Sheila Caddy

Antibiotic Prophylaxis in Gynaecologic Procedures

Abstract Objective To review the evidence and provide recommendations on antibiotic prophylaxis for gynaecologic procedures. Outcomes Outcomes evaluated include need and effectiveness of antibiotics to prevent infections in gynaecologic procedures. Evidence Medline and The Cochrane Library were searched for articles published between January 1978 and January 2011 on the topic of antibiotic prophylaxis in gynaecologic procedures. Results were restricted to systematic reviews, randomized control trials/ controlled clinical trials, and observational studies. Searches were updated on a regular basis and incorporated in the guideline to June 2011. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Values The quality of evidence obtained was rated using the criteria described in the Report of the Canadian Task Force on Preventative Health Care (Table 1). Benefits, harms, and costs Guideline implementation should result in a reduction of cost and related harm of administering antibiotics when not required and a reduction of infection and related morbidities when antibiotics have demonstrated a proven benefit. Recommendations 1. All women undergoing an abdominal or vaginal hysterectomy should receive antibiotic prophylaxis. (I-A) 2. All women undergoing laparoscopic hysterectomy or laparoscopically assisted vaginal hysterectomy should receive prophylactic antibiotics. (III-B) 3. The choice of antibiotic for hysterectomy should be a single dose of a first-generation cephalosporin. If patients are allergic to cephalosporin, then clindamycin, erythromycin, or metronidazole should be used. (I-A) 4. Prophylactic antibiotics should be administered 15 to 60 minutes prior to skin incision. No additional doses are recommended. (I-A) 5. If an open abdominal procedure is lengthy (e.g., > 3 hours), or if the estimated blood loss is > 1500 mL, an additional dose of the prophylactic antibiotic may be given 3 to 4 hours after the initial dose. (III-C) 6. Antibiotic prophylaxis is not recommended for laparoscopic procedures that involve no direct access from the abdominal cavity to the uterine cavity or vagina. (l-E) 7. All women undergoing surgery for pelvic organ prolapse and/or stress urinary incontinence should receive a single dose of firstgeneration cephalosporin. (III-B) 8. Antibiotic prophylaxis is not recommended for hysteroscopic surgery. (II-2D) 9. All women undergoing an induced (therapeutic) surgical abortion should receive prophylactic antibiotics to reduce the risk of postabortal infection. (I-A) 10. Prophylactic antibiotics are not suggested to reduce infectious morbidity following surgery for a missed or incomplete abortion. (I-E) 11. Antibiotic prophylaxis is not recommended for insertion of an intrauterine device. (I-E) However, health care professionals could consider screening for sexually transmitted infections in high-risk populations. (III-C) 12. There is insufficient evidence to support the use of antibiotic prophylaxis for an endometrial biopsy. (III-L) 13. The best method to prevent infection after hysterosalpingography is unknown. Women with dilated tubes found at the time of hysterosalpingography are at highest risk, and prophylactic antibiotics (e.g., doxycycline) should be given. (II-3B) 14. Antibiotic prophylaxis is not recommended for urodynamic studies in women at low risk, unless the incidence of urinary tract infection post-urodynamics is > 10%. (1-E) 15. In patients with morbid obesity (BMI > 35 kg/m2), doubling the antibiotic dose may be considered. (III-B) 16 Administration of antibiotics solely to prevent endocarditis is not recommended for patients who undergo a genitourinary procedure. (III-E)

Management of Group B Streptococcal Bacteriuria in Pregnancy

OBJECTIVE To provide information regarding the management of group B streptococcal (GBS) bacteriuria to midwives, nurses, and physicians who are providing obstetrical care. OUTCOMES The outcomes considered were neonatal GBS disease, preterm birth, pyelonephritis, chorioamnionitis, and recurrence of GBS colonization. EVIDENCE Medline, PubMed, and the Cochrane database were searched for articles published in English to December 2010 on the topic of GBS bacteriuria in pregnancy. Bacteriuria is defined in this clinical practice guideline as the presence of bacteria in urine, regardless of the number of colony-forming units per mL (CFU/mL). Low colony counts refer to < 100 000 CFU/mL, and high (significant) colony counts refer to ≥ 100 000 CFU/mL. Results were restricted to systematic reviews, randomized controlled trials, and relevant observational studies. Searches were updated on a regular basis and incorporated in the guideline to February 2011. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES Recommendations were quantified using the evaluation of evidence guidelines developed by the Canadian Task Force on Preventive Health Care (Table). BENEFITS, HARMS, AND COSTS The recommendations in this guideline are designed to help clinicians identify pregnancies in which it is appropriate to treat GBS bacteriuria to optimize maternal and perinatal outcomes, to reduce the occurrences of antibiotic anaphylaxis, and to prevent increases in antibiotic resistance to GBS and non-GBS pathogens. No cost-benefit analysis is provided. RECOMMENDATIONS 1. Treatment of any bacteriuria with colony counts ≥ 100 000 CFU/mL in pregnancy is an accepted and recommended strategy and includes treatment with appropriate antibiotics. (II-2A) 2. Women with documented group B streptococcal bacteriuria (regardless of level of colony-forming units per mL) in the current pregnancy should be treated at the time of labour or rupture of membranes with appropriate intravenous antibiotics for the prevention of early-onset neonatal group B streptococcal disease. (II-2A) 3. Asymptomatic women with urinary group B streptococcal colony counts < 100 000 CFU/mL in pregnancy should not be treated with antibiotics for the prevention of adverse maternal and perinatal outcomes such as pyelonephritis, chorioamnionitis, or preterm birth. (II-2E) 4. Women with documented group B streptococcal bacteriuria should not be re-screened by genital tract culture or urinary culture in the third trimester, as they are presumed to be group B streptococcal colonized. (II-2D).

Vulvovaginitis: Screening for and Management of Trichomoniasis, Vulvovaginal Candidiasis, and Bacterial Vaginosis

OBJECTIVE To review the evidence and provide recommendations on screening for and management of vulvovaginal candidiasis, trichomoniasis, and bacterial vaginosis. OUTCOMES OUTCOMES evaluated include the efficacy of antibiotic treatment, cure rates for simple and complicated infections, and the implications of these conditions in pregnancy. EVIDENCE Published literature was retrieved through searches of MEDLINE, EMBASE, CINAHL, and The Cochrane Library in June 2013 using appropriate controlled vocabulary (e.g., vaginitis, trichomoniasis, vaginal candidiasis) and key words (bacterial vaginosis, yeast, candidiasis, trichomonas vaginalis, trichomoniasis, vaginitis, treatment). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date limits, but results were limited to English or French language materials. Searches were updated on a regular basis and incorporated in the guideline to May 2014. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, and national and international medical specialty societies. VALUES The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). Summary Statements 1. Vulvovaginal candidiasis affects 75% of women at least once. Topical and oral antifungal azole medications are equally effective. (I) 2. Recurrent vulvovaginal candidiasis is defined as 4 or more episodes per year. (II-2) 3. Trichomonas vaginalis is a common non-viral sexually transmitted infection that is best detected by antigen testing using vaginal swabs collected and evaluated by immunoassay or nucleic acid amplification test. (II-2) 4. Cure rates are equal at up to 88% for trichomoniasis treated with oral metronidazole 2 g once or 500 mg twice daily for 7 days. Partner treatment, even without screening, enhances cure rates. (I-A) 5. Current evidence of the efficacy of alternative therapies for bacterial vaginosis (probiotics, vitamin C) is limited. (I) Recommendations 1. Following initial therapy, treatment success of recurrent vulvovaginal candidiasis is enhanced by maintenance of weekly oral fluconazole for up to 6 months. (II-2A) 2. Symptomatic vulvovaginal candidiasis treated with topical azoles may require longer courses of therapy to be resolved. (1-A) 3. Test of cure following treatment of trichomoniasis with oral metronidazole is not recommended. (I-D) 4. Higher-dose therapy may be needed for treatment-resistant cases of trichomoniasis. (I-A) 5. In pregnancy, treatment of symptomatic Trichomonas vaginalis with oral metronidazole is warranted for the prevention of preterm birth. (I-A) 6. Bacterial vaginosis should be diagnosed using either clinical (Amsels) or laboratory (Gram stain with objective scoring system) criteria. (II-2A) 7. Symptomatic bacterial vaginosis should be treated with oral metronidazole 500 mg twice daily for 7 days. Alternatives include vaginal metronidazole gel and oral or vaginal clindamycin cream. (I-A) 8. Longer courses of therapy for bacterial vaginosis are recommended for women with documented multiple recurrences. (I-A).

Best Practices to Minimize Risk of Infection With Intrauterine Device Insertion

BACKGROUND Intrauterine devices provide an extremely effective, long-term form of contraception that has the benefit of being reversible. Historically, the use of certain intrauterine devices was associated with increased risk of pelvic inflammatory disease. More recent evidence suggests that newer devices do not carry the same threat; however, certain risk factors can increase the possibility of infection. OBJECTIVES To review the risk of infection with the insertion of intrauterine devices and recommend strategies to prevent infection. OUTCOMES The outcomes considered were the risk of pelvic inflammatory disease, the impact of screening for bacterial vaginosis and sexually transmitted infections including chlamydia and gonorrhea; and the role of prophylactic antibiotics. EVIDENCE Published literature was retrieved through searches of PubMed, Embase, and The Cochrane Library on July 21, 2011, using appropriate controlled vocabulary (e.g., intrauterine devices, pelvic inflammatory disease) and key words (e.g., adnexitis, endometritis, IUD). An etiological filter was applied in PubMed. The search was limited to the years 2000 forward. There were no language restrictions. Grey (unpublished) literature was identified through searching the web sites of national and international medical specialty societies. VALUES The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventative Health Care (Table). Recommendations 1. All women requesting an intrauterine device should be counselled about the small increased risk of pelvic inflammatory disease in the first 20 days after insertion. (II-2A) 2. All women requesting an intrauterine device should be screened by both history and physical examination for their risk of sexually transmitted infection. Women at increased risk should be tested prior to or at the time of insertion; however, it is not necessary to delay insertion until results are returned. (II-2B) 3. Not enough current evidence is available to support routine screening for bacterial vaginosis at the time of insertion of an intrauterine device in asymptomatic women. (II-2C) 4. Routine use of prophylactic antibiotics is not recommended prior to intrauterine device insertion, although it may be used in certain high-risk situations. (I-C) 5. Standard practice includes cleansing the cervix and sterilizing any instruments that will be used prior to and during insertion of an intrauterine device. (III-C) 6. In treating mild to moderate pelvic inflammatory disease, it is not necessary to remove the intrauterine device during treatment unless the patient requests removal or there is no clinical improvement after 72 hours of appropriate antibiotic treatment. In cases of severe pelvic inflammatory disease, consideration can be given to removing the intrauterine device after an appropriate antibiotic regimen has been started. (I-B) 7. An intrauterine device is a safe, effective option for contraception in an HIV-positive woman. (I-B) 8. An intrauterine device can be considered a first-line contraceptive agent in adolescents. (I-A).

Guidelines for the Care of Pregnant Women Living With HIV and Interventions to Reduce Perinatal Transmission: Executive Summary

OBJECTIVE This guideline reviews the evidence relating to the care of pregnant women living with HIV and the prevention of perinatal HIV transmission. Prenatal care of pregnancies complicated by HIV infection should include monitoring by a multidisciplinary team with experts in this area. OUTCOMES OUTCOMES evaluated include the impact of HIV on pregnancy outcome and the efficacy and safety of antiretroviral therapy and other measures to decrease the risk of vertical transmission. EVIDENCE Published literature was retrieved through searches of PubMed and The Cochrane Library in 2012 and 2013 using appropriate controlled vocabulary (HIV, anti-retroviral agents, pregnancy, delivery) and key words (HIV, pregnancy, antiretroviral agents, vertical transmission, perinatal transmission). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English or French. There were no date restrictions. Searches were updated on a regular basis and incorporated in the guideline to June 2013. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1).

Pregnancy and Neonatal Outcomes of Women With Reactive Syphilis Serology in Alberta, 2002 to 2006

OBJECTIVES To describe the maternal characteristics, diagnosis, and pregnancy, and the neonatal outcomes of pregnant women with reactive syphilis serology in a Canadian cohort. METHODS We conducted a retrospective chart review of pregnant women in Alberta with reactive syphilis serology between 2002 and 2006. Clinical staging of syphilis in mothers and infants was determined using provincial and national surveillance criteria. RESULTS Seventy-five pregnancies met the inclusion criteria. Thirty women were adequately treated pre-conception, 20 women had infectious syphilis (10 primary, 5 secondary, 5 early latent), 24 had late latent syphilis, and one had disease of unknown stage. Seven infants with congenital syphilis and one infant with presumed congenital syphilis were born to women with primary (n = 4), secondary (n = 2), early latent (n = 1), and unknown stage (n = 1) syphilis. Treatment was provided prior to delivery in one woman; five women did not access prenatal care. Four infants had long-term sequelae. CONCLUSION All infants with congenital syphilis were born to women with infectious syphilis who had limited prenatal care. Initiatives to reach women at high risk are required to decrease the incidence of congenital syphilis.

SOGC Committee Opinion on the Management of a Pregnant Woman Exposed to or Infected With Ebola Virus Disease in Canada

OBJECTIVE To review the evidence and provide recommendations on the general management of a pregnant woman exposed to or infected with Ebola virus disease (EVD). OUTCOMES OUTCOMES evaluated include general principles of approach and specific aspects of management of EVD relevant to pregnancy. EVIDENCE Published literature was retrieved through searches of Medline, EMBASE, and CINAHL in October 2014 using appropriate controlled vocabulary and key words (Ebola and pregnancy; hemorrhagic fever and pregnancy). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English. Searches were updated and incorporated in the guideline to November 7, 2014. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, and national and international medical specialty societies. VALUES The quality of evidence in this document was rated using the criteria described in Report of the Canadian Task Force on Preventive Health Care (Table 1). CONCLUSION Individuals incubating EVD but who do not yet have symptoms are not infectious. The chance of a pregnant woman presenting with EVD in Canada is minimal, as are the chances of her infecting others if reasonable precautions are in place. EVIDENCE of maternal-fetal transmission is limited and anecdotal.

Lignes directrices quant à la prise en charge au Canada d'une femme enceinte ayant été exposée à la maladie à virus Ebola ou ayant été infectée par ce virus

Résultats : La littérature publiée a été récupérée par l’intermédiaire de recherches menées dans Medline, EMBASE et CINAHL en octobre 2014 au moyen d’un vocabulaire contrôlé et de mots clés appropriés (« Ebola and pregnancy »; « hemorrhagic fever and pregnancy »). Les résultats ont été restreints aux analyses systématiques, aux études observationnelles et aux essais comparatifs randomisés / essais cliniques comparatifs publiés en anglais. Les recherches ont été mises à jour et intégrées au présent document jusqu’au 7 novembre 2014. La littérature grise (non publiée) a été identifiée par l’intermédiaire de recherches menées dans les sites Web d’organismes s’intéressant à l’évaluation des technologies dans le domaine de la santé et d’organismes connexes, dans des collections de directives cliniques, dans des registres d’essais cliniques et auprès de sociétés de spécialité médicale nationales et internationales.