Is antibiotic prophylaxis necessary after a dilation and curettage (D&C) procedure?

Antibiotic Prophylaxis After Dilation and Curettage (D&C)

Routine antibiotic prophylaxis is not recommended after dilation and curettage (D&C) procedures due to the very low risk of infection (<1%) and lack of compelling evidence supporting its effectiveness. 1, 2

Rationale for Not Using Prophylactic Antibiotics

• D&C is considered a clean or clean-contaminated procedure with a low risk of infection that does not justify systematic antibiotic prophylaxis 1, 2
• The incidence of bacteremia during D&C has been shown to be approximately 5%, placing it in the same low-risk category as other diagnostic procedures 3
• Studies comparing antibiotic use versus no antibiotics after D&C for metrorrhagia showed no statistically significant difference in the development of pelvic inflammatory disease 4
• The French Society of Anesthesia and Intensive Care Medicine specifically states that for intrauterine procedures such as curettage, antibiotic prophylaxis is not recommended due to the very low risk of infection 1

Special Circumstances Where Prophylaxis May Be Considered

• Postpartum D&C: For postpartum dilation and curettage, antibiotic prophylaxis may be warranted with a one-time combination of ampicillin 2 g IV plus metronidazole 500 mg IV 5
• High-risk patients: Those with multiple comorbidities that increase infection risk may benefit from individualized assessment 2
• Prosthetic heart valves: The American Heart Association recommends prophylactic antibiotics for patients with prosthetic valves undergoing D&C 3
• Septic abortion: Antibiotic prophylaxis is recommended in cases of septic abortion 3

General Principles When Prophylaxis Is Required

• When antibiotics are deemed necessary, they should be administered within 60 minutes before the procedure 2
• A single dose is typically sufficient for short procedures like D&C 2
• The antibiotic selected should cover the most likely pathogens (typically vaginal flora) 2

Common Pitfalls to Avoid

• Continuing antibiotics beyond the perioperative period for prophylaxis provides no additional benefit and increases risk of adverse effects including antimicrobial resistance 2
• Failing to distinguish between prophylaxis (prevention) and treatment (active infection already present) 2
• Overuse of antibiotics in low-risk procedures contributes to antimicrobial resistance and unnecessary adverse effects 1

Algorithm for Decision-Making

1. Standard D&C for non-infectious indications: No antibiotic prophylaxis needed 1, 2
2. D&C with special circumstances:
   • Prosthetic heart valves: Provide antibiotic prophylaxis 3
   • Septic abortion: Provide therapeutic antibiotics 3
   • Postpartum D&C: Consider ampicillin 2 g IV plus metronidazole 500 mg IV 5
   • If patient has received group B Streptococcus prophylaxis, then only metronidazole is recommended 5

By following these evidence-based recommendations, clinicians can optimize patient outcomes while practicing antimicrobial stewardship.