Prevention Early onset of neonatal group B streptococcus diseases

Prepared by:Dr Ahmad Zharif HusseinRSMU

Background Group B streptococcus

Streptococcus agalactiae Gram positive, beta hemolytic bacteria Colonisation

Asymptomatic and intermittent Intestinal (<30% of adults) Vaginal (<25% of women)

Infection Newborn babies Adults: the elderly, pregnant/postpartum women, others

with underlying disease s

Clinical Manifestation period “Early onset” 0-6 days (~75% cases)

90% show within 12 hours Usually septicaemia and pneumonia 11% mortality, 7% morbidity 90% preventable IV Penicillin

“Late onset” 7-90 days (~25% cases) Usually meningitis and septicaemia 8% mortality, 21% morbidity (up to 50% with meningitis) No current prevention: good hygiene/education Vaccine: future hope for both late & early onset

Neonatal GBS disease in the UK – age at onset

Source: Heath PT, Balfour G, Weisner AM, Efstratiou A, Lamagni TL, Tighe H et al. Group B streptococcal disease in UK and Irish infants younger than 90 days. Lancet 2004; 363(9405):292-294.

Photo courtesy of Dr. Carol Baker Baylor College of Medicine, Houston, TX

US guidelines all women colonised with GBS at 35–37 weeks of

gestation should be offered IAP(intrapartum antibiotic prophylaxis

GBS Carrier’s

10% - 30% of women Higher proportion in African Americans and

nonsmokers GBS usually live in gastrointestinal tract but can spread

to the genital tract No symptoms or signs on examination Colonization comes and goes over months Not a sexually transmitted infectio

Risk factors for EOGBS infection

Previous Invasive GBS baby 10 x

GBS bacteriuria current pregnancy 4 x

GBS found current pregnancy 3 x

Maternal intrapartum fever (>380C) 3 x

PROM >18 hours before birth 3 x

Preterm labour 3 x

Antenatal screening

Not recommended Routine bacteriological screening of all

pregnant women for antenatal GBS carriage▪ cost-effective

Antenatal treatment IAP is before the onset of labour.

screening for GBS or the administration of IAP to women in whom GBS carriage was detected in a previous pregnancy

How to reduce risk of neonatal GBS

IAP to women with GBS bacteriuria during the current pregnancy higher risk of chorioamnionitis and neonatal disease urinary tract infection (growth of greater than 105

cfu/ml) during pregnancy IAP should be offered if GBS is detected on a vaginal

swab in the current pregnancy. If GBS is present in a vaginal swab, it is likely that the

risk of neonatal disease is increased(risk 2.3/1000)

Antibiotic prophylaxis specific for GBS is not required for women undergoing planned caesarean section in the absence of labour and with intact membranes.

Immediate induction of labour and IAP should be offered to all women with prelabour rupture of membranes at 37+0 weeks of gestation or more.

If chorioamnionitis is suspected, broad-spectrum antibiotic therapy including an agent active against GBS should replace GBS-specific IAP and induction of labour should be considered

• Intramuscular antibiotics pre-labour• May eradicate GBS colonisation for up to 6 weeks• Small studies & no GBS infection in control or treated

group

• Vaginal flushing with Chlorhexidine• No evidence it reduces EOGBS infection

• Oral Antibiotics• No evidence it reduces EOGBS infection (treats GBS

UTI)

Intrapartum

In preterm labour with intact membranes with no other risk factors for GBS should not routinely be offered IAP unless they are known to be colonised with GBS risk of EOGBS infection is higher in preterm than

in term infants ORACLE trial

IAP should be offered to women who are pyrexial in labour (>38°C). should be offered broad-spectrum antibiotics including an antibiotic for prevention of neonatal EOGBS disease

IAP for women with term prelabour rupture of membranes is unclear and NICE recommends that it is not given, unless there are other risk factors at term should be offered immediate induction of

labour or induction after 24 hours

IAP should be offered to women with a previous baby with neonatal GBS disease(neonatal sepsis) Subsequent infants born to these women are

likely to be at increased risk of GBS disease

antibiotic

IAP, benzylpenicillin should be administered as soon as possible after the onset of labour and given regularly until delivery.

Clindamycin should be administered to those women allergic to benzylpenicillin as soon as possible after the onset of labour the efficacy of IAP, the first dose should be given at least

2 hours prior to delivery minimum inhibitory concentration for GBS as early as 1

hour after maternal administration Oral antibiotics for IAP are not recommended

no evidence that intrapartum vaginal cleansing will reduce the risk of neonatal GBS disease

Summary IAP indicated

Universal screening of pregnant women for GBS at 35-37 weeks gestational age(only in US)

Intrapartum antibiotic prophylaxis for: GBS positive screening test GBS colonization status unknown with

Delivery <37 weeks Temperature during labor >100.4˚ F (>38.0˚ C) Rupture of membranes >18 hours

Previous infant with GBS disease GBS in the mother’s urine during current pregnancy

Penicillin preferred drug for IAP Ampicillin acceptable alternative Cefazolin preferred for penicillin-allergic at low risk of

anaphylaxis

Summary IAP not indicated: Colonization with GBS during a previous

pregnancy • Unless another indication during the current pregnancy

GBS bacteriuria during a previous pregnancy• Unless another indication during the current pregnancy

Negative vaginal and rectal GBS screening test during the current pregnancy• Regardless of intrapartum risk factors

Cesarean delivery performed before labor onset on a woman with intact amniotic membranes• Regardless of maternal GBS test status

• Regardless of gestational age

Conclusion

In a UK study of invasive GBS disease, 89% of early-onset cases were identified on day 1. Most cases (65–67%) have one or more risk factors prior

to or during labour. A significant number will also have had signs of fetal

distress, an emergency delivery and low Apgar scores. The majority of early-onset cases in these studies

presented with▪ sepsis (79.4%),▪ 11.8% had meningitis, ▪ 7.8% had pneumonia and ▪ 1% focal infection

Management for infants

Well infants at risk of EOGBS should be observed for the first 12–24 hours after birth with regular assessments of general wellbeing, feeding, heart rate, respiratory rate and temperature great majority of infants (89–94%) who develop EOGBS

infection develop signs within the first 24 hours after birth

the majority of such infants (65–67%) will have had one or more ‘conventional’ risk factors evident in or before labour.

Postnatal antibiotic prophylaxis is not recommended for asymptomatic term infants without known antenatal risk factors.

Infants with clinical signs of EOGBS should be treated promptly with appropriate antibiotics

For a well infant whose mother has had a previous infant with GBS disease, either clinical evaluation after birth and observation for around 24 hours are necessary, or blood cultures need to be obtained and the infant treated with benzylpenicillin until the culture results are available.

It is not necessary to perform routine surface cultures or blood cultures on well infants

no evidence to discourage breastfeeding

Typical signs of early-onset GBS infection

• grunting;• lethargy;• irritability;• poor feeding;• very high or low heart rate;• low blood pressure;• low blood sugar;• abnormal (high or low) temperature; and• abnormal (fast or slow) breathing rates with

blueness of the skin due to lack of oxygen (cyanosis).

Typical signs of late onset GBS infection• fever;• poor feeding and/or vomiting; • impaired consciousness;• fever, which may include the hands and

feet feeling cold, and/or diarrhoea;• refusing feeds or vomiting;• shrill or moaning cry or whimpering;• dislike of being handled, fretful;• tense or bulging fontanelle (soft spot on

the head);

• involuntary body stiffening or jerking movements;

• floppy body;• blank, staring or trance-like expression;• abnormally drowsy, difficult to wake or

withdrawn;• altered breathing patterns;• turns away from bright lights; and• pale and/or blotchy skin.

The Recommendatio

ns

MMWR, Vol 59(RR-10)

ww

w.g

bss.

org

.uk

Quiz 1

25/g4p3 @ 39/52 ANC 1.Hx of neonatal sepsis in previous pregnancy secondary to GBS

But current pregnancy no HVS taken Pt came with c/o contraction pain,LL @

28/7/2013 FM good DOA 29/7/2013 Ve os 2 cm cx 2cm st -12 MI clear liquor seenvx no cord no placent

UR mx??

Quiz 2

27 g2p1 @ 38/52 (SOD)scan correspond to date(correspond to edd)

unbooked unscreened c/o contraction pain.LL @ 25/4/2013

@ 0640am,FM good DOA 25/4/2013 1200am Ve os 4 cm cx 0.5 cm st -1 MI clear

liquor seen.vx Ur Mx?

Quiz 3

27 g1p0 @ 28 week clo contraction pain and LL @25/6/2013 0800am, FM good,diagnosis PPROM.DOA:26/6/2013

Ve os 1 cm cx 2 cm st -2 MI clear liquor seen

Contraction 2;10

Ur management?

Reference

CDC -Overview of CDC Prevention Guidelines, 2010▪ National Center for Immunization and

Respiratory DiseasesDivision of Bacterial Diseases

Green top guideline no 36 Prevention of early neonatal group B

streptococcushttp://www.gbss.org.uk/epetitio

Thank you