Department of Obstetrics and Gynaecology, Academisch Ziekenhuis Maastricht, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands
Correspondence: E-mail: jlan{at}sgyn.azm.nl
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Introduction |
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In the `screen or treat' debate Dr Ng and colleagues make a plea for a chlamydia screening policy, opposing our proposal for routine antibiotic prophylaxis in subfertile women undergoing uterine instrumentation.
Their standpoint is based on the presumption that all persisting chlamydia infections can be identified in cervical samples, and that selective treatment of only positive cases will suffice. Since evidence exists that viable chlamydia can be obtained from the upper genital tract in patients with negative test results from the cervix, cervical screening must be considered inadequate in identifying all patients at risk. Sampling from the upper genital tract can however only be performed by invasive means, and it remains to be established whether all patients develop serum antibodies. Therefore, at this moment there is no test available that can identify by simple means all patients with viable, persisting chlamydia.
It is generally agreed that antibiotic prophylaxis is indicated in procedures with a high risk for microbial contamination (e.g. intestinal surgery), as well as in procedures following which infections are rare, but may have disastrous consequences (e.g. orthopaedic operations and uterine instrumentation). In these cases the benefits of antibiotics are considered to outweigh their possible detriments, i.e. unwanted drug effects and increased antibiotic resistance. Randomized controlled trials (RCT) are the most powerful tools available for evaluating preoperative antibiotic prophylaxis policies and to prove efficacy. Appropriate evaluation of antibiotic prophylaxis for uterine instrumentation by RCT is hampered by the fact that postoperative infections are infrequent (but disastrous) and remain asymptomatic in the majority of patients.
Reports from the literature indicate that antibiotics may not efficiently eliminate chlamydia from all host cells in vitro (Dreses-Werringloer et al., 2001), in macaques (Patton et al., 1997
) and in humans (Bragina et al., 2001
). In patients with persisting chlamydia infections atypical small intracellular inclusions have been found, suggesting that antibiotics may modulate the micro-organism and render it less susceptible to antibiotics. These observations deserve further exploration, since they question the principles and efficacy of treatment of acute as well as chronic chlamydial infections.
Thus, until an adequate non-invasive screening test has been developed to identify all patients with viable chlamydia in their genital tracts, clinical guidelines concerning precautions in subfertile women undergoing uterine instrumentation can only be based on theoretical arguments.
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References |
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Dreses-Werringloer, U., Padubrin, I., Zeidler, H. and Köhler, L. (2001) Effects of azithromycin and rifampin on Chlamydia trachomatis infection in vitro. Antimicrob. Agents Chemother., 45, 30013008.
Patton, D.L., Cosgrove Sweeney, Y., Bohannon, N.J., Clark, A.M., Hughes, J.P., Cappuccio, A., Campbell, L.A. and Stamm, W.E. (1997) Effects of Doxycycline and anti-inflammatory agents on experimentally induced chlamydial upper genital tract infection in female macaques. J. Infect. Dis., 175, 648654.[ISI][Medline]