SOGC CLINICAL PRACTICE GUIDELINE
The Prevention of Early-Onset Neonatal Group B Streptococcal Disease

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Abstract

Objective

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.

Outcomes

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.

Evidence

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 Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline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.

Values

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 (Table 1).

Benefits, Harms, and Costs

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.

Section snippets

Summary Statement

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.

Recommendations

  • 1.

    Offer all women screening for colonization with group B streptococcus at 35 to 37 weeks’ gestation with culture taken from one swab first to the vagina and then to the rectum (through the anal sphincter). (II-1A) This includes women with planned Caesarean delivery because of their risk of labour or ruptured membranes earlier than the scheduled Caesarean delivery. (II-2B)

  • 2.

    Because of the association of heavy colonization with early onset neonatal disease, provide intravenous antibiotic prophylaxis

INTRODUCTION

The purpose of this guideline is to review the literature and evidence for management of pregnant women in Canada in order to minimize the risk of early-onset neonatal disease due to group B streptococcus. Since publication of the 2004 SOGC guideline "The Prevention of Early-onset Neonatal Group B streptococcal Disease,"1 there has been ongoing evaluation of screening, intrapartum antibiotic management, and neonatal outcomes.

BACKGROUND

Group B streptococci (streptococcus agalactiae) are gram- positive, aerobic diplococci that typically produce a narrow zone of beta hemolysis on 5% sheep blood agar. These organisms are divided into 10 types on the basis of capsular polysaccharides (Ia, Ib, II, and III through IX). Types Ia, Ib, II, III, and V account for approximately 95% of cases in infants in the United States. Type III is the predominant cause of early-onset meningitis and the majority of late-onset infections in infants.

STRATEGIES TO PREVENT NEONATAL GBS

Chemoprophylaxis before the onset of labour or rupture of membranes has been shown to be ineffective;41 antepartum antibiotic prophylaxis of colonized women results in a 67% recurrence of GBS colonization later in pregnancy.42 Intrapartum therapy has been found to be effective in preventing neonatal GBS disease.39,43 Immunization strategies have been proposed as a preferred prevention approach but vaccine development has been challenging, however, a multivalent capsular antigen based vaccine is

RISK-BASED VERSUS SCREENING APPROACH

No randomized trials have evaluated intrapartum antibiotic prophylaxis based on risk factors versus universal screening approaches, although a number of non-randomized studies have attempted to evaluate the merits of screening versus a risk-based approach.55,56 In most studies, the screening approach included intrapartum prophylaxis for all women who were colonized at the time of labour or rupture of membranes. A large CDC multistate study of a stratified random sample of 626 912 live births in

PRACTICAL ASPECTS OF THE SCREENING METHODS

A vaginal/rectal (not vaginal/perianal) swab is taken at 35 to 37 weeks’ gestation to screen women and detect GBS colonization of the genital tract. This is done by using a single swab first in the vagina then in the rectum and transporting it at room temperature to the laboratory in a non-nutritive transport medium; Amies or Stuart’s medium is recommended.59 These specimens should be labelled clearly to inform the laboratory of the need to perform specific GBS culturing. In addition, if the

ANTIBIOTIC CHOICES

Since GBS appears to be uniformly susceptible to the penicillins, it is recommended that IV penicillin G be used instead of IV ampicillin because of penicillin G’s narrow spectrum of action, which diminishes the risk of selective pressure on other organisms and decreases the risk of ampicillin resistance.66,67 The efficacy of alternatives to penicillin to prevent early-onset GBS disease (such as cephalosporins, clindamycin, or vancomycin) has not been evaluated in controlled trials.13

PRE-LABOUR RUPTURE OF MEMBRANES

In the term PROM study, Hannah et al. reviewed their outcomes in GBS-colonized women versus GBS-negative women.71 In that study, 4834 women were randomized to induction versus expectant management. Researchers found that 10.7% of women were GBS positive by vaginal/ rectal swab culture and 127 infants had neonatal infections, of which 10 were due to GBS, all in the expectant arm; there was one death due to GBS in the expectant group. The analysis revealed that for GBS-positive women, induction

NEONATAL MANAGEMENT

Information related to the current management of the infant at increased risk of sepsis, including risk of GBS disease, may be found on the website of the Canadian Paediatric Society (Fetus and Newborn Committee).72

REFERENCES (73)

  • S.E. Gardner et al.

    Failure of penicillin to eradicate group B streptococcal colonization in pregnant women: a couple study

    Am J Obstet Gynecol

    (1979)
  • B.S. Brozanski et al.

    Effect of a screening based prevention policy on prevalence of early-onset group B streptococcal sepsis

    Obstet Gynecol

    (2000)
  • Cheon-LeeE. et al.

    Compliance with the Centers for Disease Control and Prevention antenatal culture protocol for preventing group B streptococcal neonatal sepsis

    Am J Obstet Gynecol

    (1998)
  • G.D. Wendel et al.

    Prevention of neonatal group B streptococcal disease: a combined intrapartum and neonatal protocol

    Am J Obstet Gynecol

    (2002)
  • S.H. Factor et al.

    Effects of hospital policies based on 1996 group B streptococcal disease consensus guidelines. The Active Bacterial Core Surveillance Team

    Obstet Gynecol

    (2000)
  • M.L. Bland et al.

    Antibiotic resistance patterns for group B streptococci in late third-trimester rectovaginal cultures

    Am J Obstet Gynecol

    (2001)
  • D. Price et al.

    Self-sampling for group B streptococcus in women 35 to 37 weeks pregnant is accurate and acceptable: a randomized cross-over trial

    J Obstet Gynaecol Can

    (2006)
  • J.R. Johnson et al.

    Optimal dosing of penicillin G in the third trimester for the prophylaxis against group B streptococcus

    Am J Obstet Gynecol

    (2001)
  • M.E. Hannah et al.

    Maternal colonization with group B streptococcus and prelabor rupture of membranes at term: the role of induction of labor. Term PROM Study Group

    Am J Obstet Gynecol

    (1997)
  • S. Dobson et al.

    The prevention of early-onset neonatal group B streptococcal disease. Society of Obstetricians and Gynaecologists of Canada Clinical Practice Guideline, No. 149, September 2004

    J Soc Obstet Gynaecol Can

    (2004)

  • American Academy of Pediatrics.Pickering LK ed. Red book: 2012 report of the Committee on Infectious Diseases

    (2012)
  • H.D. Davies et al.

    Population-based active surveillance for neonatal group B streptococcal infections in Alberta, Canada: implications for vaccine formulation

    Pediatr Infect Dis J

    (2001)

  • Centers for Disease Control and Prevention. Perinatal group B streptococcal disease after universal screening recommendations–United States 2003-2005. Morb Mortal Wkly Rep

    (2007)

  • Centers for Disease Control and Prevention. Trends in perinatal group B streptococcal disease–United States 2000-2006. Morb Mortal Wkly Rep

    (2009)
  • H.D. Davies et al.

    Physicians’ prevention practices and incidence of neonatal group B streptococcal disease in 2 Canadian regions

    CMAJ

    (2001)

  • Centers for Disease Control and Prevention. Prevention of group B streptococcal disease: a public health perspective. Mor Mortal Wkly Rep

    (1996)
  • S.J. Schrag et al.

    Group B streptococcal disease in the era of intrapartum antibiotic prophylaxis

    N Engl J Med

    (2000)
  • A. Schuchat et al.

    Epidemiology of group B streptococcal disease: risk factors, prevention strategies, and vaccine development

    Epidemiol Rev

    (1994)

  • Centers for Disease Control and Prevention. Prevention of perinatal group B streptococcal disease. Mor Mortal Wkly Rep

    (2010)
  • A. Schuchat et al.

    Multistate case-control study of maternal risk factors for neonatal group B streptococcal disease

    Pediatr Infect Dis J

    (1994)
  • Royal College of Obstetricians and Gynaecologists

    The prevention of early-onset neonatal group B streptococcal disease

    Green-top Guideline No. 36

    (2012)
  • S. Håkansson et al.

    Impact and risk factors for early-onset group B streptococcal morbidity: 1997-2001. BJOG 2006

    analysis of a national, population-based cohort in Sweden

    (2006)
  • K. Persson et al.

    Group B streptococci at delivery: high count in urine increases risk for neonatal colonization

    Scand J Infect Dis

    (1986)
  • J.A. Regan et al.

    Vaginal Infections and Prematurity Study Group. The epidemiology of group B streptococcal colonization in pregnancy

    Obstet Gynecol

    (1991)
  • S.J. Bliss et al.

    Group B streptococcus colonization in male and nonpregnant female university students: a cross-sectional prevalence study

    Clin Infect Dis

    (2002)
  • P. Dadvand et al.

    Climate and group B streptococci colonization during pregnancy: present implications and future concerns

    BJOG

    (2011)

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    This Clinical Practice Guideline has been prepared by the Infectious Disease Committee, reviewed by the Infectious Diseases and Immunization and the Fetus and Newborn Committees of the Canadian Paediatric Society, and the SOGC Family Practice Advisory Committee, and approved by the Executive and Council of the Society of Obstetricians and Gynaecologists of Canada.

    Disclosure statements have been received from all members of the committees

    This document reflects emerging clinical and scientific advances on the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate amendments to these opinions. They should be well documented if modified at the local level. None of these contents may be reproduced in any form without prior written permission of the SOGC.

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    Copyright © 2013 Society of Obstetricians and Gynaecologists of Canada. Published by Elsevier Inc. All rights reserved.