Early onset of neonatal group b streptococcus diseases zharif


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Early onset of neonatal group b streptococcus diseases zharif

  1. 1. Prepared by: DrAhmad Zharif Hussein RSMU
  2. 2.  Streptococcus agalactiae  Gram positive, beta hemolytic bacteria  Colonisation  Asymptomatic and intermittent  Intestinal (<30% of adults)  Vaginal (<25% of women)  Infection  Newborn babies  Adults: the elderly, pregnant/postpartum women, others with underlying disease s
  3. 3.  “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
  4. 4. Source: Heath PT, Balfour G, Weisner AM, Efstratiou A, Lamagni TL,Tighe H et al. Group B streptococcal disease in UK and Irish infants younger than 90 days. Lancet 2004; 363(9405):292-294.
  5. 5. Photo courtesy of Dr. Carol Baker Baylor College of Medicine, Houston,TX
  6. 6.  US guidelines  all women colonised with GBS at 35–37 weeks of gestation should be offered IAP(intrapartum antibiotic prophylaxis
  7. 7.  10% - 30% of women  Higher proportion in African Americans and nonsmokers  GBS usually live in gastrointestinal tract but can spread to the genital tract  No symptoms or signs on examination  Colonization comes and goes over months  Not a sexually transmitted infectio
  8. 8.  Previous Invasive 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
  9. 9.  Not recommended  Routine bacteriological screening of all pregnant women for antenatal GBS carriage ▪ cost-effective  Antenatal treatment IAP is before the onset of labour.  screening for GBS or the administration of IAP to women in whom GBS carriage was detected in a previous pregnancy
  10. 10.  IAP to women with GBS bacteriuria during the current pregnancy  higher risk of chorioamnionitis and neonatal disease  urinary tract infection (growth of greater than 105 cfu/ml) during pregnancy  IAP should be offered if GBS is detected on a vaginal swab in the current pregnancy.  If GBS is present in a vaginal swab, it is likely that the risk of neonatal disease is increased(risk 2.3/1000)
  11. 11.  Antibiotic prophylaxis specific for GBS is not required for women undergoing planned caesarean section in the absence of labour and with intact membranes.  Immediate induction of labour and IAP should be offered to all women with prelabour rupture of membranes at 37+0 weeks of gestation or more.
  12. 12.  If chorioamnionitis is suspected, broad-spectrum antibiotic therapy including an agent active against GBS should replace GBS-specific IAP and induction of labour should be considered
  13. 13. • Intramuscular antibiotics pre-labour • May eradicate GBS colonisation for up to 6 weeks • Small studies & no GBS infection in control or treated group • Vaginal flushing with Chlorhexidine • No evidence it reduces EOGBS infection • Oral Antibiotics • No evidence it reduces EOGBS infection (treats GBS UTI)
  14. 14.  In preterm labour with intact membranes with no other risk factors for GBS should not routinely be offered IAP unless they are known to be colonised with GBS  risk of EOGBS infection is higher in preterm than in term infants  ORACLE trial
  15. 15.  IAP should be offered to women who are pyrexial in labour (>38 C). should be offered broad-spectrum antibiotics including an antibiotic for prevention of neonatal EOGBS disease  IAP for women with term prelabour rupture of membranes is unclear and NICE recommends that it is not given, unless there are other risk factors  at term should be offered immediate induction of labour or induction after 24 hours
  16. 16.  IAP should be offered to women with a previous baby with neonatal GBS disease(neonatal sepsis)  Subsequent infants born to these women are likely to be at increased risk of GBS disease
  17. 17.  IAP, benzylpenicillin should be administered as soon as possible after the onset of labour and given regularly until delivery.  Clindamycin should be administered to those women allergic to benzylpenicillin  as soon as possible after the onset of labour  the efficacy of IAP, the first dose should be given at least 2 hours prior to delivery  minimum inhibitory concentration for GBS as early as 1 hour after maternal administration  Oral antibiotics for IAP are not recommended
  18. 18.  no evidence that intrapartum vaginal cleansing will reduce the risk of neonatal GBS disease
  19. 19.  Universal screening of pregnant women for GBS at 35-37 weeks gestational age(only in US)  Intrapartum antibiotic prophylaxis for:  GBS positive screening test  GBS colonization status unknown with  Delivery <37 weeks  Temperature during labor >100.4˚ F (>38.0˚ C)  Rupture of membranes >18 hours  Previous infant with GBS disease  GBS in the mother’s urine during current pregnancy  Penicillin preferred drug for IAP  Ampicillin acceptable alternative  Cefazolin preferred for penicillin-allergic at low risk of anaphylaxis
  20. 20.  Colonization with GBS during a previous pregnancy •  GBS bacteriuria during a previous pregnancy •  Negative vaginal and rectal GBS screening test during the current pregnancy •  Cesarean delivery performed before labor onset on a woman with intact amniotic membranes • •
  21. 21.  In a UK study of invasive GBS disease,  89% of early-onset cases were identified on day 1.  Most cases (65–67%) have one or more risk factors prior to or during labour.  A significant number will also have had signs of fetal distress, an emergency delivery and low Apgar scores.  The majority of early-onset cases in these studies presented with ▪ sepsis (79.4%), ▪ 11.8% had meningitis, ▪ 7.8% had pneumonia and ▪ 1% focal infection
  22. 22.  Well infants at risk of EOGBS should be observed for the first 12–24 hours after birth with regular assessments of general wellbeing, feeding, heart rate, respiratory rate and temperature  great majority of infants (89–94%) who develop EOGBS infection develop signs within the first 24 hours after birth  the majority of such infants (65–67%) will have had one or more ‘conventional’ risk factors evident in or before labour.
  23. 23.  Postnatal antibiotic prophylaxis is not recommended for asymptomatic term infants without known antenatal risk factors.  Infants with clinical signs of EOGBS should be treated promptly with appropriate antibiotics
  24. 24.  For a well infant whose mother has had a previous infant with GBS disease, either clinical evaluation after birth and observation for around 24 hours are necessary, or blood cultures need to be obtained and the infant treated with benzylpenicillin until the culture results are available.
  25. 25.  It is not necessary to perform routine surface cultures or blood cultures on well infants  no evidence to discourage breastfeeding
  26. 26. • 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).
  27. 27. Typical signs of late onset GBS infection • 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);
  28. 28. • 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.
  29. 29. The Recommendations MMWR,Vol 59 (RR-10)
  30. 30. www.gbss.org. uk
  31. 31.  25/g4p3 @ 39/52 ANC 1.Hx of neonatal sepsis in previous pregnancy secondary to GBS  But current pregnancy no HVS taken  Pt came with c/o contraction pain,LL @ 28/7/2013 FM good  DOA 29/7/2013  Ve os 2 cm cx 2cm st -12 MI clear liquor seen vx no cord no placent UR mx??
  32. 32.  27 g2p1 @ 38/52 (SOD)scan correspond to date(correspond to edd)  unbooked unscreened  c/o contraction pain.LL @ 25/4/2013 @ 0640am,FM good  DOA 25/4/2013 1200am  Ve os 4 cm cx 0.5 cm st -1 MI clear liquor seen.vx  Ur Mx?
  33. 33.  27 g1p0 @ 28 week clo contraction pain and LL @25/6/2013 0800am, FM good,diagnosis PPROM.DOA:26/6/2013  Ve os 1 cm cx 2 cm st -2 MI clear liquor seen  Contraction 2;10  Ur management?
  34. 34.  CDC -Overview of CDC Prevention Guidelines, 2010 ▪ National Center for Immunization and Respiratory Diseases Division of Bacterial Diseases  Green top guideline no 36  Prevention of early neonatal group B streptococcus http://www.gbss.org.uk/epetitio
  35. 35.  Thank you