New CDC guidelines for prevention of perinatal group B streptococcal disease

Abstract

We have previously stated that the guidelines of the US Centers for Disease Control and Prevention (CDC) for prevention of group B streptococcal (GBS) disease, based on epidemiological data, do not necessarily correlate with local data in other parts of the world, and therefore may leave their relevance in many places questionable.1Jakobi P Goldstick O Sujov P Itskovitz-Eldor J New CDC guidelines for prevention of perinatal group B streptococcal disease.Lancet. 1996; 348: 969Summary Full Text Full Text PDF PubMed Scopus (9) Google Scholar The CDC have revised these guidelines, and report a 70% decline of the disease, to 0·5 cases per 1000 livebirths in the USA.2Prevention of perinatal group B streptococcal diseaseRevised guidelines from CDC.MMWR Morb Mortal Wkly Rep. 2002; 51: 1-22Google Scholar In many countries where no local guidelines are available, those of the CDC are the basis for standards of care, for doctors and for lawyers. Since publication of our report,1Jakobi P Goldstick O Sujov P Itskovitz-Eldor J New CDC guidelines for prevention of perinatal group B streptococcal disease.Lancet. 1996; 348: 969Summary Full Text Full Text PDF PubMed Scopus (9) Google Scholar additional data on GBS disease were accumulated in our region, further strengthening our rationale for not implementing the CDC guidelines in Israel. GBS disease rates reported in Israel—0·27–0·56 per 1000 in a cohort of about 160 000 neonates—without implementation of CDC guidelines are substantially lower than those in the USA, even after proposed intervention.3Jakobi P Goldstick O Sujov P Itskovitz-Eldor J Intrapartum prophylaxis for perinatal group B streptococcal disease: do the CDC guidelines apply in Israel? The Rambam experience.Israel J Obstet Gynecol. 2000; 11: 47-50Google Scholar In many other countries, the situation might be similar to ours. Furthermore, prevention of early-onset GBS disease in accordance with the CDC guidelines means prophylactic treatment for 15–26% of all parturients, and screening programmes have several logistic and economic limitations as well. Furthermore, two reports provide good examples of the dilemma of universal implementation of these guidelines.4Stoll BJ Hansen N Fanaroff AA et al.Changes in pathogens causing early-onset sepsis in very-low-birth-weight infants.N Engl J Med. 2002; 347: 240-247Crossref PubMed Scopus (672) Google Scholar, 5Edwards RK Clark P Sistrom CL Duff P Intrapartum antibiotic prophylaxis 1: relative effects of recommended antibiotics on gram-negative pathogens.Obstet Gynecol. 2002; 100: 534-539Crossref PubMed Scopus (64) Google Scholar In one study, reduction in the GBS disease rate after acceptance of the CDC guidelines was accompanied by a concomitant increase of Escherichia coli sepsis of a similar amount, leaving the overall incidence of early-onset neonatal sepsis unchanged.4Stoll BJ Hansen N Fanaroff AA et al.Changes in pathogens causing early-onset sepsis in very-low-birth-weight infants.N Engl J Med. 2002; 347: 240-247Crossref PubMed Scopus (672) Google Scholar Workers on the second study reported that intrapartum antibiotic prophylaxis with either ampicillin or penicillin increased exposure of neonates to ampicillin-resistant enterobacteriaceae.5Edwards RK Clark P Sistrom CL Duff P Intrapartum antibiotic prophylaxis 1: relative effects of recommended antibiotics on gram-negative pathogens.Obstet Gynecol. 2002; 100: 534-539Crossref PubMed Scopus (64) Google Scholar We must remember that E coli is one of the main causes of early-onset neonatal sepsis, and sepsis caused by ampicillin-resistant E coli results in a greater likelihood of mortality than does sepsis with GBS or ampicillin-sensitive E coli.5Edwards RK Clark P Sistrom CL Duff P Intrapartum antibiotic prophylaxis 1: relative effects of recommended antibiotics on gram-negative pathogens.Obstet Gynecol. 2002; 100: 534-539Crossref PubMed Scopus (64) Google Scholar These data suggest that implementation of the CDC guidelines in areas with a low incidence of GBS disease—though still providing prophylactic antibiotics to as many as 25% of pregnant women—could result in a rise in the overall sepsis rate: the increase of E coli sepsis because of prophylaxis might be higher than the number of preventable cases of GBS disease. Thus, in areas with a low incidence of GBS sepsis, such as in Israel, implementation of the CDC guidelines is not justified and could prove harmful. In such areas continuous surveillance of the disease is advised.