Obstet Gynecol. J Infect Dis 1990;162:672--7. Stoll BJ, Hansen N, Fanaroff AA, et al. Ventura VL, South Med J 1979;72:1410--2. • Unknown GBS status at the onset of labor (culture not done, incomplete, or results unknown) and any of the following: -- Intrapartum temperature ≥100.4°F (≥38.0°C)¶, • Cesarean delivery performed before onset of labor on a woman with intact amniotic membranes, regardless of GBS colonization status or gestational age, Abbreviation: NAAT = Nucleic acid amplification tests. Multicenter study of a rapid molecular-based assay for the diagnosis of group B. Aziz N, Baron EJ, D'Souza H, Nourbakhsh M, Druzin ML, Benitz WE. Shorter durations of appropriate antibiotics might provide some protection; in particular, colonization data suggest durations of ≥2 hours before delivery might confer some protection (86). Cervical, perianal, perirectal or perineal specimens are not acceptable, and a speculum should not be used for culture collection. Schuchat A, Three studies have compared both intrapartum NAAT on nonenriched samples and late antepartum enriched culture results to intrapartum enriched culture (179,182,185). Clin Pharmacokinet 1979;4:297--309. provided as a service to MMWR readers and do not constitute or imply After the issuance of the 2002 recommendation for universal culture screening, implementation was rapid and widespread. BARBARA S. APGAR, M.D., M.S., is a clinical professor in the Department of Family Medicine at the University of Michigan Medical School, Ann Arbor. The 1996 guidelines did not specify a colony-count threshold for defining GBS bacteriuria. Gibbs R, Obstet Gynecol. Women admitted with signs and symptoms of preterm labor who have unknown GBS colonization status at admission or a positive GBS screen within the preceding 5 weeks should receive GBS prophylaxis at hospital admission (AII). The swab should be rotated several times and pressed firmly on the inside wall of the tube above the fluid level. Braun D, Selective enrichment broth also can contain chromogenic substrates that provide for a change in color in the setting of beta-hemolytic GBS. Cefazolin is recommended in women allergic to penicillin who are at low risk of anaphylaxis. Am J Obstet Gynecol 1966;96:938--42. Wayne, PA; 2010. Rosa-Fraile M, Rodrguez-Granger J, Haidour-Benamin A, Cuerva J, Sampedro A. Granadaene: proposed structure of the group B, Church DL, Baxter H, Lloyd T, Miller B, Elsayed S. Evaluation of StrepB carrot broth versus Lim broth for detection of group B, Martinho F, Prieto E, Pinto D, et al. RR-7). Petri W. Penicillins, Cephalosporins, and other B-lactam antibiotics. Dr. Apgar earned a master’s degree in anatomy from the University of Michigan. Velaphi S, Siegel JD, Wendel GD Jr, Cushion N, Eid WM, Sanchez PJ. Robinson A. Obstet Gynecol 2010;115:1225--32. Heinemann J, Gillen G, Sanchez-Ramos L, Kaunitz A. Early-onset group B streptococcal disease—United States, 1998–1999. Efforts to monitor the emergence of perinatal infections caused by other organisms are also encouraged (CIII). Krohn MA, Hillier SL, Baker CJ. 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). Cushion NB. Ottolini MC, Lundgren K, Mirkinson LJ, Cason S, Ottolini MG. Utility of complete blood count and blood culture screening to diagnose neonatal sepsis in the asymptomatic at risk newborn. Weeks JW, Myers SR, Lasher L, Goldsmith J, Watkins C, Gall SA. Edwards RK, Clark P, Sistrom CL, Duff P. Intrapartum antibiotic prophylaxis 1: relative effects of recommended antibiotics on gram-negative pathogens. N Engl J Med 2009;360:2626--36. Previous delivery of an infant with invasive GBS disease is a risk factor for early-onset disease in subsequent deliveries (59--62). Am J Obstet Gynecol 2002;187:495--500. ¶¶¶ Duration of incubation in selective enrichment broth varied (range: 4--24 hours). Barber EL, Zhao G, Buhimschi IA, Illuzzi JL. 2nd ed. Baker CJ, Rench MA, Edwards MS, Carpenter RJ, Hays BM, Kasper DL. Scand J Infect Dis. Although much progress has been made in the prevention of early-onset GBS disease, important challenges remain. N Engl J Med. Pediatrics 2000;106(2 Pt 1):256--63. The management of well-appearing infants whose mothers received inadequate intrapartum antibiotic prophylaxis (because of either a short duration of exposure before delivery or use of an agent with limited efficacy data) can be challenging. Results of studies conducted during 1996--2002 were inconsistent, reporting increased (255), stable (256), or decreased (257) use of health services (including diagnostic tests, antibiotics, and/or length of hospital stay) for neonates born to women receiving intrapartum antibiotics. In: Adkinson N, Bochner B, Busse W, Holgate S, Simons F, eds. Farley MM, Comparison of gen-probe AccuProbe group B, Montague N, Cleary T, Martinez O, Procop G. Detection of group B streptococci in Lim broth by use of group B, Peltroche-Llacsahuanga H, Fiandaca M, von Oy S, Ltticken R, Haase G. Rapid detection of, Goodrich JS, Miller MB. Middleton's allergy: principles and practice. Colonization with group B streptococci in pregnancy and adverse outcome. Obstet Gynecol 2008;112(2 Pt 1):259--64. Whitney CG, American College of Obstetricians and Gynecologists. Epidemiology of group B streptococcal disease. 5(March 1, 2005) Neonates who appear to be septic and those born to mothers with chorioamnionitis should receive a diagnostic work-up including blood culture, CBC with differential, and possible lumbar puncture before antibiotics are initiated. et al. Patterns of antibiotic resistance among group B. Castor ML, Whitney CG, Como-Sabetti K. Antibiotic resistance patterns in invasive group B streptococcal isolates. Comparison of BD GeneOhm real-time polymerase chain reaction with chromogenic and conventional culture methods for detection of group B. Carvalho MD, Facklam R, Jackson D, Beall B, McGee L. Evaluation of three commercial broth media for pigment detection and identification of group B streptococci (GBS). Revisiting the need for vaccine prevention of late-onset neonatal group B streptococcal disease. Women receiving group B. Mercer BM, Miodovnik M, Thurnau GR, et al. J Clin Microbiol 2004;42:5184--8. Schuchat A. J Infect Dis 1982;145:800--3. ¶ See One study from a vertically integrated health system in Utah found an elevated risk for early-onset GBS disease among infants born to women with low colony-count GBS bacteriuria compared with those whose mothers did not have GBS bacteriuria (135). 1986;314:1665–9. When comparing swabs collected at the two different time points, two of the studies found intrapartum NAAT to be slightly more sensitive (95.8% and 90.7%, respectively) than antepartum culture (83.3% and 84.3%, respectively) (182,185), although with widely overlapping confidence intervals. When the time between the start of antibiotics and delivery is less than one hour, the rate of GBS transmission is 46 percent compared with 1.2 percent if the interval is more than four hours.31, Penicillin G—initial dose: 5 million units IV, Subsequent dosing: 2.5 million units IV every four hours until delivery, Alternative (if penicillin G not available), Subsequent dosing: 1 g IV every four hours until delivery, Clindamycin (Cleocin)—900 mg IV every eight hours until delivery, Erythromycin—500 mg IV every six hours until delivery, GBS susceptible to clindamycin and erythromycin, Vancomycin (Vancocin)—1 g IV every 12 hours until delivery, GBS resistance to clindamycin or susceptibility unknown, Subsequent dosing: 1 g IV every eight hours until delivery. 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). Such sentinel events include the emergence of penicillin resistance among GBS isolates and an increase in the incidence of disease or deaths due to neonatal pathogens other than GBS that offsets the burden of early-onset disease prevented by intrapartum antibiotic prophylaxis. Abate G, As effective prevention strategies are increasingly implemented, a growing proportion of the remaining relatively low burden of disease will reflect inherent limitations in the strategies. Lou Y, Barton LL, Feigin RD, Lins R. Group B beta hemolytic streptococcal meningitis in infants. Epidemiology of group B streptococcal disease. Prevention of perinatal group B streptococcal disease--revised guidelines from CDC, 2010. Ronald Gibbs disclosed receiving a consulting fee from Novartis for consulting on potential vaccine complications (unrelated to GBS); Lee Hampton disclosed owning shares in General Electric; and Laura Riley disclosed receiving an honorarium from Up To Date for services as a writer. Similar trends have been reported among infants delivered in all U.S. military hospitals (229). Maternal culturing between 35 and 37 weeks of gestation is recommended. MMWR Morb Mortal Wkly Rep. TABLE 1. Gotoff SP. Changes in pathogens causing early-onset sepsis in very-low-birth-weight infants. In the mid 1980s, it was demonstrated that GBS was carried in the vaginal and anorectal flora of up to 30 percent of women.5 Maternal colonization can be intermittent, transient, or persistent.6 Fortunately, the attack rate in newborns is low. GBS identified in clean-catch urine specimens during any trimester is considered a surrogate for heavy maternal colonization and also is associated with a higher risk for early-onset GBS disease (46--50). Foxman B, This report presents CDC's updated guidelines, which have been endorsed by the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, the American College of Nurse-Midwives, the American Academy of Family Physicians, and the American Society for Microbiology. However, in the context of universal late antenatal GBS screening, it is unclear how much additional disease is prevented by screening for low colony-count GBS bacteriuria and whether identification of low colony-count bacteriuria is cost-effective. The Clinical and Laboratory Standards Institute (CLSI) recommends disk diffusion or broth microdilution testing for susceptibility testing of GBS. (Note: Other validated tests to detect GBS with inducible clindamycin resistance may be used. Safety and immunogenicity of capsular polysaccharide-tetanus toxoid conjugate vaccines for group B streptococcal types Ia and Ib. One longitudinal study of GBS early-onset sepsis found that although the overall rate of GBS early-onset disease declined over time, erythromycin-resistant GBS caused an increasing proportion of disease during this interval; however, the incidence of antibiotic-resistant GBS early-onset sepsis remained stable (105). 4. The yield of vaginal cultures for GBS is only 60 percent of the yield of vaginal and rectal cultures combined.24 Use of a speculum is not required. The use of intrapartum prophylaxis against group B Streptococcus has increased, and rates of invasive group B streptococcal infection within … The cases are created by experts in the field and are designed to emphasize the basic principles of the disease process and fundamentals of patient evaluation and management. A classic prospective cohort study conducted during the 1980s revealed that pregnant women with GBS colonization were >25 times more likely than pregnant women with negative prenatal cultures to deliver infants with early-onset GBS disease (34). Obstet Gynecol 2006;108:1254--65. Vermillion ST, Group B streptococci at delivery: high count in urine increases risk for neonatal colonization. The following are key components of specimen collection and processing: GBS colonization status should be determined by collecting both vaginal and rectal specimens at 35--37 weeks' gestation. Saunders B, However, data from clinical trials also have suggested that certain antibiotics administered for preterm premature rupture of membranes can be associated with necrotizing enterocolitis in the neonate (125,126) and that antibiotics administered in the setting of spontaneous preterm labor can be associated with adverse neonatal outcomes, such as increased need for supplementary oxygen (127) or cerebral palsy (128). Maternal and transplacental pharmacokinetics of cefazolin. Beginning in the mid 1980s, clinical trials and well-designed observational studies demonstrated that administering intravenous antibiotics during labor to women at risk for transmitting GBS to their newborns could prevent invasive disease in the first week of life (i.e., early-onset disease) (6--11). Am J Obstet Gynecol 2000;182:1344--54. Even when appropriate transport media are used, the sensitivity of culture is greatest when the specimen is stored at 4°C before culture and processed within 24 hours of collection (139,155--157). Other rapid tests in addition to NAAT have been developed to detect GBS rapidly from nonenriched samples, including optical immunoassays and enzyme immunoassays; however, none is sufficiently sensitive when used on a direct specimen to detect GBS colonization reliably in the intrapartum setting (180,189--192). Sweet R, Obstet Gynecol 2007;109:1105--10. Effects of hospital policies based on 1996 group B streptococcal disease consensus guidelines. Washington, DC: ASM Press; 2009. These updated guidelines replace CDC's 2002 guidelines. Faxelius G, Bremme K, Kvist-Christensen K, Christensen P, Ringertz S. Neonatal septicemia due to group B streptococci---perinatal risk factors and outcome of subsequent pregnancies. § Consultation with obstetric providers is important to determine the level of clinical suspicion for chorioamnionitis. 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). If a patient with a history of PTL is re-admitted with signs and symptoms of PTL and had a negative GBS screen >5 weeks prior, she should be rescreened and managed according to this algorithm at that time. Enhanced antenatal detection of group B streptococcus colonization. 1998;17:499–503. Signs of sepsis in any newborn can be an indication of early-onset GBS disease, regardless of maternal colonization status. Pediatrics 2000;105(1 Pt 1):21--6. 71/No. Antimicrob Agents Chemoth 2008;52:2890--7. Providers using the risk-based method identified candidates for intrapartum chemoprophylaxis according to the presence of any of the following intrapartum risk factors: delivery at <37 weeks' gestation, intrapartum temperature ≥100.4ºF (≥38.0ºC), or rupture of membranes for ≥18 hours. The CDC and ACOG strongly discourage combining protocols such as administering intrapartum antibiotics to a woman with ruptured membranes at more than 18 hours despite a negative GBS culture at 35 to 37 weeks of gestation.13,23, The choice of intrapartum prophylactic antibiotics for GBS-positive women depends on maternal allergy history and antibiotic susceptibility (Table 5, Figure 1).13 The first choice is intravenous penicillin G, 5 million units initially followed by 2.5 million units every four hours until delivery.13 Penicillin G is preferred because of its narrow spectrum profile, although ampicillin is an acceptable alternative if penicillin G is unavailable. Effect of specimen storage, antibiotics, and feminine hygiene products on the detection of group B. Stoner KA, Rabe LK, Hillier SL. Ann Inter Med 2008;149:W20--4. Obstet Gynecol 2003;102:875--82. US Preventive Services Task Force. The origins of stillbirth: infectious diseases. Balter S, Zell ER, O'Brien KL, et al. 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). Predominance of serotype V and frequency of erythromycin resistance in. Duration of intrapartum prophylaxis for neonatal group B streptococcal disease: a systematic review. Zywicki SS, Impact of maternal group B streptococcal screening on pediatric management in full-term newborns. The sensitivity and specificity of cultures obtained one to five weeks before delivery were 87 and 97 percent, respectively. For topics on which several sources of data were available, evidence was summarized in tables. Baker CJ, Barrett FF, Gordon RC, Yow MD. Therefore, it is recommended that routine susceptibility testing of GBS isolates be performed.28 Several patterns of isolate resistance have emerged. Committee on Obstetric Practice. J Matern Fetal Neonatal Med 2005;18:225--9. Markenson GR. Hall RT, Barnes W, Krishnan L, Harris DJ, Rhodes PG, Fayez J, et al. J Perinat Med 1988;16:423--30. * Patients with a history of any of the following after receiving penicillin or a cephalosporin are considered to be at high risk for anaphylaxis: anaphylaxis, angioedema, respiratory distress, or urticaria. Although the findings have not been replicated, a study in the state of Washington suggested that the risk for KD might be linked to perinatal exposures, including older maternal age, maternal group B streptococcal colonization, and hospitalization in early infancy for a bacterial illness, which was associated with a 2.8-fold higher risk. † If patient has undergone vaginal-rectal GBS culture within the preceding 5 weeks, the results of that culture should guide management. Newman TB, Puopolo KM, Wi S, Draper D, Escobar GJ. Gerdes JS, Polin RA. Pulver LS, Hopfenbeck MM, Young PC, Stoddard GJ, Korgenski K, Daly J, et al. ** Source: Atkins KL, Atkinson RM, Shanks A, Parvin CA, Dunne WM, Gross G. Evaluation of polymerase chain reaction for group B Streptococcus detection using an improved culture method. Rectal colonization with group B. Dillon HC, Gray E, Pass MA, Gray BM. Maternal and transplacental pharmacokinetics of cefazolin. Eur J Clin Microbiol Infect Dis 2004;23:61--2. Strategies for chemoprophylaxis of GBS early-onset infections. Consultation with obstetric providers to assess whether chorioamnionitis was suspected is important to determine neonatal management (CIII). Protecting People.™, Laboratories should identify GBS when present at. If the infant is well-appearing and either <37 weeks and 0 days' gestational age or the duration of membrane rupture before delivery was ≥18 hours, then the infant should undergo a limited evaluation and observation for ≥48 hours (BIII). Acta obstetricia et gynecologica Scandinavica. Blackwelder WC, Although the incidence of neonatal group B strep infection has been decreasing, the incidence of GBS infection in nonpregnant adults has been increasing. Ideally, a rapid test for intrapartum use also would be able to detect mutations likely to confer resistance to clindamycin and/or erythromycin in order to guide antibiotic choice for penicillin-allergic women. J Clin Microbiol 2010;48:3095--9. Institution of universal screening for group B. Puopolo K, Eichenwald E. No change in the incidence of ampicillin-resistant, neonatal, early-onset sepsis over 18 years. Muller A, Mouton J, Oostvogel P, et al. With improved obstetrical management and evidence-based use of intrapartum antimicrobial therapy, early-onset neonatal sepsis is becoming less frequent. There also is a need to monitor for potential adverse consequences of intrapartum antibiotic prophylaxis (e.g., emergence of bacterial antimicrobial resistance or increased incidence or severity of non-GBS neonatal pathogens). Revised guidelines from CDC. The accuracy of late antenatal screening cultures in predicting genital group B streptococcal colonization at delivery. § See Universal screening and intrapartum antibiotic prophylaxis have had no measurable impact on late-onset GBS disease, prenatal-onset disease (including stillbirths and miscarriages), or GBS disease among nonpregnant adults. 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. Penicillin allergies are common, but are likely over-reported or misinterpreted by the patient.32 Before determining whether an alternative drug is necessary, the nature of the reported reaction to penicillin should be confirmed.13 For women with a history of penicillin allergy other than immediate hypersensitivity reactions, cefazolin is the preferred antibiotic because its transplacental transfer is similar to that of ampicillin.13,33, Guidelines for management of the newborn whose mother received adequate IAP for prevention of early-onset GBS disease* or suspected chorioamnionitis.†. Various streptococcal grouping latex agglutination tests or other tests for GBS detection (e.g., GBS Accuprobe) may be used for specific identification, or the CAMP test can be employed for presumptive identification. Expert opinion was sought from working group members regarding topics on which no new evidence was available. J Clin Microbiol 2004;42:83--9. The figure tracks the steady decline in early-onset GBS as GBS-prevention recommendations were implemented. Eur J Obstet Gynecol Reprod Biol 1981;12:143--50. Although the exact duration of antibiotics needed to prevent vertical transmission of GBS has been debated (84,85), beta-lactam antibiotics for GBS prophylaxis administered for ≥4 hours before delivery have been found to be highly effective at preventing vertical transmission of GBS (86) and early-onset GBS disease (68). One study reported a statistically significant difference between the sensitivity of swabs collected intrapartum and tested with NAAT (94.0%) compared with enriched culture performed on swabs collected prenatally (54.3%) (179). Miranda JA, Currently available evidence does not suggest any increase in non-GBS early-onset sepsis among term infants. ¶ Source: de la Rosa M, Perez M, Carazo C, Pareja L, Peis JI, Hernandez F. New Granada medium for detection and identification of group B streptococci. Antimicrob Agents Chemother 2008;52:2915--8. Pediatr Infect Dis J 1994;13:623--9. Infants with early-onset GBS disease generally present with respiratory distress, apnea, or other signs of sepsis within the first 24--48 hours of life (3,31). Herruzo AJ, Summary of the workshop on perinatal infections due to group B. Regan JA, Klebanoff MA, Nugent RP. Hager WD, Meeting of the Society for Pediatric and Perinatal Epidemiologic Research, Salt Lake City, Utah; June 14--15, 2004. Bland ML, Vermillion ST, Soper DE. FIGURE 4. 13, no. Lower vaginal and rectal cultures for GBS are collected at 35 to 37 weeks of gestation, and routine clindamycin and erythromycin susceptibility testing is performed in women allergic to penicillin. They are intended for providers of prenatal, obstetric, and neonatal care; supporting microbiology laboratories, hospital administrators, and managed-care organizations; childbirth educators; public health authorities; and expectant parents and their advocates. Prevention of perinatal group B streptococcal disease. Early-onset disease has declined among all racial and ethnic groups, yet significant disparities persist. Sanchez MJ, Boyer KM, Gadzala CA, Kelly PD, Burd LI, Gotoff SP. Because the signs of sepsis in newborns can be nonspecific and insensitive, a conservative approach to management has been advocated. Algorithm for secondary prevention of early-onset group B streptococcal (GBS) disease among newborns. Br J Obstet Gynaecol 1983;90:633--5. The influence of intrapartum antibiotics on the clinical spectrum of early-onset group B streptococcal infection in term infants. Erythromycin is no longer an acceptable alternative for intrapartum GBS prophylaxis for penicillin-allergic women at high risk for anaphylaxis. Figure 7), Remove swab(s) from transport medium. † —Patients with penicillin allergy who have taken cephalosporins in the past without reaction should receive cefazolin. Burd LI, Number 173, June 1996. 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. The development of relatively rapid laboratory tests to identify GBS moves us closer to the possibility of an intrapartum test for GBS colonization screening. Well-appearing infants whose mothers had no chorioamnionitis and no indication for GBS prophylaxis should be managed according to routine clinical care (CIII). 1986;18:525–31. On the basis of data from CDC's Active Bacterial Core surveillance (ABCs) system, a network of 10 sites across the United States that conduct active, population-based surveillance, CDC estimates that in recent years, GBS has caused approximately 1,200 cases of early-onset invasive disease per year (30); approximately 70% of cases are among babies born at term (≥37 weeks' gestation) (19). For assistance, please send e-mail to: mmwrq@cdc.gov. Pediatr Infect Dis J 2008;27:1057--64. † Antibiotic therapy should be directed toward the most common causes of neonatal sepsis, including intravenous ampicillin for GBS and coverage for other organisms (including Escherichia coli and other gram-negative pathogens) and should take into account local antibiotic resistance patterns. Zywicki SS, Media for isolation-cultivation-identification-maintenance of medical bacteria. Colombo DF, Lew JL, Pedersen CA, Johnson JR, Fan-Havard P. Optimal timing of ampicillin administration to pregnant women for establishing bactericidal levels in the prophylaxis of group B. Fossieck B, Parker RH. Kubilis P, Bronchopulmonary dysplasia (BPD; formerly chronic lung disease of infancy) is a chronic lung disease in which premature infants, usually those who were treated with supplemental oxygen, require long-term oxygen.
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