Presentation given by our Chief Executive, Jane Plumb for midwives at St George’s Hospital about group B Strep prevention and guidelines

1. Group B Strep in
pregnancy &
newborn babies
24 January 2013
Jane Plumb MBE, Chief Executive
Group B Strep Support
www.gbss.org.uk
14/03/2013 Group B Strep Support :
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2. GBSS Medical Advisory Panel
Dr Alison Bedford
Russell MRCP
Neonatal Consultant,
Birmingham Women's
Clinical Lead, South
West Midlands
Newborn Network &
Hon Associate Clinical
Professor, Warwick
Medical School
Dr Christine
McCartney OBE
FRCPath,
Executive Director,
Health Protection
Agency’s
Microbiology
Services, London
Philippa Cox
Consultant Midwife,
Supervisor of
Midwives, Homerton
Hospital, London
Prof Philip Steer BSC
MD FRCOG (Chair)
Emeritus professor at
Imperial College &
consultant obstetrician at
the Chelsea and
Westminster Hospital,
London
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3. Streptococci
• Classified into groups - B, A, G and C
• Group B Streptococcus (S. agalactiae)
– Infection (1647 cases E,W & NI 2011)
• Newborn babies
• Adults: the elderly, pregnant/postpartum women, others
with underlying disease
– Colonisation
• Asymptomatic & intermittent
• Intestinal (<30% of adults)
• Vaginal (<25% of women)
14/03/2013 Group B Strep Support :
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4. Rates of GBS bacteraemia by
age: England, Wales & N. Ireland, 2011
Source: Health Protection Report Vol. 6 No. 46 – 16 November 201214/03/2013 Group B Strep Support :
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5. UK GBS disease 0-90 days:
Age at onset
Source: Heath PT, Schuchat A. Perinatal group B streptococcal disease. Best
Practice & Research Clin Obs Gynaec. Vol 21, No 3, 411-424. 2007.
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6. GBS infection in babies
• “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
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7. Typical signs of early-onset
GBS infection (0-6 days)
• 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).
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8. Typical signs of late onset GBS
infection (7-90 days)
• 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.
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9. EOGBS known risk factors
• Previous 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 3 x
• Preterm labour 3 x
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10. Reducing EOGBS risk
• Intrapartum IV antibiotic prophylaxis
– Only proven effective method of prevention available
– 90% prevention (Boyer, 1986)
• Intramuscular antibiotics pre-labour
– studies & no GBS infection in control or treated group
• Vaginal flushing with Chlorhexidine
– No evidence it reduces EOGBS infection (Cutland, 2009)
• Oral Antibiotics
– No evidence it reduces EOGBS infection (treats GBS UTI)
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11. UK Guidelines
Routine screening of all pregnant women
for GBS carriage not recommended
NICE Antenatal Care Guideline 2012 (review 2014)
http://guidance.nice.org.uk/CG62
UK National Screening Committee 2012 (review 2015/6)
http://www.screening.nhs.uk/groupbstreptococcus
Royal College of Obstetricians & Gynaecologists 2012
(review 2015)
www.rcog.org.uk/womens-health/clinical-guidance/prevention-early-onset-neonatal-
group-b-streptococcal-disease-green-
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12. Guidelines: Health Protection Agency
Processing Swabs for GBS carriage
– B 58 (2006 updated 2012)
– “…provides a standardised method for culture where
clinicians decide to investigate specific patients …”
To improve sensitivity & specificity of
detection of colonisation at delivery:
– 35-37 weeks of pregnancy
– LVS & anorectal swabs
– Enriched culture medium
http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1317132860736
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13. Which GBS tests for carriage
are used in the UK?
• NHS: not routine but if offered, usually:
– High vaginal swab, sometimes using speculum
– Direct agar plating (misses up to 50% of carriers)
– 24-48 hours to culture
• Privately/few NHS trusts (HPA Gold Standard):
– Low vaginal & rectal swab(s)
– Enriched Culture Medium (very predictive for 5 weeks)
– 24-48 hours to culture
• Private PCR:
– Low vaginal & rectal swab(s)
– Potentially intrapartum (some less than 2 hours)
– Not validated for use in the UK (FDA & Health Canada
approved & bears CE mark for Europe)14/03/2013 Group B Strep Support :
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14. Guidelines: NICE Antibiotics for early
onset neonatal infection 1
New
August 2012
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15. Guidelines: NICE Antibiotics for early
onset neonatal infection 2
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16. Guidelines: NICE Antibiotics for early
onset neonatal infection 3
• guidance.nice.org.uk/CG149
http://guidance.nice.org.uk/CG149
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17. Guidelines: RCOG 1
Extras to NICE Antibiotics for EONI
– Offer IV antibiotic prophylaxis (IAP) & immediate induction
for prelabour ROM at ≥37 weeks + GBS carriage
– No IV antibiotics against GBS for
• Planned Caesarean section without labour or ROM
• Preterm prelabour ROM and not known to carry GBS
• Term prelabour ROM and not known to carry GBS
Conflict with NICE Antibiotics for EONI:
– No IAP for preterm labour with or without ruptured
membranes GBS status unknown (NICE says consider)
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18. Guidelines: RCOG 2
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19. Countries routinely screening
pregnant women for GBS
 Australia*
 Argentina
 Belgium
 Canada
 Chile
 Czech Republic
 France
 Germany
 Hong Kong
 Italy
 Kenya
 New Zealand*
 Poland
 Spain
 Slovenia
 Switzerland
 USA
*Dual14/03/2013 Group B Strep Support :
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20. USA Incidence of early- & late-onset
invasive group B Strep disease — Active
Bacterial Core surveillance areas, 1990–2008
Prevention of
Perinatal Group B
Streptococcal
Disease
Revised
Guidelines from
CDC, 2010
and adapted from
Jordan HT, et al.
Revisiting the need
for vaccine prevention
of late-onset neonatal
group B streptococcal
disease.
Pediatr Infect Dis J
2008;27:1057–64.
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21. Reduction of EOGBS
incidence in other countries
• Australia 82% (Daley et al, 2004)
• Spain 86% (Andreu et al, 2003)
• France 71% (Albouy-Llaty et al, 2011)
• USA 86% (Jordan et al, 2008)
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22. 0
0.05
0.1
0.15
0.2
0.25
0.3
0.35
0.4
0.45
2003 2004 2005 2006 2007 2008 2009 2010 2011
England, Wales & NI Culture-
proven EOGBS infection 2003-11
2003 RCOG
guidelines
introduced
Source: Health Protection Agency
Reported incidence per 1,000 live births
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23. Known risk factors for EOGBS
infection
• Previous 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
40% of EOGBS babies have no risk factors
Without testing mums, carriage risk unidentified so
preventative measures can’t be taken (Vergnano)
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24. • Risk-factor-based screening is not cost-effective
compared with screening based on culture.
• IAP directed by ECM screening at 35-37 weeks for
low risk term women & treating all preterm & high
risk women would be more cost effective
Kaambwa B, Bryan S, Gray J, Milner P, Daniels J, Khan KS et al. Cost-effectiveness of rapid
tests and other existing strategies for screening and management of early-onset group B
streptococcus during labour. BJOG 2010; 117(13):1616-1627.
Daniels J, Gray J, Pattison H, Roberts T, Edwards E, Milner P et al. Rapid testing for group B
streptococcus during labour: a test accuracy study with evaluation of acceptability and cost-
effectiveness. Health Technol Assess 2009; 13(42):1-iv.
Colbourn TE, Asseburg C, Bojke L, Philips Z, Welton NJ, Claxton K et al. Preventive strategies
for group B streptococcal and other bacterial infections in early infancy: cost effectiveness and
value of information analyses. BMJ 2007; 335(7621):655.
UK cost effectiveness studies
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25. Poll November 2011
• 28th October to 1st November 2011
• 1,000 interviews
• UK women aged 20-35
• www.comres.co.uk
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26. Poll November 2011
www.comres.co.uk 0% 20% 40% 60% 80% 100%
Info on GBS should be routinely given
to all pregnant women
Women should be offered screening
for GBS late in pregnancy
Antibiotics should be offered in labour
to pregnant women carrying GBS
If carrying GBS, I would
definitely/probably accept the
antibiotics
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27. Questions?
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28. NICE Antibiotics for early
onset neonatal infection 1
• Antibiotics for Early Onset Neonatal
Infection (EONI) CG149
– Published August 2012
– Use table 1 to identify risk factors for EONI
– Use table 2 to identify clinical indicators of
EONI
http://publications.nice.org.uk/antibiotics-for-
early-onset-neonatal-infection-cg149
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29. NICE Antibiotics for EONI 2
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30. NICE Antibiotics for EONI 3
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31. NICE Antibiotics for EONI 4
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32. NICE Antibiotics for EONI 5
In babies whether there are ANY risk
factors or clinical indicators of EONI:
– perform a careful clinical assessment ASAP
– review the maternal & neonatal history
– carry out a physical examination of the baby, including an
assessment of the vital signs
Babies with suspected EONI should be
treated ASAP
– Give antibiotics ASAP & always <1 hour of decision to treat
– Use IV benzylpenicillin with gentamicin unless
microbiological surveillance data indicate otherwise
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33. NICE Antibiotics for EONI 6
In babies with any red flags or 2 or more
non-red flags:
– Perform investigations
– Start antibiotic treatment (do not delay starting antibiotics
pending results)
In babies with 1 non-red flag consider
whether:
– It is safe to withhold antibiotics
– It is necessary to monitor baby’s vital signs & clinical
condition (if required, continue for 12+ hours at 0, 1 & 2
hours, then 2-hourly for 10 hours)
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34. NICE Antibiotics for EONI 7
When starting antibiotic treatment in babies
– blood culture before first dose
– CRP concentration at presentation
– lumbar puncture before starting antibiotics if safe and
• strong clinical suspicion of infection, or
• clinical symptoms or signs suggesting meningitis.
– If lumbar puncture would unduly delay starting antibiotics,
perform it ASAP after starting antibiotics.
Do not perform
– Routine urine tests as part of investigations
– Skin swab tests without clinical signs of localised infection
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35. NICE Antibiotics for EONI 8
If baby needs antibiotic treatment for
suspected EONI
– Give ASAP (always within 1 hour of decision to treat)
– Use IV benzylpenicillin with gentamicin unless local
microbiological surveillance data indicate a different
antibiotic
Duration of antibiotics: 7 days for babies with
positive blood culture & those with a negative
blood culture but a strong suspicion of sepsis
– Guideline describes some situations to consider stopping
antibiotics treatment at 36 hours/ extending for >7 days
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36. NICE Antibiotics for EONI 9
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37. NICE Antibiotics for EONI 10
If there has been concern about EONI before discharge,
advise parents verbally & in writing to seek medical
advice if the baby:
• is showing abnormal behaviour (for example, inconsolable
crying or listlessness), or
• is unusually floppy, or
• develops difficulties with feeding or with tolerating feeds, or
• has an abnormal temperature unexplained by environmental
factors (lower than 36°C or higher than 38°C), or
• has rapid breathing, or
• has a change in skin colour.
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38. Final thoughts
• ~25% of women carry GBS
• IAP highly effective : offer to all carriers
• 1 : 300 babies develop EOGBS born GBS
carriers without IAP
• 1 : 6000 babies with IAP
• Up to 60% of EOGBS babies have known
antenatal risk factors
• Not all tests for GBS carriage are equally
reliable (though a positive result is)
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39. www.gbss.org.uk
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