What is the recommended treatment for an infected Intrauterine Device (IUD) removal?

Management of Infected IUD

For an infected IUD, initiate antibiotic treatment first and consider removal only after antibiotics have been started to avoid the potential risk of bacterial spread during the removal procedure. 1

Initial Management

Antibiotic Treatment

• Begin appropriate antibiotic therapy according to CDC Sexually Transmitted Diseases Treatment Guidelines for pelvic inflammatory disease (PID) 1
• The IUD does not need to be removed immediately if the woman needs ongoing contraception
• Antibiotics should be started before any removal procedure to reduce the risk of bacterial spread

Assessment and Follow-up

• Reassess the patient in 24-48 hours after initiating antibiotics
• If no clinical improvement occurs:
  • Continue antibiotics
  • Consider removal of the IUD at this point 1

IUD Removal Considerations

When to Remove

• If the woman wants to discontinue IUD use: Remove after antibiotics have been started
• If clinical symptoms persist despite 24-48 hours of antibiotic therapy: Consider removal
• If the woman is pregnant with an IUD in place: Remove as soon as possible if strings are visible (due to increased risk of septic abortion) 1

Removal Procedure

1. Ensure antibiotics have been initiated before removal
2. For visible strings: Remove by gently pulling on the strings
3. For non-visible strings:
   • Perform transvaginal ultrasound to locate the IUD and determine its position 2
   • If not visualized in the uterus, obtain abdominal X-ray to check for extrauterine location 2
   • Surgical removal (preferably laparoscopy) is recommended for migrated IUDs 2

Special Considerations

Actinomyces on IUD

• In asymptomatic women with Actinomyces-like organisms (ALO) on Pap smear, IUD removal is not necessary and antibiotics are not required 3
• However, IUDs should be changed at least every five years to limit the risk of developing pelvic actinomycosis 3

Bacterial Colonization

• Most IUDs develop bacterial colonization over time, but this does not necessarily indicate infection requiring treatment 4, 5
• Culture of removed IUDs and therapeutic management based on these cultures are not recommended when women are asymptomatic for PID 4

Common Pitfalls to Avoid

• Do not remove an infected IUD before starting antibiotics, as this may increase the risk of bacterial spread
• Do not assume all IUDs with bacterial colonization require removal; treatment decisions should be based on clinical symptoms
• Avoid unnecessary antibiotic treatment in asymptomatic women with incidental findings of ALO on Pap smear
• Do not delay removal if clinical improvement fails to occur within 24-48 hours of antibiotic therapy

Following these evidence-based guidelines will help optimize outcomes when managing patients with suspected infected IUDs while minimizing complications related to the removal procedure.