A Population-Based Comparison of Strategies to Prevent Early-Onset Group B Streptococcal Disease in Neonates

Johns Hopkins University, Baltimore, Maryland, United States
New England Journal of Medicine (Impact Factor: 55.87). 08/2002; 347(4):233-9. DOI: 10.1056/NEJMoa020205
Source: PubMed


Guidelines issued in 1996 in the United States recommend either screening of pregnant women for group B streptococcal colonization by means of cultures (screening approach) or assessing clinical risk factors (risk-based approach) to identify candidates for intrapartum antibiotic prophylaxis.
In a multistate retrospective cohort study, we compared the effectiveness of the screening and risk-based approaches in preventing early-onset group B streptococcal disease (in infants less than seven days old). We studied a stratified random sample of the 629,912 live births in 1998 and 1999 in eight geographical areas where there was active surveillance for group B streptococcal infection, including all births in which the neonate had early-onset disease. Women with no documented culture for group B streptococcus were considered to have been cared for according to the risk-based approach.
We studied 5144 births, including 312 in which the newborn had early-onset group B streptococcal disease. Antenatal screening was documented for 52 percent of the mothers. The risk of early-onset disease was significantly lower among the infants of screened women than among those in the risk-based group (adjusted relative risk, 0.46; 95 percent confidence interval, 0.36 to 0.60). Because women whose providers had no strategy for prophylaxis may have been misclassified in the risk-based group, we excluded all women with risk factors and adequate time for prophylaxis who did not receive antibiotics. The adjusted relative risk of early-onset disease associated with the screening approach in this secondary analysis was similar--0.48 (95 percent confidence interval, 0.37 to 0.63).
Routine screening for group B streptococcus during pregnancy prevents more cases of early-onset disease than the risk-based approach. Recommendations that endorse both strategies as equivalent warrant reconsideration.

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    • "For categorical variables, the í µí¼’ 2 test was used and the paired í µí±¡ test for continuous measures. In multivariate analysis, odds ratios (OR) were assumed to approximate relative risks (RR) because clinical sepsis was rare in this population [16]. Multivariate logistic regression analysis was performed on independent variables with a í µí±ƒ < .10 to estimate the adjusted OR with 95% confidence interval (CI) to control for factors that would affect the rate of clinical diagnosis of sepsis. "
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    ABSTRACT: Background: Infants born to mothers who are colonized with group B streptococcus (GBS) but received <4 hours of intrapartum antibiotic prophylaxis (IAP) are at-risk for presenting later with sepsis. We assessed if <4 hours of maternal IAP for GBS are associated with an increased incidence of clinical neonatal sepsis. Materials and methods: A retrospective cohort study of women-infant dyads undergoing IAP for GBS at ≥37-week gestation who presented in labor from January 1, 2003 through December 31, 2007 was performed. Infants diagnosed with clinical sepsis by the duration of maternal IAP received (< or ≥4-hours duration) were determined. Results: More infants whose mothers received <4 hours of IAP were diagnosed with clinical sepsis, 13 of 1,149 (1.1%) versus 15 of 3,633 (0.4%), P = .03. Multivariate logistic regression analysis showed that treatment with ≥4 hours of IAP reduced the risk of infants being diagnosed with clinical sepsis by 65%, adjusted relative risk 0.35, CI 0.16-0.79, and P = .01. Conclusion: The rate of neonatal clinical sepsis is increased in newborns of GBS colonized mothers who receive <4 hours compared to ≥4 hours of IAP.
    Full-text · Article · Mar 2013 · Infectious Diseases in Obstetrics and Gynecology
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    • "If the GBS colonization status from the current pregnancy is not known, and if onset of labor or rupture of membranes occurred before 37 weeks’ gestation with a substantial risk for preterm delivery, then GBS screening should be performed and IAP for GBS should be provided pending culture results [12]. The Polish IAP against GBS infection corresponds with the CDC recommendations from 2002 [11]. For IAP for women with GBS carriage, IV administration of Penicillin G or, as an alternative, Ampicillin, was recommended. "
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    ABSTRACT: Background In 2008, the Polish Gynecological Society issued recommendations to screen pregnant women for GBS colonization and offer antibiotic prophylaxis at delivery. The goal of this study was to assess compliance with these recommendations among women delivering very low birth weight infants (VLBW) in Poland. Material/Methods The 6 Polish Perinatological Institutions managing infections in the framework of the Polish Perinatological Network were subjected to the analysis. A retrospective case-cohort study for 2009 was conducted using the standard protocols and definitions. The collected data pertained to 812 pregnant women who gave birth to 910 babies with VLBW. Results The statistical variation across the 6 studied centers associated with GBS prevention of infections was noted. Bacteriological examinations of samples taken from the vagina were performed only in 273 (34%) of the women, ranging between 2% and 93%, depending on the center. GBS carriage was proven in 19% of these women, ranging between 8% and 27%. The culture method was inadequate because of highly variable results. It was found that the rate of GBS determination is statistically connected with the number of women’s screenings performed in the study centers. The intrapartum antibiotic prophylaxis (IAP) was used only in the half of GBS-positive women (47%). Six cases of early-onset GBS infections (5 blood stream infections and 1 pneumonia) were registered in the studied newborns, of which 4 neonates were born to women who received IAP against GBS. The incidence rate of GBS infection in VLBW neonates was 6.6 per 1000 live births, with a high death rate (up to 33%). Conclusions Poor compliance with GBS screening and antibiotic prevention were observed among women delivering very low birth weight infants. GBS infection was noted in a significant proportion of VLBW neonates; we believe a uniform policy should be put in place to manage these high-risk women and babies.
    Full-text · Article · Jan 2013 · Medical science monitor: international medical journal of experimental and clinical research
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    • "The guidelines recommended by The Centers for Disease Control and Prevention (CDC) and The American College of Obstetricians and Gynecologists (ACOG) includes: (i) the sampling of the vaginal and anorectal regions with the aid of a swab which is submitted to bacteriological culture usually into selective broth medium (enrichment culture) followed by subculture onto sheep blood agar plates (1, 3, 10), and (ii) the intrapartum chemoprophylaxis for those pregnant women with: positive maternal GBS screening, positive GBS urine culture during the current pregnancy, and a previous infant who had GBS infection (10). An oral chemoprophylaxis approach with antibiotics is not recommended because it is unlikely to eradicate maternal genital GBS colonization (13, 14, 29). However, although the laboratory methods for the identification of GBS have evolved, there remains a clinical need for greater accuracy, particularly in the case of asymptomatic colonization with low GBS charge (4, 15). "
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    ABSTRACT: Group B Streptococcus (GBS) is the most common cause of life-threatening infection in neonates. Guidelines from CDC recommend universal screening of pregnant women for rectovaginal GBS colonization. The objective of this study was to compare the performance of a combined enrichment/PCR based method targeting the atr gene in relation to culture using enrichment with selective broth medium (standard method) to identify the presence of GBS in pregnant women. Rectovaginal GBS samples from women at ≥36 weeks of pregnancy were obtained with a swab and analyzed by the two methods. A total of 89 samples were evaluated. The prevalence of positive results for GBS detection was considerable higher when assessed by the combined enrichment/PCR method than with the standard method (35.9% versus 22.5%, respectively). The results demonstrated that the use of selective enrichment broth followed by PCR targeting the atr gene is a highly sensitive, specific and accurate test for GBS screening in pregnant women, allowing the detection of the bacteria even in lightly colonized patients. This PCR methodology may provide a useful diagnostic tool for GBS detection and contributes for a more accurate and effective intrapartum antibiotic and lower newborn mortality and morbidity.
    Full-text · Article · Jun 2012 · Brazilian Journal of Microbiology
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