Maternal antibody at delivery protects neonates from early onset group B streptococcaldisease. Eur J Clin Microbiol Infect Dis 2005;24:649--53. There are two strategies which are presently being investigated: active immunization of antibody negative pregnant women (7, 51) and passive immunization with specific antibody. Middleton's allergy: principles and practice. GBS is found in the urine of 2%--7% of pregnant women (46--48,129,130). Rapid group B streptococci screening using a real-time polymerase chain reaction assay. J Clin Microbiol 2008;45:2863--71. If no susceptibility testing is performed, or the results are not available at the time of labor, vancomycin is the preferred agent for GBS intrapartum prophylaxis for penicillin-allergic women at high risk for anaphylaxis. If this happens, it can (but does not always) trigger early labour. Diagn Microbiol Infect Dis 2008;61:369--72. Prevention of group B streptococcal infection in pregnant women and neonates. Heath PT, Feldman RG. Comparison of carrot broth- and selective Todd-Hewitt broth-enhanced PCR protocols for real-time detection of Streptococcus agalactiae in prenatal vaginal/anorectal specimens. N Engl J Med 1964;271:1221-1228. [PubMed], 18. Antibiotic treatment of parturient women colonized with group B streptococci. Isolates that are D-zone positive are considered to have inducible clindamycin resistance and are presumed to be resistant although the clinical significance of this resistance is not clear (196). Barber EL, Zhao G, Buhimschi IA, Illuzzi JL. These early studies were therefore encouraging but indicated that a more immunogenic vaccine would have to be developed before considering large trials to evaluate the safety and efficacy of this strategy. JAMA 1987;257:2464--70. Obstet Gynecol 2008;112(2 Pt 1):259--64. §§§ Source: Alfa MJ, Sepehri S, De Gagne P, Helawa M, Sandhu G, Harding GK. Centelles-Serrano MJ, Perez-Moreno MO, Llovet-Lombarte MI, Cortell-Ortola M, Jardi-Baiges AM, Buj-Gonzalez JI. ¶ If amnionitis is suspected, broad-spectrum antibiotic therapy that includes an agent known to be active against GBS should replace GBS prophylaxis. Antibiotics given to prolong latency for preterm premature rupture of membranes with adequate GBS coverage (specifically 2 g ampicillin administered intravenously followed by 1 g administered intravenously every 6 hours for 48 hours) are sufficient for GBS prophylaxis if delivery occurs while the patient is receiving that antibiotic regime (CIII). Low or unprotective antibody concentrations were defined as < 2 µg/ ml. Specimen transport options and timing until processing are clarified. In June 2009, an in-person meeting of the technical working group was held to review available data and develop updated recommendations using an evidence-based approach when possible and relying on expert scientific opinion when sufficient data were lacking (Table 1). [Epub ahead of print]. Tuppurainen N, Hallman M. Prevention of neonatal group B streptococcal disease: intrapartum detection and chemoprophylaxis of heavily colonized parturients. Although available NAATs have demonstrated high sensitivity when performed on enriched samples, enrichment is not feasible in the intrapartum setting when results are needed quickly. * Inoculate swab(s) into a recommended selective broth medium, such as Todd-Hewitt broth supplemented with either gentamicin (8
Acta Obstet Gynecol Scand 2008;87:50--8. The accuracy of late antenatal screening cultures in predicting genital group B streptococcal colonization at delivery. 3). J Matern Fetal Neonatal Med 2009;22:111--4. J Clin Microbiol 2004;42(5):2282--4. Clin Inf Dis 1992;14:492-6. [PubMed], 35. Neurotoxicity induced by beta-lactam antibiotics: from bench to bedside. However, lack of randomization in observational studies can result in confounding, because certain procedures might be used more frequently in high-risk settings (64). Antibiotic killing kinetics of group B streptococci. In addition, intrapartum antibiotic prophylaxis administration for the indications of GBS bacteriuria or having delivered a previous infant with GBS disease was also low (73.5%) among preterm deliveries. Patients who state that they are allergic to penicillin should be evaluated for risk for anaphylaxis. In addition, the evidence is incomplete for several key areas related to GBS prevention, including: strategies to prevent early-onset GBS disease among preterm infants, the role of bacteriuria as a risk factor in the era of universal screening, effectiveness of recommended intrapartum antibiotic prophylaxis agents for penicillin-allergic women at high risk for anaphylaxis, the impact and effectiveness of recommendations for secondary prevention of early-onset GBS disease among neonates, and factors contributing to the higher-than-anticipated proportion of early-onset GBS disease cases occurring among infants born to women with negative prenatal GBS screens. Trends in perinatal group B streptococcal disease---United States, 2000--2006. Early onset group B streptococcal infection in neonates (prior to 7 days of age) most commonly manifests with symptoms of respiratory distress and a chest radiographic appearance suggesting respiratory distress syndrome vs. severe pneumonia. Walker SH, Santos AQ, Quintero BA. Transfer of ampicillin into fetus and amniotic fluid from maternal plasma in late pregnancy. N Engl J Med 1993;328:1843-1844. [PubMed], 53. If an intrapartum risk factor subsequently develops, antibiotic prophylaxis should be administered regardless of the intrapartum testing results (AIII). Continued efforts are needed to sustain and improve on the progress achieved in the prevention of GBS disease. Hocker JR, Simpson PM, Rabalais GP, Stewart DL, Cook LN. Data are not sufficient to make recommendations regarding the timing of procedures intended to facilitate progression of labor, such as amniotomy, in GBS-colonized women. A comparison of intrapartum versus immediate postpartum treatment of intra-amniotic infection. Sutkin G, Krohn MA, Heine RP, Sweet RL. Such broths can facilitate the identification of beta-hemolytic GBS; however, nonhemolytic isolates will not be detected by these broths alone (162--168). ¶ Limited evaluation includes blood culture (at birth) and CBC with differential and platelets (at birth and/or at 6--12 hours of life). Boyer KM, Gotoff SP. Revisiting the need for vaccine prevention of late-onset neonatal group B streptococcal disease: a multistate, population-based analysis. However, multistate surveillance data suggest that although epidural use is common (in 67% of births), intrapartum temperature of ≥100.4ºF [≥38.0ºC] (3.3% of births) and physician diagnoses of chorioamnionitis (3.1% of births) remain relatively rare (102) (CDC, unpublished data, 2009). §§ Source: Edwards RK, Novak-Weekley SM, Koty PP, Davis T, Leeds LJ, Jordan JA. The key changes in the 2010 guidelines include the following: expanded recommendations on laboratory methods for the identification of GBS. Examples of selective enrichment broths include Todd-Hewitt broth supplemented either with gentamicin (8 µg/ml) and nalidixic acid (15 µg/ml) [TransVag broth] or with colistin (10 µg/ml) and nalidixic acid (15 µg/ml) [Lim broth] (160). Therefore 8-15% of all newborns have the potential for acquiring early onset Group B streptococcal disease (15). Selective broth medium for isolation of group B streptococci. Schauf V, Deveikis A, Riff L, Serota A. Low dosages of penicillin used in the 1970s may in part explain the high rate of relapses initially reported in infants (17, 26, 47, 49). GBS isolates can remain viable in transport media for several days at room temperature; however, the recovery of isolates declines during 1--4 days, particularly at high temperatures. Asymptomatic bacteriuria during pregnancy with special reference to group B streptococci. positive by culture, No. N. Engl J Med 1986;314:1665-1669. [PubMed], 11. Dahesh S, Hensler ME, Van Sorge NM, et al. Clin Pharmacokinet 1979;4:297--309. Selective intrapartum chemoprophylaxis of neonatal group B streptococcal early-onset disease. Number 173,June 1996. Because a fetus or newborn is unlikely to have had a previous exposure to the antibiotic, and because specific maternal IgE antibodies are not transmitted across the placenta (103), there is no risk for anaphylaxis in the fetus or newborn resulting from intrapartum antibiotic prophylaxis. Siegel JD, Cushion NB. Early trials suggested an efficacy of 100% for intrapartum antibiotic prophylaxis to prevent early-onset disease among infants born to women with GBS colonization (7,8,10,11). To detect potential sepsis cases in newborns as early as possible, newborns should be managed according to the algorithm provided (Figure 9).The following are key components of the neonatal management algorithm: Any newborn with signs of sepsis should receive a full diagnostic evaluation and receive antibiotic therapy pending the results of the evaluation. Risk factors for neonatal sepsis. Krohn MA, Hillier SL, Baker CJ. Algorithm for screening for group B streptococcal (GBS) colonization and use of intrapartum prophylaxis for women with preterm* premature rupture of membranes (pPROM). In June 2009, a meeting of clinical and public health representatives was held to reevaluate prevention strategies on the basis of data collected after the issuance of the 2002 guidelines. Following enrichment, the conventional means for identifying GBS is through isolation on subculture to blood agar plates and presumptive identification by the CAMP test (169) or serologic identification using latex agglutination with group B streptococcal antisera (170). Because GBS colonization status can change over the course of a pregnancy, the timing of specimen collection for determination of colonization status is important. Because an association has been observed between epidural labor analgesia and fever, chorioamnionitis might be overdiagnosed in women with epidurals, which could lead to unnecessary diagnostic evaluations and unnecessary exposure to empirical antibiotics in neonates (216). Routine screening for asymptomatic bacteriuria is recommended in pregnant women, and laboratories should screen urine culture specimens for the presence of GBS in concentrations of 104 colony-forming units (cfu)/ml or greater. However final data from 2008, including enhanced race/ethnicity reporting on cases and the 2008 live birth denominators, and more years of data are needed to determine whether this trend is sustained. Eur J Clin Microbiol Infect Dis 2001;20:120--2. Role of antibody to native type III polysaccharide of group B streptococcus in infant infection. Maternal and transplacental pharmacokinetics of cefazolin. Br J Obstet Gynaecol 1984;91:237--9. Type 508 Accommodation and the title of the report in the subject line of e-mail. Clinical pharmacology of penicillin in newborn infants. Early-onset neonatal sepsis in the era of group B streptococcal prevention. Penicillin in infants weighing two kilograms or less with early-onset group B streptococcal disease. Clindamycin still might be effective clinically in some cases.". Shortly thereafter the adult pattern of rectal carriage is established. Intrapartum antibiotic prophylaxis increases the incidence of gram-negative neonatal sepsis. For osteomyelitis and septic arthritis, drainage of the infected site is often an important adjunct to antimicrobial therapy. FIGURE 2. Aharoni A, Potasman I, Levitan Z, Golan D, Sharf M. Postpartum maternal group B streptococcal meningitis. Safety and immunogenicity of capsular polysaccharide-tetanus toxoid conjugate vaccines for group B streptococcal types Ia and Ib. Comparison of BD GeneOhm real-time polymerase chain reaction with chromogenic and conventional culture methods for detection of group B Streptococcus in clinical samples. Intermittent carriage is more common, which well accounts for limitations in the accurate prediction of carriage during labor based on cultures obtained at some time point much earlier in pregnancy. Figure 7), Remove swab(s) from transport medium. In the presence of 1 µg/ml of ampicillin, elimination of group A strains is complete at four hours while sterilization of group B strains does not occur until 20-24 hours even at concentrations of 10 µg/ ml (39). This is your waters breaking. BOX 1. Adams WG, Kinney JS, Schuchat A, et al. Rev Infect Dis 1990;12:273--6. Medicine 1995;74:176- 190. [PubMed], 14. Among women receiving clindamycin for prophylaxis, clindamycin and erythromycin susceptibility testing were performed rarely despite recommendations that susceptibility testing be conducted on all vaginal-rectal specimens from women who are allergic to penicillin and at high risk for anaphylaxis (15,102). Eickhoff TC, Klein JO, Daly AK, Ingall D, Finland M. Neonatal sepsis and other infections due to group B beta-hemolytic streptococci. If any of these conditions is not met, the infant should be observed in the hospital for at least 48 hours and until discharge criteria are achieved. Adults are more likely to die from Group B streptococcal infection than are children. Acta Obstet Gynecol Scand 1978;57:127--8. Antimicrobial susceptibility testing should be ordered for antenatal GBS cultures performed on penicillin-allergic women at high risk for anaphylaxis because of a history of anaphylaxis, angioedema, respiratory distress or urticaria following administration of a penicillin or a cephalosporin (AII). Edwards RK, Jamie WE, Sterner D, Gentry S, Counts K, Duff P. Intrapartum antibiotic prophylaxis and early-onset neonatal sepsis patterns. Antimicrobial susceptibility testing of GBS isolates is crucial for appropriate antibiotic prophylaxis selection for penicillin-allergic women who are at high risk for anaphylaxis because resistance to clindamycin, the most common agent used in this population, is increasing among GBS isolates. An association between intrapartum antibiotic exposure and ampicillin resistance in newborns with E. coli or other non-GBS early-onset sepsis has been observed in several studies among all newborns (55,239,242,250--252) and among preterm or very low birth-weight infants (245,246). RR-7). TABLE 3. † Doses ranging from 2.5 to 3.0 million units are acceptable for the doses administered every 4 hours following the initial dose. Diagn Microbiol Infect Dis 2007;59:17--22. Striking declines in disease incidence coincided with increased prevention activities in the 1990s (17), and a further reduction occurred following the issuance of the recommendation for universal screening in 2002 (18). However, urine assays may be positive in otherwise healthy infants who are heavily colonized with group B streptococci. Desa DJ, Trevenen CL. Siegel JD, Shannon KM, DePasse BM. Clinical disease is usually after 7 days and by definition late onset (11). Philipson A, Sabath LD, Charles D. Transplacental passage of erythromycin and clindamycin. United States Government Printing Office; 2000. Early-onset disease has declined among all racial and ethnic groups, yet significant disparities persist. Kelkar PS, Li JT. Although an effective GBS vaccine would be a powerful tool against GBS disease, no licensed vaccine is yet available. Recommended regimens for intrapartum antibiotic prophylaxis for prevention of early-onset group B streptococcal (GBS) disease*. GBS colonization during pregnancy can be transient, intermittent, or persistent (39--41). Heinemann J, Gillen G, Sanchez-Ramos L, Kaunitz A. There are two exceptions to the requirement that colonization is a prerequisite for treatment. § Sources: Church DL, Baxter H, Lloyd T, Miller B, Elsayed S. Evaluation of StrepB carrot broth versus Lim broth for detection of group B Streptococcus colonization status of near-term pregnant women. Incidence of early- and late-onset invasive group B streptococcal (GBS) disease --- Active Bacterial Core surveillance areas, 1990--2008, and activities for prevention of GBS disease. Bloom SL, Cox SM, Bawdon RE, Gilstrap LC. Jamie WE, Edwards RK, Duff P. Vaginal-perianal compared with vaginal-rectal cultures for identification of group B streptococci. Pediatrics 1999;103:e77. mmwrq@cdc.gov. Cochrane database of systematic reviews (Online) 2005(1):CD000451. Antibiotic treatment of parturient women colonized with Group B streptococci. MMWR May 1996;45:RR-7.  [PubMed], 2. Before active prevention was initiated, an estimated 7,500 cases of neonatal GBS disease occurred annually in the United States (16). A systematic review. (Modified from Verani JR, McGee L, Schrag SJ. Direct plating has a lower sensitivity than enriched culture and should not be used as sole means to identify GBS. Dosages in neonates of penicillin G as high as 500,000 units/kg/day or ampicillin at 300-400 mg/ kg/ day are recommended by some experts (4). Obstet Gynecol 2001;98:1075--9. If a rapid test performed on enriched broth yields positive results and antimicrobial susceptibility testing is recommended (for penicillan-allergic women at high risk for anaphylaxis), the enriched broth should be subcultured to obtain an isolate. Am J Obstet Gynecol 2002;186:618--26. J Infect Dis 1983;148:802--9. This conversion might result in character translation or format errors in the HTML version. The changing spectrum of group B streptococcal disease. Most promising are studies examining maternal active immunization with Group B streptococcal vaccines as a method for preventing neonatal invasive disease. Illuzzi JL, Bracken MB. GBS detection using chromogenic broth is possible only for beta-hemolytic strains,¶ and therefore all broths that are negative (i.e., no color detection) should be subcultured to a sheep blood agar plate with 5% sheep blood or tested for GBS antigen or by DNA probe to further identify nonhemolytic GBS strains. An original paper copy of this issue can be obtained from the Superintendent of Documents, U.S.
Although lower concentrations (<104 cfu/ml) of GBS in the urine can be associated with vaginal-rectal colonization (134), relatively few data are available on the risk for early-onset GBS disease among infants born to women with low colony-count GBS bacteriuria (48). Outbreak of early onset group B streptococcal sepsis. The presence of chronic respiratory, genitourinary or gastrointestinal infections in patients with Group B streptococcal infection suggests that the hospital is the source for the acquisition of bacteremia. For assistance, please send e-mail to: mmwrq@cdc.gov. Cervical, perianal, perirectal or perineal specimens are not acceptable, and a speculum should not be used for culture collection. Obstet Gynecol 2002;99:1036--9. Users are referred to the electronic PDF version (http://www.cdc.gov/mmwr)
Prevention of early-onset group B streptococcal disease in newborns. Indications and nonindications for intrapartum antibiotic prophylaxis to prevent early-onset group B streptococcal (GBS) disease, Intrapartum GBS prophylaxis not indicated, • Previous infant with invasive GBS disease, • Colonization with GBS during a previous pregnancy (unless an indication for GBS prophylaxis is present for current pregnancy), • GBS bacteriuria during any trimester of the current pregnancy*, • GBS bacteriuria during previous pregnancy (unless an indication for GBS prophylaxis is present for current pregnancy), • Positive GBS vaginal-rectal screening culture in late gestation† during current pregnancy*, • Negative vaginal and rectal GBS screening culture in late gestation† during the current pregnancy, regardless of intrapartum risk factors. Identification of group B Streptococcus (GBS) bacteriuria in pregnant women. Ostroff RM, Steaffens JW. J Pediatr 1980;96:1063--7. Well-appearing infants whose mother had an indication for GBS prophylaxis but received no or inadequate intrapartum antibiotics can be managed with observation for ≥48 hours, unless the infant is <37 weeks and 0 days' gestational age or membranes were ruptured ≥18 hours before delivery, in which case a limited evaluation and observation for ≥48 hours is recommended (BIII). Int J Gynaecol Obstet 1996;54:197--205. The mitral valve is the most commonly affected (48 percent) followed by aortic (29 percent), mitral and aortic (10 percent) and tricuspid valves (5 percent). Assessing the need for intrapartum prophylaxis for these women also can be difficult because GBS colonization status often is unknown when labor or rupture of membranes occur before 35--37 weeks' gestation. The following updated recommendations for the prevention of early-onset GBS disease are based on critical appraisal of data that have become available since publication of previous CDC (13,15) and ACOG (258) recommendations and replace previous recommendations from CDC.