jan 2013 st george's presentation for midwives

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 :

www.gbss.org.uk 1

http://www.gbss.org.uk/

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

14/03/2013 Group B Strep Support :

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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)


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Rates of GBS bacteraemia by

age: England, Wales & N. Ireland, 2011

Source: Health Protection Report Vol. 6 No. 46 – 16 November 2012 14/03/2013 Group B Strep Support :

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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. 14/03/2013 Group B Strep Support :

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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 14/03/2013 Group B Strep Support :

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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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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. 14/03/2013 Group B Strep Support :

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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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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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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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http://www.rcog.org.uk/womens-health/clinical-guidance/prevention-early-onset-neonatal-group-b-streptococcal-disease-green-






















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 14/03/2013 Group B Strep Support :

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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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Guidelines: NICE Antibiotics for early

onset neonatal infection 1

New

August 2012


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• guidance.nice.org.uk/CG149



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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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Guidelines: RCOG 2


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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 *Dual 14/03/2013 Group B Strep Support :

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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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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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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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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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• 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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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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http://www.comres.co.uk/

Poll November 2011

www.comres.co.uk 0% 20% 40% 60% 80% 100%

Info on GBS should be routinely givento all pregnant women

Women should be offered screeningfor GBS late in pregnancy

Antibiotics should be offered in labourto pregnant women carrying GBS

If carrying GBS, I woulddefinitely/probably accept the

antibiotics


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http://www.comres.co.uk/

Questions?


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NICE Antibiotics for early


• 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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http://publications.nice.org.uk/antibiotics-for-early-onset-neonatal-infection-cg149













NICE Antibiotics for EONI 2


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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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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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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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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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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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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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jan 2013 st george's presentation for midwives

Health & Medicine