Best practices to minimize risk of infection with intrauterine device insertion.

General

Guideline Title

Best practices to minimize risk of infection with intrauterine device insertion.

Bibliographic Source(s)

• Caddy S, Yudin MH, Hakim J, Money DM, Infectious Disease Committee. Best practices to minimize risk of infection with intrauterine device insertion. J Obstet Gynaecol Can. 2014 Mar;36(3):266-74. [66 references] PubMed

Guideline Status

This is the current release of the guideline.

Recommendations

Major Recommendations

The quality of evidence assessment ( I-III ) and classification of recommendations ( A-D, L ) are defined at the end of the “Major Recommendations” field.

Risk of Pelvic Inflammatory Disease (PID) After Insertion

Recommendation

1. All women requesting an intrauterine device (IUD) should be counselled about the small increased risk of PID in the first 20 days after insertion. ( II-2A )

Role of and Indications for Screening for Sexually Transmitted Infections (STIs)

Recommendation

1. All women requesting an IUD should be screened by both history and physical examination for their risk of STI. 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 )

Bacterial Vaginosis

Recommendation

1. Not enough current evidence is available to support routine screening for bacterial vaginosis at the time of insertion of an IUD in asymptomatic women. ( II-2C )

Role of Prophylactic Antibiotics

Recommendation

1. Routine use of prophylactic antibiotics is not recommended prior to IUD insertion, although it may be used in certain high-risk situations. ( I-C )

Insertion Technique

Recommendation

1. Standard practice includes cleansing the cervix and sterilizing any instruments that will be used prior to and during insertion of an IUD. ( III-C )

Management of PID with IUD In Situ

Recommendation

1. In treating mild to moderate PID, it is not necessary to remove the IUD during treatment unless the patient requests removal or there is no clinical improvement after 72 hours of appropriate antibiotic treatment. In cases of severe PID, consideration can be given to removing the IUD after an appropriate antibiotic regimen has been started. ( I-B )

Special Populations

Human Immunodeficiency Virus (HIV)-Positive Women

Recommendation

1. An IUD is a safe, effective option for contraception in an HIV-positive woman. ( I-B )

Adolescents

Recommendation

1. An IUD can be considered a first-line contraceptive agent in adolescents. ( I-A )

Definitions:

Quality of Evidence Assessment*

I : Evidence obtained from at least one properly randomized controlled trial

II-1 : Evidence from well-designed controlled trials without randomization

II-2 : Evidence from well-designed cohort (prospective or retrospective) or case-control studies, preferably from more than one centre or research group

II-3 : Evidence obtained from comparisons between times or places with or without the intervention. Dramatic results in uncontrolled experiments (such as the results of treatment with penicillin in the 1940s) could also be included in this category

III : Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees

*Adapted from the Evaluation of Evidence criteria described in the Canadian Task Force on Preventive Health Care.

Classification of Recommendations†

A. There is good evidence to recommend the clinical preventive action

B. There is fair evidence to recommend the clinical preventive action

C. The existing evidence is conflicting and does not allow to make a recommendation for or against use of the clinical preventive action; however, other factors may influence decision-making

D. There is fair evidence to recommend against the clinical preventive action

E. There is good evidence to recommend against the clinical preventive action

L. There is insufficient evidence (in quantity or quality) to make a recommendation; however, other factors may influence decision-making

†Adapted from the Classification of Recommendations criteria described in the Canadian Task Force on Preventive Health Care.

Clinical Algorithm(s)

None available

Scope

Disease/Condition(s)

Infection (pelvic inflammatory disease [PID]) caused by intrauterine devices (IUDs)

Guideline Category

• Counseling
• Management
• Risk Assessment
• Screening

Clinical Specialty

• Family Practice
• Infectious Diseases
• Obstetrics and Gynecology

Intended Users

• Advanced Practice Nurses
• Nurses
• Physician Assistants
• Physicians

Guideline Objective(s)

To review the risk of infection with the insertion of intrauterine devices (IUDs) and recommend strategies to prevent infection

Target Population

Women requesting an intrauterine device (IUD)

Interventions and Practices Considered

1. Counseling on pelvic inflammatory disease (PID) risks
2. History and physical examination
3. Assessment of risks for sexually transmitted infections (STIs)
4. Insertion of intrauterine device (IUD) * Cleansing the cervix and sterilizing instruments * Removal in cases of severe PID
5. Use in human immunodeficiency virus (HIV)-positive women and adolescents

Note : The following interventions were considered but either not recommended or there was not enough current evidence available to support a recommendation:

• Routine screening for bacterial vaginosis
• Routine use of use of prophylactic antibiotics

Major Outcomes Considered

• Risk of pelvic inflammatory disease (PID)
• Impact of screening for bacterial vaginosis and sexually transmitted infections (STIs) including chlamydia and gonorrhea
• Role of prophylactic antibiotics

Methodology

Methods Used to Collect/Select the Evidence

• Searches of Electronic Databases
• Searches of Unpublished Data

Description of Methods Used to Collect/Select the 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.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence

• Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

Quality of Evidence Assessment*

I: Evidence obtained from at least one properly randomized controlled trial

II-1: Evidence from well-designed controlled trials without randomization

II-2: Evidence from well-designed cohort (prospective or retrospective) or case-control studies, preferably from more than one centre or research group

II-3: Evidence obtained from comparisons between times or places with or without the intervention. Dramatic results in uncontrolled experiments (such as the results of treatment with penicillin in the 1940s) could also be included in this category

III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees

*Adapted from The Evaluation of Evidence criteria described in the Canadian Task Force on Preventive Health Care.

Methods Used to Analyze the Evidence

• Review of Published Meta-Analyses
• Systematic Review

Description of the Methods Used to Analyze the Evidence

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 (see the “Rating Scheme for the Strength of the Evidence” field).

Methods Used to Formulate the Recommendations

• Expert Consensus

Description of Methods Used to Formulate the Recommendations

Not stated

Rating Scheme for the Strength of the Recommendations

Classification of Recommendations †

A. There is good evidence to recommend the clinical preventive action

B. There is fair evidence to recommend the clinical preventive action

C. The existing evidence is conflicting and does not allow to make a recommendation for or against use of the clinical preventive action; however, other factors may influence decision-making

D. There is fair evidence to recommend against the clinical preventive action

E. There is good evidence to recommend against the clinical preventive action

L. There is insufficient evidence (in quantity or quality) to make a recommendation; however, other factors may influence decision-making

†Adapted from the Classification of Recommendations criteria described in the Canadian Task Force on Preventive Health Care.

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation

• Internal Peer Review

Description of Method of Guideline Validation

This committee opinion has been prepared by the Infectious Disease Committee, reviewed by the Family Practice Advisory Committee, the Registered Nurse Advisory Committee, the Aboriginal Health Initiative, and the Canadian Paediatric and Adolescent Gynaecology and Obstetricians Committee, and approved by the Executive and Council of the Society of Obstetricians and Gynaecologists of Canada.

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the “Major Recommendations” field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate practices to minimize risk of infection with intrauterine device (IUD) insertion

Potential Harms

• When sexually transmitted infection (STI) testing first and delaying insertion to a follow-up appointment, consideration must be given to the likelihood of the patient being able to return, and the potential benefit of decreasing the risk of pelvic inflammatory disease (PID) from 0–5% to 0–2% must be weighed against the risk of unintended pregnancy during this time.
• The role of poor aseptic technique in the risk of PID after intrauterine device (IUD) insertion is not well-known, but it is well documented in other areas including puerperal and postabortion infection. Intrauterine microbial contamination is highest in the first month of insertion and decreases with time. The risk of potentially infectious vectors being introduced into the cavity at the time of IUD insertion is long established; however, this risk is short-lived.

Contraindications

Contraindications

The World Health Organization (WHO) lists current pelvic inflammatory disease (PID), purulent cervicitis, and current chlamydial or gonorrheal infection, among others, as absolute contraindications to the insertion of an intrauterine device (IUD).

Qualifying Statements

Qualifying Statements

This document reflects emerging clinical and scientific advances on the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate amendments to these opinions. They should be well documented if modified at the local level. None of these contents may be reproduced in any form without prior written permission of the Society of Obstetricians and Gynaecologists of Canada (SOGC).

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools

• Foreign Language Translations

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need

• Staying Healthy

IOM Domain

• Effectiveness
• Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)

• Caddy S, Yudin MH, Hakim J, Money DM, Infectious Disease Committee. Best practices to minimize risk of infection with intrauterine device insertion. J Obstet Gynaecol Can. 2014 Mar;36(3):266-74. [66 references] PubMed

Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released

2014 Mar

Guideline Developer(s)

• Society of Obstetricians and Gynaecologists of Canada - Medical Specialty Society

Source(s) of Funding

Society of Obstetricians and Gynaecologists of Canada

Guideline Committee

Infectious Disease Committee

Composition of Group That Authored the Guideline

Principal Authors : Sheila Caddy, MD, Edmonton AB; Mark H. Yudin, MD, Toronto ON; Julie Hakim, MD, Ottawa ON; Deborah M. Money, MD, Vancouver BC

Infectious Disease Committee : Mark H. Yudin, MD ( Chair ), Toronto ON; Victoria M. Allen, MD, Halifax NS; Céline Bouchard, MD, Quebec QC; Marc Boucher, MD, Montreal QC; Sheila Caddy, MD, Edmonton AB; Eliana Castillo, MD, Calgary AB; Deborah M. Money, MD, Vancouver BC; Kellie E. Murphy, MD, Toronto ON; Gina Ogilvie, MD, Vancouver BC; Caroline Paquet, RM, Trois-Rivieres QC

Special Contributor : Wendy V. Norman, MD, Vancouver BC

Financial Disclosures/Conflicts of Interest

Disclosure statements have been received from all contributors.

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available from the Society of Obstetricians and Gynaecologists of Canada (SOGC) Web site. Also available in French from the SOGC Web site.

Print copies: Available from the Society of Obstetricians and Gynaecologists of Canada, La société des obstétriciens et gynécologues du Canada (SOGC) 780 promenade Echo Drive Ottawa, ON K1S 5R7 (Canada); Phone: 1-800-561-2416.

Availability of Companion Documents

None available

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on May 7, 2014. The information was verified by the guideline developer on June 4, 2014.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer’s copyright restrictions.

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