Prevention Of Early-onset Neonatal Group Research Articles

RCOG guidance: early‐onset neonatal GBS disease

In September 2017, the Royal College of Obstetricians and Gynaecologists (RCOG) published their updated Green‐top Guideline on the prevention of earlyonset neonatal group B streptococcal (GBS) disease. Here, Dr Williams summarises some of the main changes to the guidance and their implications for antenatal and peripartum care.

Prevention of Early-onset Neonatal Group B Streptococcal Disease: Green-top Guideline No. 36.

Prevention of Early-onset Neonatal Group B Streptococcal Disease: Green-top Guideline No. 36.

The Prevention of Early-Onset Neonatal Group B Streptococcal Disease.

To review the evidence in the literature and to provide recommendations on the management of pregnant women in labour for the prevention of early-onset neonatal group B streptococcal disease. The key revisions in this updated guideline include changed recommendations for regimens for antibiotic prophylaxis, susceptibility testing, and management of women with pre-labour rupture of membranes. Maternal outcomes evaluated included exposure to antibiotics in pregnancy and labour and complications related to antibiotic use. Neonatal outcomes of rates of early-onset group B streptococcal infections are evaluated. Published literature was retrieved through searches of MEDLINE, CINAHL, and The Cochrane Library from January 1980 to July 2012 using appropriate controlled vocabulary and key words (group B streptococcus, antibiotic therapy, infection, prevention). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to May 2013. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table1). The recommendations in this guideline are designed to help clinicians identify and manage pregnancies at risk for neonatal group B streptococcal disease to optimize maternal and perinatal outcomes. No cost-benefit analysis is provided. There is good evidence based on randomized control trial data that in women with pre-labour rupture of membranes at term who are colonized with group B streptococcus, rates of neonatal infection are reduced with induction of labour (I). There is no evidence to support safe neonatal outcomes with expectant management in this clinical situation.

Neonatal Early-Onset Sepsis: Epidemiology and Risk Assessment

Neonatal early-onset sepsis (EOS) continues to be a significant source of morbidity and mortality among newborns, especially among very low-birth-weight infants. Epidemiologic risk factors for EOS have been defined, and considerable resources are devoted to the identification and evaluation of infants at risk for EOS. The widespread implementation of intrapartum antibiotic prophylaxis for the prevention of early-onset neonatal group B streptococcal disease has reduced the overall incidence of neonatal EOS and influenced the microbiology of persistent early-onset infection. Recommendations for perinatal risk factor–based evaluation and empiric antibiotics treatment of neonates result in a large proportion of uninfected infants undergoing medical intervention, including antibiotic therapy. Objective risk assessment tools have been developed that may allow safe restriction of medical intervention in uninfected newborns, promote antibiotic stewardship, and optimize resource use.

Survey of American obstetricians regarding group B streptococcus: opinions and practice patterns

The objective of the study was to evaluate attitudes and practice patterns of obstetricians related to screening for group B streptococcal colonization and providing intrapartum antibiotic prophylaxis against early-onset neonatal infections with group B streptococcus. We mailed a survey to 546 members of the American College of Obstetricians and Gynecologists, including members of the Collaborative Ambulatory Research Network and non-Collaborative Ambulatory Research Network members. Stratified random selection was used to generate samples from both of these groups. The survey response rate was 60% for Collaborative Ambulatory Research Network members and 42% for non-Collaborative Ambulatory Research Network members. Of the 206 respondents who reported providing prenatal care, 97% collect screening samples at 35-37 weeks' gestational age. Anatomic sites used to collect samples were more variable: 62% include lower vagina and rectum, 26% include lower vagina and perianal skin but not rectum, and 5% include neither the perianal skin nor the rectum. First-line agents for intrapartum antibiotic prophylaxis were penicillin (71%), ampicillin (27%), and cefazolin (2%). For patients reporting a nonanaphylactic penicillin allergy, drugs used for intrapartum antibiotic prophylaxis were more varied: cefazolin (51%), clindamycin (36%), vancomycin (8%), and erythromycin (5%). For patients undergoing a labor induction starting with a cervical ripening agent, less than 40% typically give the first dose of intrapartum antibiotic prophylaxis before or at the time of cervical ripening agent administration, and 15% wait until the patient reaches the active phase of labor. Gaps in knowledge and reported practice related to the prevention of early-onset neonatal group B streptococcus infections were similar to gaps in implementation of guidelines demonstrated in past studies. New approaches to improve implementation are warranted.

Prevention of neonatal group B streptococcal sepsis in Hungary in 2012. Preliminary data of a nation-wide survey

At present, there is no obligatory guideline for the prevention of early-onset neonatal group B streptococcal disease in Hungary. The aim of the present study was to gain insight into the spontaneously developed preventive strategy of the domestic obstetric divisions and departments in Hungary. Standardized questionnaire was sent out to each of the 71 obstetric divisions and departments in Hungary. Overall, 20 (27.4%) of the chairpersons replied, and thus, 39.9% of the total number of live births in Hungary were included in the study. Despite missing public health guidelines, each of the divisions and departments developed their own strategy to prevent neonatal group B streptococcal disease. In 95% of cases, bacterial culture of the lower vagina was the method of identifying pregnant women at risk. In 5% of the cases intrapartum antibiotic prophylaxis was based on risk assessment only. Of the departments using culture-based prophylaxis, 58% departments sampled women after completion of 36th gestational weeks. Antibiotic of choice was penicillin or ampicillin in 100% of cases. Of the study participants, 80% reported on multiple administration of colonized pregnant women after onset of labor or rupture of the membranes. The authors concluded that the rate of participation in the study was low. However, prevention of early-onset neonatal group B streptococcal infection is a priority of obstetric care in Hungary. Lack of a nation-wide public health policy did not prevent obstetric institutions in this country to develop their own prevention strategy. In the majority of cases and institutions, the policy is consistent with the widely accepted international standards.

PLD.33 Intrapartum antibiotic prophylaxis against early onset Neonatal Group B Streptococcal (GBS) sepsis in women known to be colonised; how good are we?

ObjectivesEvaluate practice in tertiary care obstetric unit on the prevention of early-onset neonatal GBS disease.BackgroundThe single most important risk factor for early-onset GBS infection is maternal colonisation leading to fetal...

The Prevention of Early-Onset Neonatal Group B Streptococcal Disease

ObjectiveTo review the evidence in the literature and to provide recommendations on the management of pregnant women in labour for the prevention of early-onset neonatal group B streptococcal disease. The key revisions in this updated guideline include changed recommendations for regimens for antibiotic prophylaxis, susceptibility testing, and management of women with pre-labour rupture of membranes. OutcomesMaternal outcomes evaluated included exposure to antibiotics in pregnancy and labour and complications related to antibiotic use. Neonatal outcomes of rates of early-onset group B streptococcal infections are evaluated. EvidencePublished literature was retrieved through searches of MEDLINE, CINAHL, and The Cochrane Library from January 1980 to July 2012 using appropriate controlled vocabulary and key words (group B streptococcus, antibiotic therapy, infection, prevention). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to May 2013. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. ValuesThe quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). Benefits, Harms, and CostsThe recommendations in this guideline are designed to help clinicians identify and manage pregnancies at risk for neonatal group B streptococcal disease to optimize maternal and perinatal outcomes. No cost-benefit analysis is provided.

Antepartum vaginal administration of chloramphenicol for prevention of early-onset neonatal group B streptococcal

Antepartum vaginal administration of chloramphenicol for prevention of early-onset neonatal group B streptococcal

Prevention of Early-onset Neonatal Group B Streptococcal Disease.

Streptococcus agalactiae, also known as Group B Streptococcus (GBS), is an opportunistic pathogen that colonizes the gastrointestinal and genitourinary tracts of up to 50% of healthy adults and newborns; it is responsible for significant morbidity and mortality. Early detection can be used to establish the use of antibiotic prophylaxis to significantly reduce neonatal sepsis. This article reviews methods of detection and prevention of GBS infection in the neonate.

Cost‐effectiveness of rapid tests and other existing strategies for screening and management of early‐onset group B streptococcus during labour

To determine the cost-effectiveness of alternative screening and prevention strategies, including rapid intrapartum testing, for prevention of early-onset neonatal group B streptococcus (GBS) infection in the UK. A decision model was developed to investigate the cost-effectiveness of screening and prevention strategies for GBS. A strategy of doing nothing was also considered. Deterministic and probabilistic sensitivity analyses were carried out. Two large UK based obstetric units. Test accuracy data were obtained from a primary study of rapid tests at the onset of labour and risk factors from 1400 women. Incremental health sector costs per case of early-onset GBS death avoided. Compared with a strategy of do nothing, the incremental cost-effectiveness ratio was £32,000 per Early-Onset GBS Disease avoided and £427,000 per Early-Onset GBS Death avoided for the strategy of providing routine intrapartum antibiotic prophylaxis to all women without prior screening; Based on their current sensitivity, specificity and cost, screening using rapid tests was dominated by other more cost-effective strategies. The most cost-effective strategy was shown to be the provision of routine intrapartum antibiotic prophylaxis to all women without prior screening but, given broader concerns relating to antibiotic use, this is unlikely to be acceptable. In its absence, intrapartum antibiotic prophylaxis directed by screening with enriched culture becomes cost-effective. The current strategy of risk-factor-based screening is not cost-effective compared with screening based on culture.

Epidemiology of Neonatal Early-onset Sepsis

Neonatal early-onset sepsis (EOS) continues to be a significant source of morbidity and mortality among newborns, especially among very-low birthweight infants. Epidemiologic risk factors for EOS have been defined, and considerable resources are devoted to the identification and evaluation of infants at risk for EOS. The widespread implementation of intrapartum antibiotic prophylaxis for the prevention of early-onset neonatal group B Streptococcus (GBS) disease has reduced the overall incidence of neonatal EOS and influenced the microbiology of persistent early-onset infection. Most early-onset neonatal GBS disease now occurs in preterm infants or in term infants born to mothers who have negative GBS screening cultures. Ongoing clinical challenges include reassessment of clinical risk factors for EOS in the era of GBS prophylaxis; more accurate identification of GBS-colonized women; and continued surveillance of the impact of GBS prophylaxis practices on the microbiology of EOS, particularly among very low-birthweight infants.

RETIRED: The Prevention of Early-Onset Neonatal Group B Streptococcal Disease

This document has been archived because it contains outdated information. It should not be consulted for clinical use, but for historical research only. Please visit the journal website for the most recent guidelines.

Early-onset neonatal group B streptococcal infection: 2002 guidelines for prevention

In 1996, the Centers for Disease Control and Prevention (CDC) and relevant professional organizations jointly released guidelines for prevention of early-onset neonatal group B streptococcal infections. The guidelines recommended that all obstetric providers and institutions providing intrapartum services follow one of two strategies. This year, on the basis of multistate surveillance data collected since prevention strategies were initiated, the CDC has released revised prevention recommendations. This article reviews the new guidelines and discusses clinical implications for practice in a variety of settings.

The effectiveness of risk-based intrapartum chemoprophylaxis for the prevention of early-onset neonatal group B streptococcal disease

Objective: Our purpose was to evaluate the effectiveness of a risk-based intrapartum antibiotic prophylaxis strategy for the prevention of early-onset neonatal group B streptococcal disease. Study Design: Cases and controls were selected from infants born to women with one or more risk factors: preterm labor or rupture of membranes, prolonged rupture of membranes (>18 hours), fever during labor, or previous child with group B streptococcal disease. Cases were matched with controls by birth hospital and gestational age. Data abstracted from medical records were analyzed to estimate the effectiveness of intrapartum antibiotic prophylaxis. Results: We analyzed data from 109 cases and 207 controls. Nineteen (17%) case versus 69 (33%) control mothers received an acceptable regimen of intrapartum antibiotic prophylaxis. In adjusted analyses, the effectiveness of intrapartum antibiotic prophylaxis was 86% (95% confidence interval, 66%-94%). When the first dose of antibiotics was given ≥2 hours before delivery, the effectiveness increased to 89% (95% confidence interval, 70%-96%); when it was given within 2 hours of delivery, the effectiveness was 71% (95% confidence interval, –8%-92%). Effectiveness was lowest in mothers with intrapartum fever (72%, 95% confidence interval, –9%-93%). On the basis of a 70% prevalence of maternal risk factors expected among cases in the absence of intrapartum antibiotic prophylaxis, we estimate that the risk-based strategy could reduce early-onset group B streptococcal disease by 60%. Conclusions: The risk-based approach to intrapartum antibiotic prophylaxis is effective in preventing early-onset group B streptococcal disease. To achieve the maximum preventive effect, the first dose of antibiotics should be administered at least 2 hours before delivery. (Am J Obstet Gynecol 2001;184:1204-10.)

The capture rate of at-risk term newborns for early-onset group B streptococcal sepsis determined by a risk factor approach

Objective: Currently, the Centers for Disease Control and Prevention, The American College of Obstetricians and Gynecologists, and the American Academy of Pediatrics recommend that health care providers for pregnant women implement 1 of 2 strategies for the potential prevention of early-onset neonatal group B streptococcal sepsis. Both algorithms recommend intrapartum antibiotic chemoprophylaxis for patients delivered of their neonates at <37 weeks’ gestation. The basic difference lies in the management of the term pregnancy. One protocol suggests treatment of all patients with term pregnancies with a positive culture for group B Streptococcus obtained at 35 to 37 weeks’ gestation. The second approach recommends treatment on the basis of risk factors of membrane rupture of ≥18 hours’ duration or intrapartum temperature of ≥38°C. The capture rate of at-risk neonates determined by the risk factor strategy is quoted as being approximately 70%; however, the basis for this percentage was from studies that used slightly different definitions than the current guidelines and never separated the term from the preterm newborn. Our objective was to prospectively collect every case of blood culture–proven early-onset neonatal group B streptococcal sepsis and determine whether risk factors, as currently defined, were present that might have warranted maternal intrapartum antibiotic chemoprophylaxis. Study Design: A prospective study was initiated on July 1, 1987, and completed on December 31, 1996. Every patient that was delivered of a neonate in whom early-onset group B streptococcal sepsis developed was analyzed in detail for possible intrapartum risk factors. Results: A total of 49 cases of early-onset group B streptococcal sepsis occurred in 46,959 deliveries. Of these 49 newborns, 9 (18%) were delivered at <37 weeks’ gestation. The remaining 40 newborns were delivered at term, and only 12 (30%) were delivered with an intrapartum risk factor of either membrane rupture of ≥18 hours’ duration or temperature of ≥38°C or both. Conclusions: On the basis of the data from this study and the current literature, the risk factor approach with the current guideline recommendations would capture <50% of the term newborns in whom sepsis develops. (Am J Obstet Gynecol 1999;181:1243-9.)

Maternal and neonatal infection rates with three different protocols for prevention of group B streptococcal disease

Objectives: We compared maternal and neonatal infection rates under 3 different group B streptococcal prevention strategies and also evaluated reasons for each protocol’s failures in preventing neonatal disease. Study Design: Women who were delivered at our center from August 1, 1991, through April 30, 1998, were managed by 1 of 3 protocols for prevention of early-onset neonatal group B streptococcal infection: a selective screening protocol, The American College of Obstetricians and Gynecologists protocol, and the Centers for Disease Control and Prevention–recommended universal screening strategy. We compared maternal infection rates and neonatal group B streptococcal infection rates under each protocol. We also compared reasons for each protocol’s failures in preventing neonatal infection. Results: Clinical chorioamnionitis rates were 7.4% with selective screening, 7.7% under The American College of Obstetricians and Gynecologists’ protocol, and 5.2% with universal screening (relative risk 0.7, 95% confidence interval 0.6-0.8). Endometritis rates were 4.0% with selective screening, 4.6% with The American College of Obstetricians and Gynecologists protocol, and 2.8% with universal screening (relative risk 0.7, 95% confidence interval 0.6-0.8). Overall neonatal group B streptococcal infection rates were lower under the 2 more recent strategies, but not significantly so. Despite the ability of universal screening to find more women at risk for group B streptococcal transmission, half of the neonatal infections under this protocol occurred when the mothers were not considered candidates for prophylaxis. Conclusions: The Centers for Disease Control and Prevention–endorsed universal screening strategy for group B streptococcal infection prevention was associated with significantly lower rates of clinical chorioamnionitis and endometritis than were the other strategies. We were unable to document statistically significant improvement in neonatal outcome under the universal screening protocol. (Am J Obstet Gynecol 1999;180:416-22.)

Prevention of early-onset neonatal group B streptococcal disease with selective intrapartum chemoprophylaxis

Abstract Most cases of neonatal group B streptococcal disease with early onset have an intrapartum pathogenesis. Attack rates are increased substantially in infants born to mothers with prenatal group B streptococcal colonization and various perinatal risk factors (premature labor, prolonged membrane rupture, or intrapartum fever). In a randomized controlled trial, we studied the effect of selective intrapartum prophylaxis with ampicillin in 160 such high-risk women. In infants born to mothers who received intravenous ampicillin during labor, as compared with controls who received no treatment, neonatal colonization with group B streptococci was present in 8 of 85 (9 percent) versus 40 of 79 (51 percent; P<0.001), colonization at multiple (≥3) sites was observed in 3 of 85 (4 percent) versus 24 of 79 (30 percent; P<0.001), and bacteremia occurred in none of 85 versus 5 of 79 (6 percent; P = 0.024). The side effects of ampicillin were limited to a single episode of urticaria in a mother who had no history ...