Appropriateness of Intrapartum Antibiotic Prophylaxis to Prevent Neonatal Group B Streptococcus Disease

Adherence to universal screening for group B Streptococcus in pregnancy and prevalence of colonised pregnancies in Caserta province, Italy

Group B Streptococcus (Streptococcus agalactiae; GBS) infection is a significant contributor to neonatal morbidity and mortality. In the early 1970s, the neonatal mortality rate for infants with invasive GBS disease was 55%. With the adoption of the first medical community guidelines to prevent GBS infection in the 1990s, the mortality rate decreased to approximately 5%. The main obstetric procedure for preventing vertical transmission of GBS infection involves universal screening of pregnant women using a vaginal-rectal swab (VRS) to identify those eligible for intrapartum antibiotic prophylaxis (IAP). The study analyzes the adherence of screening and the trend of GBS infection in pregnancy in the province of Caserta, Italy. Data were obtained from pregnant women who gave birth in a first level birthing center in 2022 from birth assistance certificate (CEDAP), obstetric and neonatal record. Postnatal evaluation collected through computer-assisted telephone interviews. 567 women delivered at our center during the study period. The average coverage of GBS testing in pregnancy was 99.2% (562), and the proportion of GBS colonised women was 12.6% (71) according with the national average, which is about 10-20%. The spread of positive cases appears to fluctuate among the various groups of pregnant women studied, indicating no significant statistical variance among presence of a partner, among women who have given birth multiple times, among Italian nationals, or across different ages, but a significant statistical excess is evident among mothers with less education. In 93% (66) of GBS carrier mothers, intrapartum antibiotic prophylaxis (IAP) was administered correctly, regardless of the type of delivery performed. Despite the successful integration of GBS screening, a significant gap remains between the ideal scenario and the actual implementation of IAP. At the three-month assessment, no child required hospitalization, consistent with the relatively low incidence of invasive GBS infection. Nevertheless, for those who are not eligible to VRS screening, such as preterm birth, or IAP, as in precipitous birth, the identification of biomarkers enabling early recognition of invasive GBS disease remains essential. Additionally, the emergence of vaccines administered during gestation, conferring passive immunity to newborns represents a promising possible new direction. Therefore, to ensure the practical application of GBS screening and actual IAP by healthcare providers, periodic audits and regular monitoring should be encouraged.

Timing and dosage of intrapartum prophylactic penicillin for preventing early-onset group B streptococcal disease: assessing maternal and umbilical cord blood concentration

OBJECTIVE

Timing of administration of antibiotics and concentrations in maternal blood and the umbilical cord blood are important prerequisites for optimal intrapartum antibiotic prophylaxis (IAP) of neonatal early-onset group B streptococcus (GBS) disease. This cohort study aimed to explore penicillin concentrations in mothers and infants at birth in relation to time elapsed from administration to delivery and to the minimal inhibitory concentration (MIC) for GBS.

MAIN OUTCOME MEASURES

Penicillin G concentrations in maternal and umbilical cord blood in relation to time and dose from administration to time of delivery.

RESULTS

In 44 mother-infant dyads, median maternal penicillin G concentration was 0.2 mg/L (IQR 0-0.8 mg/L; range 0-1.6 mg/L). Median infant penicillin G concentration was 1.2 mg/L (IQR 0.5-5.0 mg/L; range 0-12.7 mg/L). In all infants (N=38) born less than 4 hours after the latest IAP administration, penicillin G concentrations far exceeded MIC (0.125 mg/L), even after short time intervals between IAP administration and birth. The highest plasma concentrations were reached in umbilical cord blood within 1 hour from IAP administration to birth.For 44 mother-infant dyads, maternal concentrations were very low compared with their infants'; particularly, very high concentrations were seen in the 20 infants with only one dose of IAP.

CONCLUSION

High concentrations of penicillin G were found in umbilical cord blood of infants born less than 4 hours after IAP administration, well above the MIC for GBS.

Screening of group B Streptococcus infection in pregnancy and neonatal outcomes in the province of Trento, Italy

The study analyzes the trend of group B streptococcal (GBS) infection in pregnancy in the province of Trento, Italy, where a universal screening of GBS infection in pregnancy has been active for some time. Data from pregnant women who gave birth at local maternity units between 2015-2019 were obtained from birth attendance certificates (BAC), the main - and mandatory - source of information for monitoring pregnancies, births and neonatal health in Italy. The BAC used in the province of Trento acquires the results of a vast range of infections in pregnancy. The data collected from the BAC were integrated with those provided by the Hospital Information System (SIO). The occurrence of neonatal GBS infection was investigated on 2019 birth cohort, using the hospital discharge archive as an ancillary information source. Between 2015-2019, 20,905 pregnant women received care at maternity units of the province of Trento, Italy, of whom 25.5% were foreigners. The average coverage of GBS testing in pregnancy was 91.8% (95% CI 91.25-92.35) without significant variations from one year to the next. Test coverage varies in relation to maternity units and some socio-demographic characteristics of mothers. The average proportion of GBS positive cases over the study period was 21.0% (95% CI 20.7-21.3), a value that does not show statistically significant changes from one year to the next. The proportion of positive cases appears uneven among the subgroups of pregnant women considered, even if the differences are not statistically significant. In the 2019 birth cohort, newborns to GBS-positive mothers had an excess of stillbirths, of those born with Apgar at 5 minutes <7 and hospitalized at birth. However, these excesses were not statistically significant. Intravenous Antibiotic Prophylaxis (IAP) was performed in 86.8% of births from GBS positive mothers who had an indication for IAP. IAP was inadequate in 7.4% of the GBS positive mothers. Postnatal evaluation of 783 live births to GBS positive mothers identified 3 cases of early neonatal GBS infection. The incidence of neonatal GBS infection over the whole series of live births is 0.71/1,000 (95% CI 0.56-0.86), 0.68/1000 (CI 95% 0.55-0.79) in Italians and 1.07/1000 (95% CI 0.45-1.65) in foreigners. Data collection on infections in pregnancy through BAC allows area-based assessment. The quality of the data recorded in the BAC can be considered satisfactory but it was necessary to access to other information sources. The local availability of various information sources should allow periodic audits and closer monitoring of neonatal GBS infection.

A Structural, Cognitive, and Behavioral Model for Error Analysis of Group B Streptococcus Prophylaxis in Pregnancy

The objective of this study was to develop a structural-cognitive-behavioral model for error analysis of group B streptococcus (GBS) prophylaxis failure, classify delivery cases into this model, and examine compliance with treatment guidelines. A retrospective, cohort study was conducted of women with liveborn pregnancies greater than 24 weeks in April 2018 at a single hospital. We created a structural-cognitive-behavioral model of five assessments for adherence to GBS prophylaxis guidelines and then classified these into four distinct error stages. A descriptive analysis was performed to determine if the pregnancy had a perfect process, a GBS prophylaxis failure, or a fortuitous outcome. There were 313 women who met the study criteria. The rate of GBS positive was 12.8%, negative 37.4%, and unknown 49.8%. The most common errors were cognitive perception errors related to incorrectly documenting GBS status, 57.7% ( N  = 79). Of these errors, 15.2% ( N  = 12) led to GBS prophylaxis failure. Perfect outcomes occurred in 62.7% ( N  = 196) women, GBS prophylaxis failure occurred in 13.7% ( N  = 43), and fortuitous outcomes occurred in 23.6% ( N  = 74). In our study, we were able to identify structural, cognitive, and behavioral errors that contribute to GBS prophylaxis failures. In other cases, these errors may contribute to fortuitous outcomes.

Appropriateness of Antibiotic Prescription for Prophylactic Purposes among Italian Dental Practitioners: Results from a Cross-Sectional Study

The primary objective of this study was to investigate the pattern of antibiotic prescription for prophylaxis purposes among Italian DPs (dental practitioners). A nationwide cross-sectional study was conducted using a multi-stage sampling design. A structured questionnaire was used to collect socio-demographic data and information about antibiotic prophylaxis (AP) prescriptions for selected dental diagnoses and surgical procedures. The presence of an indication and appropriateness of AP were defined according to international guidelines. In total, 563 DPs answered the questionnaire (response rate 52.6%). The proportions of DPs who prescribed AP in the presence of an indication ranged from 39.1% for luxation injury with soft tissue trauma to 73.1% for dental implants, whilst DPs who prescribed AP in healthy patients ranged from 41.9% in luxation injury with soft tissue trauma to 70.3% for bone grafting. The course of AP reported by DPs was not consistent with the guidelines in 70.9% of explored procedures. A high proportion of AP prescriptions before dental procedures were unnecessary. This highlights the urgent need to incorporate recommendations for best practices into national and local protocols as soon as they are established. Specific antibiotic stewardship strategies targeted to DPs should be implemented and assessed for effectiveness in improving prescribing of antibiotics.

Birth signalling hormones and the developmental consequences of caesarean delivery

Rates of delivery by caesarean section (CS) are increasing around the globe and, although several epidemiological associations have already been observed between CS and health outcomes in later life, more are sure to be discovered as this practice continues to gain popularity. The components of vaginal delivery that protect offspring from the negative consequences of CS delivery in later life are currently unknown, although much attention to date has focused on differences in microbial colonisation. Here, we present the case that differing hormonal experiences at birth may also contribute to the neurodevelopmental consequences of CS delivery. Levels of each of the 'birth signalling hormones' (oxytocin, arginine vasopressin, epinephrine, norepinephrine and the glucocorticoids) are lower following CS compared to vaginal delivery, and there is substantial evidence for each that manipulations in early life results in long-term neurodevelopmental consequences. We draw from the research traditions of neuroendocrinology and developmental psychobiology to suggest that the perinatal period is a sensitive period, during which hormones achieve organisational effects. Furthermore, there is much to be learned from research on developmental programming by early-life stress that may inform research on CS, as a result of shared neuroendocrine mechanisms at work. We compare and contrast the effects of early-life stress with those of CS delivery and propose new avenues of research based on the links between the two bodies of literature. The research conducted to date suggests that the differences in hormone signalling seen in CS neonates may produce long-term neurodevelopmental consequences.

Oral probiotics to reduce vaginal group B streptococcal colonization in late pregnancy

This study aimed to evaluate the potential of oral probiotics to eradicate vaginal GBS colonization during the third trimester of pregnancy. We screened 1058 women for GBS colonization at 33–37 gestational weeks using a combination of vaginal-to-rectal swab and culture-based methods. Women who tested GBS positive were randomized to either the verum group, receiving a dietary probiotic supplement of four viable strains of Lactobacillus twice-daily for 14 days, or to the placebo group. Women underwent follow-up smears, whereat GBS colonization upon follow-up was considered the primary endpoint. We found that 215 women (20.3%) were positive for GBS upon screening, of which 82 (38.1%) were eligible for study inclusion; 41 (50%) of these were randomized to the verum and placebo groups each. After treatment, 21/33 (63.6%) members of the verum group, and 21/27 (77.8%) of the placebo group were still GBS positive (p = 0.24). Four (9.8%) women in the verum group and one (2.4%) in the placebo group experienced preterm birth (p = 0.20); smokers showed significantly higher rates of preterm birth (p = 0.03). Hence, the findings did not support the hypothesis that oral probiotics can eradicate GBS during pregnancy, although we observed a trend toward reduced GBS persistence after probiotic intake.

Towards accurate exclusion of neonatal bacterial meningitis: a feasibility study of a novel 16S rDNA PCR assay

Background

PCRctic is an innovative assay based on 16S rDNA PCR technology that has been designed to detect a single intact bacterium in a specimen of cerebro-spinal fluid (CSF). The assay’s potential for accurate, fast and inexpensive discrimination of bacteria-free CSF makes it an ideal adjunct for confident exclusion of bacterial meningitis in newborn babies where the negative predictive value of bacterial culture is poor. This study aimed to stress-test and optimize PCRctic in the “field conditions” to attain a clinically useful level of specificity.

Methods

The specificity of PCRctic was evaluated in CSF obtained from newborn babies investigated for meningitis on a tertiary neonatal unit. Following an interim analysis, the method of skin antisepsis was changed to increase bactericidal effect, and snap-top tubes (Eppendorf™) replaced standard universal containers for collection of CSF to reduce environmental contamination.

Results

The assay’s specificity was 90.5% in CSF collected into the snap-top tubes – up from 60% in CSF in the universal containers. The method of skin antisepsis had no effect on the specificity. All CSF cultures were negative and no clinical cases of neonatal bacterial meningitis occurred during the study.

Conclusions

A simple and inexpensive optimization of CSF collection resulted in a high specificity output. The low prevalence of neonatal bacterial meningitis means that a large multi-centre study will be required to validate the assay’s sensitivity and its negative predictive value.

Intrapartum beta-lactam antibiotics for preventing group B streptococcal early-onset disease: can we abandon the concept of 'inadequate' intrapartum antibiotic prophylaxis?

Introduction: Neonatal sepsis remains a serious and potentially fatal illness. Intrapartum antibiotic prophylaxis (IAP) prevents group B streptococcal (GBS) early-onset sepsis. The optimal duration of IAP (adequate IAP) to reduce vertical transmission of GBS has been debated. Understanding the mechanism of action of IAP may help in minimizing neonatal evaluation and unnecessary antibiotic use.Areas covered: In recent years, several studies on pharmacokinetics and clinical use of IAP have been published. Although penicillin and ampicillin are the most preferred antibiotics, the clinical efficacy of non-beta-lactam antibiotics, including clindamycin and vancomycin, used in cases of penicillin anaphylaxis-associated allergy, remains debatable. This is a narrative review of the literature regarding the impact of 'inadequate' IAP on the clinical management of women and newborns.Expert opinion: Recent evidence suggests that 'inadequate' IAP with beta-lactams is more effective in preventing vertical transmission of GBS than previously thought. Newborns exposed to intrapartum beta-lactams and who are asymptomatic at birth are likely uninfected, irrespective of IAP duration before delivery. Hence, we may abandon the concept of 'inadequate' IAP with beta-lactams in early-onset GBS sepsis, relying primarily on clinical signs observed at birth for managing IAP-exposed neonates.

Group B Streptococcus (Streptococcus agalactiae)

Invasive disease due to group B Streptococcus infection (Streptococcus agalactiae) results in a wide spectrum of clinical disease. In North America, serotypes Ia, Ib, II, III, and V are most frequently associated with invasive disease. Group B Streptococcus remains a continuing source of morbidity and mortality in high-risk populations, including pregnant women, neonates, and the elderly; an increasing incidence of invasive disease has been observed in nonpregnant adults. Group B Streptococcus remains the most common culture-confirmed neonatal bacterial infection in the United States and is a significant source of neonatal morbidity globally. Intrapartum antibiotic prophylaxis has reduced the incidence of early-onset neonatal disease without a notable impact on the incidence of late-onset neonatal disease. Penicillin G remains the mainstay of therapy, although reduced penicillin susceptibility has been observed in select isolates. Increased frequency of resistance to non-beta-lactam antibiotics, including clindamycin, erythromycin, and fluoroquinolones, has been observed, with some isolates demonstrating resistance to vancomycin. The development and implementation of strategies to identify hosts, treat judiciously with antimicrobials with the narrowest spectra, and prevent invasive disease, with vaccines, are essential to reduce the burden of group B Streptococcus disease.

Evaluation of hospital readmissions for surgical site infections in Italy

Background

The objectives of this investigation are to assess the prevalence of hospital readmissions for surgical site infections (SSIs) in patients aged ≥18 in Italy and to describe the clinical characteristics of these patients and evaluate the possible association with readmission for SSIs.

Methods

A retrospective epidemiological study was conducted between January and May 2015 considering a sample of patients aged ≥18 years admitted to the surgical wards of two hospitals in Naples and undergoing surgery in the year 2014.

Results

3.8% of patients had been readmitted and 28.8% of them were readmitted to hospital due to SSIs. The multiple logistic regression model showed that readmissions for SSIs were significantly more common in smokers (odds ratio [OR] = 3.14; 95% confidence interval [CI] = 1.13-8.69), in patients with immunosuppression status (OR = 8.28; 95% CI = 1.76-38.87), in patients with low serum albumin (OR = 3.07; 95% CI = 1.05-9.01) and in patients who had undergone a surgical procedure classified as contaminated (OR = 10:44; 95% CI = 3.11-35.01) compared with those that had undergone a surgical procedure classified as clean.

Conclusions

The results point to the need that hospital infection prevention strategies are implemented in order to reduce morbidity and mortality for patients. Moreover, the measures taken to prevent infections would lead to a reduction in health spending since almost one third of readmissions to the hospital in our study were due to SSIs.

Prevalence of colonisation by group B streptococcus in pregnant patients in Taguatinga, Federal District, Brazil: a cross-sectional study

PROPOSE

Group B streptococcus is responsible for severe infections in neonates resulting from vertical transmission from pregnant women colonized in the anal, perineal or vaginal regions. The identification of colonized patients and use of intrapartum prophylaxis may reduce the risk of neonatal infection.

METHODS

A cross-sectional study of pregnant women of gestational age between 35 and 37 weeks was conducted. Material was collected from patients for laboratory identification of group B streptococcus. Epidemiological data, including weight, height, body mass index, antibiotic use during pregnancy, pathologies during pregnancy (diabetes, hypertensive diseases, and hypothyroidism), twinning, and others, were also collected from patients.

RESULTS

The sample consisted of 501 pregnant women, and the prevalence of group B streptococcus was 14%. The mean age was 29 years, and the mean BMI was 30.7. During pregnancy, 204 patients had some type of infection, and 201 used antibiotics. Ninety-five patients were diagnosed with gestational diabetes mellitus and 74 with some type of hypertensive disease.

CONCLUSIONS

The prevalence of group B streptococcus observed did not differ from that observed in other studies. None of the factors studied can be considered as risk or protective factors for maternal colonization by group B streptococcus.