Correspondence
Rates of Serious Infection after Medical Abortion
N Engl J Med 2009; 361:1511-1512October 8, 2009
- Article
To the Editor:
Fjerstad et al. (July 9 issue)1 report a link between changes in the protocol for medical abortion and a reduction in the rate of infection in a large U.S. clinic network. However, it is not possible to draw definitive conclusions from a retrospective report regarding two interventions that took place without controls. Two thirds of the decrease in the rate of serious infection appears to have occurred with a change from vaginal to buccal administration of misoprostol; a further decrease occurred after antibiotics were required. Notably, changing to buccal administration is cost-free and easy to implement without increasing the rate of serious adverse events.
Before we move to an antibiotic mandate, more information is needed on the efficacy and safety of universal antibiotic administration in healthy populations undergoing low-risk procedures. The present report does not address the costs of an intervention with inherent potential for adverse events, yet may lead clinicians and others to provide antibiotic treatment in the absence of a diagnosis of infection. Careful consideration of the benefits and risks of universal antibiotic administration in different economic, social, medical, and legal environments is necessary.
1 ReferencesNathalie Kapp, M.D., M.P.H.
World Health Organization, Geneva, SwitzerlandBeverly Winikoff, M.D., M.P.H.
Gynuity Health Projects, New York, NY
bwinikoff@gynuity.org Paul D. Blumenthal, M.D., M.P.H.
Stanford University, Stanford, CA1
Fjerstad M ,Trussell J ,Sivin I ,Lichtenberg ES ,Cullins V . Rates of serious infection after changes in regimens for medical abortion. N Engl J Med 2009;361:145-151
Full Text | Web of Science | Medline
Author/Editor Response
We agree with Kapp et al. that a critical examination of our findings in relation to needs, costs, and benefits in different countries would be useful. We did not conduct a cost–benefit analysis of the changes in regimen in Planned Parenthood or in any other clinical setting. We deliberately did not recommend the adoption of routine administration of antibiotics.
We are puzzled that the correspondents read our findings as attributing 67% of the decline in the rate of serious infection to the change from vaginal to buccal administration of misoprostol. That is the maximum contribution; the minimum is 0%. We found that the maximum contribution of the universal use of antibiotics could be as high as 100% and no lower than 33%.
The characterization of our study as uncontrolled is incorrect. Our control group was the 72,195 women in Period 1, who underwent no systematic screening for sexually transmitted infections or standardized infection-prevention regimen. Rates of serious infection in that group provided a baseline for comparison with similar women who were profiled during subsequent periods.
Mary Fjerstad, N.P., M.H.S.
Ipas, Chapel Hill, NC
fjerstadm@ipas.org James Trussell, Ph.D.
Princeton University, Princeton, NJIrving Sivin, M.A.
Population Council, New York, NY
