STI/RTI basics
Chapter 2. Preventing STIs/RTIs and their complications

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How to prevent iatrogenic infections

As discussed in Chapter 1, many STI/RTI complications occur when sexually transmitted, endogenous or other organisms reach the upper genital tract. The most effective way to prevent STI/RTI complications, such as infertility and ectopic pregnancy, is to prevent upper genital tract infections from occurring (Table 2.1). This involves:

• STI prevention and management (Chapter 2 and Chapter 8);
• good antenatal care and safe delivery practices (Chapter 7 and Chapter 9);
• safe performance of transcervical procedures (Chapter 2);
• good postabortion care and management of complications (Chapter 9).

Interventions that reduce the spread of STIs/RTIs or prevent existing infection reaching the uterus are key to preventing complications. During most of the menstrual cycle, cervical mucus forms a thick barrier that is difficult for germs to penetrate. STIs such as gonorrhoea or chlamydia in the cervix may, however, spread to the uterus during menstruation or may be pushed in during transcervical procedures. Non-sexually-transmitted organisms from the vagina or from outside the body may also cause pelvic inflammatory disease if they are pushed into the uterus.

 

Intervention	Methods to prevent infections and complications
STI prevention	Counsel on: delaying sexual activity reducing numbers of partners using condoms correctly and consistently
STI management	Early detection and treatment of STI
Safe delivery practices	Use aseptic technique Manage postpartum infection effectively
Safe transcervical procedures	Use aseptic technique Rule out infection prior to procedure
Postabortion care	Use aseptic technique Manage postabortion infection effectively

 

Safe performance of transcervical procedures

Infection can reach the uterus through medical procedures that pass instruments through the cervix (transcervical procedures). Manual vacuum aspiration, dilatation and curettage, insertion of an intrauterine device (IUD) and endometrial biopsy are examples of such procedures. The risk of infection following a transcervical procedure varies greatly depending on factors such as background STI prevalence, resource and capacity level, and conditions under which procedures are performed. In settings where prevalence of cervical infection is low, the risk of introducing infection to the upper genital tract is minimal.

However, women who harbour pathogens such as N. gonorrhoeae or C. trachomatis in their cervix are at increased risk of upper genital tract infection after a transcervical procedure compared with uninfected women.

Upper genital tract infection following transcervical procedures can be reduced by:

• using appropriate infection prevention procedures and aseptic techniques, and
• treating any existing cervical infection.

 

Reducing risk of infection

Clinical practices

Appropriate infection prevention procedures and aseptic techniques (Box 2.1) provide protection against transmission of infection.

 

Box 2.1. Infection prevention techniques for transcervical procedures

Wash hands. Wear gloves, both for the procedure and when handling contaminated waste materials or used instruments. Decontaminate, clean and high-level disinfect all instruments (e.g. specula, tenacula, forceps, and uterine sound). High-level disinfection can be done by boiling instruments for 20 minutes in a container with a lid. Clean the cervix and vagina with antiseptic solution. Use �no touch� technique. This means avoiding contamination of the uterine sound or other instruments by inadvertently touching the vaginal wall or speculum blades.

See Annex 2 for details of disinfection and universal precautions.

 

Treatment of cervical infections

While infection prevention procedures can reduce the chance of introducing infection from the outside, they do not prevent existing gonorrhoea or chlamydial infection from being carried into the uterus during transcervical procedures. When cervical infection is present, even sterile instruments passed through the endocervix can become contaminated and carry bacteria into the upper genital tract.

The safest approach to avoid the spread of infection to the upper genital tract is to rule out or treat any cervical infection that may be present, prior to performing a transcervical procedure (see Chapter 3 and Annex 1). It is important to bear in mind that cervical infection can be asymptomatic in some women. In resource-poor settings where cervical infection is less common, it may be acceptable for health care workers to rely on clinical judgement to rule out the presence of infection. However, in resource-poor settings where the prevalence of cervical infection is high and the provider is unable to rule out infection, a full curative dose (presumptive treatment) of antibiotics effective against gonorrhoea and chlamydia may be considered (see Table 2.2).

After a transcervical procedure, all women should be counselled to contact a health provider immediately if, in the next few weeks, they develop symptoms suggestive of infection, such as fever, low abdominal pain, or abnormal vaginal discharge.

A prophylactic dose of antibiotics (100 mg of doxycycline orally 1 hour before the procedure and 200 mg after the procedure) reduces infection rates associated with induced abortion and should be given to all women undergoing this procedure irrespective of STI prevalence. For IUD insertion though, antibiotic prophylaxis provides minimal benefit and hence is not recommended.

Note: Laboratory tests to screen for STIs contribute substantially to safe and effective use of IUDs, but implementation should be considered within the public health and service context. The risk of not performing the tests should be balanced against the benefits of making the contraceptive method available.

 

Table 2.2. Recommended antibiotic treatment for gonorrhoea and chlamydia infection

Coverage	First choicea Choose one from each of the two boxes below (2 drugs)	Effective substitutesc
Gonorrhoea	cefixime 400 mg orally as a single dose, or ceftriaxone 125�250 mg by intramuscular injection	ciprofloxacinc 500 mg orally as a single dose, or spectinomycin 2 g by intramuscular injection
	See Treatment table 2 in Chapter 8 for additional treatments that can be substituted for gonorrhoea.
Chlamydia	doxycycline 100 mg orally twice a day for 7 days, or azithromycinb 1 g orally as a single dose	ofloxacinc 300 mg orally twice a day for 7 days, or tetracycline 500 mg orally 4 times a day for 7 days

^a. Single dose regimens where available are preferable to multidose treatments since they avoid potential problems of noncompliance.

^b. Azithromycin 1 g alone is a single-dose treatment that cures more than 90% of cervical infections due to gonorrhoea or chlamydia. Addition of a second drug for gonorrhoea increases the cure rate to almost 100%.

^c. The use of quinolones should take into consideration the patterns of Neisseria gonorrhoeae resistance, such as in the WHO South-East Asia and Western Pacific Regions.