Barriers to prevention of perinatal group B streptococcal disease

Prevalence of oropharyngeal group B Streptococcus colonization in mothers, family, and health care providers

Objective

To determine the prevalence and serotype of oropharyngeal Group B Streptococcal (GBS) colonization of mothers, their family & friends, and health care providers of recently delivered patients as a potential reservoir of neonatal exposure to GBS.

Methods

This is a prospective, single-center observational study of: (1) patients, (2) their family and friends, and (3) health care providers all of whom may come in close contact with neonates. Oropharyngeal GBS colonization and serotype was determined.

Results

Three hundred and seventy three samples were collected. The prevalence of oropharyngeal GBS colonization among all study participants was 23.1% (N = 86). The most commonly found serotypes were 1b (12.8%, N = 11), III (27.9%, N = 24), and V (17.4%, N = 15). The prevalence of oropharyngeal GBS colonization among mothers was 26% (N = 31/121), 22% (N = 39/178) in family and friends, and 21.6% (N = 16/74) in health care providers.

Conclusion

Group B Streptococcus colonizes the oropharynx in 1 in 5 mothers, family and friends, and health care providers who come in direct contact with neonates. Further research is needed to determine if this potential reservoir for neonatal exposure could lead to early or late onset neonatal GBS colonization or infection.

Mainstreaming nutrition in maternal, newborn and child health: barriers to seeking services from existing maternal, newborn, child health programmes

In the light of mainstreaming nutrition programs into health services, this review article approaches the issue of barriers to existing maternal child health programs from both theoretical and applied perspectives. It begins with a discussion of salient literature on models of health service utilization. The mid-section of the paper presents the results of a review of research studies that illuminate the barriers to care. Categorical themes emerged from the review of studies in the form of barriers based on geographic factors, temporal factors, a myriad of socio-cultural factors, financial factors and quality of care. The discussion focuses on the need to overcome existing restrictions to health services in order to facilitate initiatives to mainstream nutrition and achieve Millennium Development Goal #1.

Trends in the epidemiology of neonatal sepsis of vertical transmission in the era of group B streptococcal prevention

AIM

To assess trends in the epidemiology of culture-proven and clinical neonatal sepsis of vertical transmission in the era of intrapartum antibiotic prophylaxis.

METHODS

Since 1995, the neonatal services of 28 acute-care teaching hospitals in Spain ("Grupo de Hospitales Castrillo") have been involved in the prospective surveillance of neonatal infection of vertical transmission. We here report the comparison of the incidence for the periods 1996-1997 and 2000-2001, and look separately at two groups of hospitals according to the time at which the official hospital policy to provide intrapartum antibiotic prophylaxis for group B Streptococcus (GBS) prevention was adopted. In 16 hospitals the policy was adopted in 1999 and in 10 before 1998 (nine hospitals in 1996, one in 1997).

RESULTS

The incidence of proven sepsis decreased significantly by 22% and 54% in the hospitals that started prophylaxis in 1999 and before 1998, respectively. The incidence of GBS sepsis also declined significantly by 36.4% and 65.4% in both groups of hospitals, respectively. Significant variations in the incidence of clinical vertical sepsis as well as in the incidence of sepsis caused by Haemophilus influenzae and Klebsiella were not found. Sepsis caused by Escherichia coli increased in the hospitals with prophylaxis from 1999 and decreased in those that began prophylaxis before 1998, in which the mortality rate of proven and clinical sepsis also decreased significantly by 58.6%.

CONCLUSIONS

There was a substantial decline in the incidence of proven vertical sepsis, with a significant reduction of GBS sepsis, although decreases were more marked when antibiotic prophylaxis was started before 1998. In this group of hospitals, there was also a decrease in the mortality rate. Fluctuations in the incidence of E. coli infection suggest the need for continuing epidemiological surveillance.

Neonatal early-onset group B streptococcal disease in the era of intrapartum chemoprophylaxis: residual problems

OBJECTIVE

To identify limitations of current strategies for intrapartum prophylaxis of neonatal early-onset group B streptococcal infection.

METHODS

Retrospective review of infants with culture-proven early-onset group B streptococcal infection admitted to two nurseries and their mothers from July 1992, when ACOG and AAP guidelines for intrapartum prophylaxis were first issued, through December 2001. Information was recorded regarding clinical risk factors for early-onset group B streptococcal infection, collection and processing of specimens to assess maternal colonization, delivery of prophylaxis, duration of hospitalization before delivery, and outcome.

RESULTS

Among 92 infants with early-onset group B streptococcal infection admitted from 23 institutions, 68 had received no intrapartum prophylaxis. Of these 68 who received no prophylaxis, 34 had identifiable risk factors before delivery (32 clinical, two positive maternal culture), while 34 had no risk factors. Prenatal culture for group B streptococcal colonization was performed in 22 of these women. Of the 18 cultures that were negative for group B streptococcus, 15 were obtained using suboptimal culture technique or were collected more than 6 weeks before delivery. Of the 68 with no prophylaxis, 14 required extracorporeal membrane oxygenation and three died. Of the 24 who received some intrapartum prophylaxis, nine had received >/=two doses for >/=4 hours immediately before delivery. Among the 24 receiving some intrapartum prophylaxis, two required extracorporeal membrane oxygenation and one died. No deaths occurred in those who received >4 hours of prophylaxis, although one such infant required extracorporeal membrane oxygenation. After the CDC guidelines were issued in May 1996, there was a decrease both in the number of cases of early-onset group B streptococcal infection (56 versus 36) as well as in the number with clinical risk factors but no intrapartum prophylaxis (24/56 (43%) versus 5/28 (18%)).

CONCLUSIONS

The use of clinical risk factors alone will inevitably result in missed opportunity for intrapartum antibiotic prophylaxis. With maternal screening, false-negative results will be reduced but not necessarily eliminated by assuring that specimens are obtained from proper sites using selective media within 6 weeks of delivery. Better strategies are needed to assure timely administration when prophylaxis is indicated. The nine neonates with early-onset group B streptococcal infection despite intrapartum antibiotics for the recommended duration illustrate that disease may occur even when guidelines are implemented appropriately.

Integrated monitoring of a new group B streptococcal disease prevention program and other perinatal infections

OBJECTIVE

To determine levels of prenatal screening for several infections, intrapartum recognition of risk factors, and prophylaxis against mother-to-child transmission of group B streptococcus.

METHODS

Review of stratified random sample of hospital records for deliveries in Connecticut during 1996. SUDAAN analysis was used to adjust for the complex survey design, and weighting adjusted for the probability of being sampled and nonresponse.

RESULTS

Of 992 records requested, 868 (88%) were abstracted and analyzed. Thirty-six percent of women had prenatal screening for group B streptococcus and 26% had been tested for human immunodeficiency virus (HIV), while 97-99% of women had been screened prenatally for hepatitis B surface antigen, rubella, and syphilis. Of those women tested, 17% were detected as group B streptococcus carriers, and 78% of these received intrapartum antibiotic prophylaxis. Among women who were not screened for group B streptococcus prenatally, 22% met risk-based criteria for prophylaxis, but only 45% of these received intrapartum prophylaxis. Among unscreened women with a risk factor, those with shorter hospital stays prior to delivery, admitted on evening or night shifts, or who delivered on the weekend were significantly less likely to receive intrapartum prophylaxis.

CONCLUSION

In 1996, the majority of women who delivered in Connecticut were not tested prenatally for group B streptococcus and the majority of those not tested in whom there was an indication for prophylaxis were not treated. Compliance with group B streptococcus prevention recommendations can be improved through increased prenatal testing and/or better recognition of risk-based criteria for intrapartum prophylaxis.

Preventing neonatal group B streptococcal disease: cost-effectiveness in a health maintenance organization and the impact of delayed hospital discharge for newborns who received intrapartum antibiotics

OBJECTIVES

To estimate the cost and health benefits of implementing a risk factor-based prevention strategy for early-onset neonatal group B streptococcal (GBS) disease, using baseline assumptions and costs from a health maintenance organization. With the risk factor-based strategy, intrapartum antibiotics (IPAs) would be provided to women with fever, prolonged rupture of membranes, or preterm labor. A second objective was to determine the impact of an increased length of stay for well term infants with mothers who received IPAs.

METHODS

We used decision analysis to compare the costs and benefits of the prevention strategy with usual obstetric practice for a cohort of 100 000 women and their newborn infants. We derived baseline values from a previous study based on chart review and automated cost data from a health maintenance organization in Northern California. In sensitivity analyses, we varied baseline assumptions, including additional costs for observing well term infants who received IPAs.

RESULTS

If adherence to guidelines were 100%, 17% of mothers would receive IPAs at a cost of $490,000; $1.6 million would be saved by preventing 66 GBS cases (64% reduction). The net savings would be $1.1 million and 61 life-years. The net cost is sensitive to the cost of caring for well infants who received IPAs. If each term infant of a mother who received IPAs had 1 more day of observation than other term infants, there would be a net cost of $8.1 million; the cost per GBS case prevented would be $120,000 and the cost per life-year saved would be $130,000.

CONCLUSIONS

Implementation in a health maintenance organization of a risk factor-based strategy to prevent neonatal GBS disease can prevent substantial disease and be cost saving. However, if the length of hospital stay were extended among well term infants whose mothers received IPAs, the strategy would be relatively costly compared with other medical interventions.

Epidemiology of group B streptococcal disease in the United States: shifting paradigms

Since its emergence 25 years ago, group B streptococcus has become recognized as a cause of serious illness in newborns, pregnant women, and adults with chronic medical conditions. Heavy colonization of the genital tract with group B streptococcus also increases the risk that a woman will deliver a preterm low-birthweight infant. Early-onset infections (occurring at < 7 days of age) are associated with much lower fatality than when they were first described, and their incidence is finally decreasing as the use of preventive antibiotics during childbirth increases among women at risk. New serotypes of group B streptococcus have emerged as important pathogens in adults and newborns. Clinical and laboratory practices--in obstetrics, pediatrics, and clinical microbiology--have an impact on disease and/or its prevention, and protocols established at the institutional level appear to be critical tools for the reduction of perinatal disease due to group B streptococcus. Since intrapartum antibiotics will prevent at best only a portion of the full burden of group B streptococcal disease, critical developments in vaccine evaluation, including study of polysaccharide-protein conjugate vaccines, offer the potential for enhanced prevention in the relatively near future.

Management of asymptomatic term neonates whose mothers received intrapartum antibiotics--Part 1: Rationale for intrapartum antibiotic therapy

The evaluation of the potentially septic newborn is often a source of frustration for practitioners. In the past, it has often been standard practice to evaluate and treat empirically all neonates whose mothers received antibiotics during labor, regardless of whether the infant had any signs or symptoms suggestive of infection. With the advent of recommendations for intrapartum antibiotic therapy to prevent early-onset neonatal group B streptococcal infections, this strategy is no longer practicable because too many infants would thus be evaluated and treated needlessly. This two-part review addresses the issues involved in managing asymptomatic newborns whose mothers received intrapartum antibiotics. This first part reviews the rationale behind strategies for preventing intrapartum transmission of bacterial infection. The administration of intravenous antibiotics to laboring mothers appears to reduce the incidence of group B streptococcal infections in neonates. Additionally, intrapartum antibiotic therapy for maternal chorioamnionitis may inhibit transmission of infection to the infant. Part 2--to be published separately--will address the evaluation and management of the newborn.

Revised guidelines for prevention of early-onset group B streptococcal (GBS) infection. American Academy of Pediatrics Committee on Infectious Diseases and Committee on Fetus and Newborn

In 1992, the Committee on Infectious Diseases and Committee on Fetus and Newborn of the American Academy of Pediatrics provided guidelines for prevention of early-onset group B streptococcal (GBS) disease through intrapartum chemoprophylaxis of selected maternal GBS carriers. The guidelines were based on demonstrated efficacy in randomized, controlled clinical trials and selected only women with GBS colonization who had an obstetric risk factor. The guidelines were controversial and their implementation incomplete. Since 1992, additional data have become available, and experience with the guidelines has been gained in numerous medical centers. Recently, consensus guidelines were developed by obstetricians, pediatricians, family practitioners, and public health authorities and published by the Centers for Disease Control and Prevention. These recommendations are supported by the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics. This statement reviews the selection of pregnant women for chemoprophylaxis and provides an algorithm for management of their newborns.