for this review included IUI and embryo transfer (ET) but these are now the topics of other Cochrane systematic reviews.

Notes

None.

Characteristics of studies

Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion
Bhattacharya 1995The study reported on the outcome bacteraemia following hysteroscopic surgery; this is not relevant to this review's objective which is to assess the effect of antibiotic prophylaxis on infectious morbidity.
Brook 2006This is a randomised controlled trial to assess the rate of bacterial contamination on the transfer catheter tip during embryo transfer and the success rate for a clinical pregnancy. The study's outcomes of interest are not relevant to this review's objective which is to assess the effect of antibiotic prophylaxis on infectious morbidity.
Kasius 2011There were 2 participating hospitals. They enrolled subjects for the intervention arm from one hospital and the control arm from another hospital. This is a therefore a quasi-randomised trial.
Makris 2000There were 2 groups in the study. The authors did not mention how they separated participants into the 2 groups. We cannot confirm from the publication that this was a randomised trial. We sent a letter to the first author to clarify this issue, however we had not received any information at the time of completing the review. The authors mentioned in the article that this was a follow-up study in women given antibiotics or not after endometrial curettage for menorrhagia. It seems to us that this is not a randomised controlled trial.
Marchino 1994This was a 1-arm clinical trial; there was no control group in the study
McCausland 1993There were 2 groups in the study. The authors did not mention how they separated participants into the 2 groups. We cannot confirm from the publication that this was a randomised trial. We sent a letter to the first author to clarify this issue, however we had not received any information at the time of completing the review. There were 200 women who did not receive prophylactic antibiotics and 500 women who received prophylactic antibiotics. There was a large difference between the numbers of participants in the 2 groups. It seems to us that this could not be a randomised controlled trial.
N'Gbesso 2003This was a clinical controlled trial where even and odd enrolment numbers were used to assign the participants to receive the intervention or not
Peikrishvili 2004The study reported on the outcome of interest which was rate of pregnancy loss during IVF cycles according to the prescription of antibiotics or not; this is not relevant to this review's objective which is to assess the effect of antibiotic prophylaxis on infectious morbidity
Pittaway 1983The study reported on acute pelvic inflammatory disease after hysterosalpingogram in the first group without antibiotic prophylaxis, who were recruited between 1 October 1980 and 1 September 1981, and the second group, who were recruited between 1 October 1981 and 1 October 1982, and received antibiotic prophylaxis. This study is therefore a non-concurrent controlled trial.
Primi 2004This was a randomised controlled trial to assess the success rate of implantation on assisted hatching and immunosuppressive/antibiotic treatment. The study's outcome of interest was not relevant to this review's objective which is to assess the effect of antibiotic prophylaxis on infectious morbidity.

Ancillary