|
Group B Strep
What is Group B Strep (GBS)?
• Group B Streptococci (GBS, Streptococcus agalactiae)
is a type of normal bacteria that 10-30% of healthy people
carry in the vagina and/or lower intestine of their bodies.
• “Colonization of GBS” Lots of people carry
GBS but are not infected.
• GBS colonization isn’t contagious.
• Rarely the GBS bacteria can attack the body and cause
infection (Called GBS disease)
How does a baby get GBS?
• A baby may be colonized before, during or after birth
by coming in contact with GBS bacteria.
• Approximately 50% of babies born to mothers with GBS
colonization are colonized [CDC 2002].
• 98 % of babies colonized will have no symptoms.
• 2% of babies colonized will become ill with Group
B Strep Disease.
• It is unknown why some infants develop the disease
and others don’t.
How Can GBS disease affect my infant?
• GBS disease is the most common cause of sepsis (infection
of the blood).
• GBS disease is also the most common cause of meningitis
(infection of the fluid and lining surrounding the brain).
• GBS disease is a frequent cause of newborn pneumonia
and respiratory issues.
• Ten to twenty percent of babies that develop GBS disease
die
• Some babies that survive, especially those who develop
meningitis, may develop long-term medical problems, including
hearing or vision loss, varying degrees of physical and learning
disabilities, and cerebral palsy.
• Premature babies are at increased risk for GBS disease
and long term complications or death as a result.
Early and Late Onset Group B Strep Disease:
• 2 Kinds of GNS disease.
• Early onset presents within the 1st week of life.
• Most early onset GBS disease babies present with respiratory
distress symptoms and are ill within the first few hours of
life.
• Babies who develop early onset disease may have one
or more of the following symptoms: problems with temperature
regulation, grunting sounds, fever, seizures, breathing problems,
unusual change in behavior, stiffness, or extreme limpness.
• Late onset GBS disease can also develop in infants
1 week – several months.
• Meningitis is more common with late onset GBS disease.
• A baby with late onset GBS disease may display the
following signs: stiffness, limpness, inconsolable screaming,
fever, or refusal to nurse
• Screening for Group B Strep Bacteria:
• Some practitioners culture urine for Group B Strep
Bacteria at 34 weeks.
• At 36 weeks a Group B Strep test is offered by culturing
the the introitus and the rectum.
• If bacteria grow, the woman is colonized (positive);
if no bacteria grow, the test is negative.
• When both lower vaginal and rectal sites are sampled
and inoculated into selective broth media, almost 100% of
GBS carriers are detected.
• Colonization can be chronic (40%), intermittent or
transient.
• Can have a positive culture during the 2nd trimester
and test negative at 36 weeks.
• 4 to 7 percent of women who had negative cultures
late in second trimester will have positive GBS culture at
delivery, but about 33% of women who have positive GBS cultures
during the second trimester have negative cultures at delivery
which is why testing is not recommended until 36 weeks.
• Two obstetricians from Stanford Medical Center designed
a culture test in 1999 to detect GBS status in one hour. The
test is called Strep B OIA. It is performed using a sterile
swab with sampling obtained from the lower 1/3 of the vagina
(no rectal culturing is done). Cultures must be processed
within 72 hours, results available within one hour [ACDM,
1999, par.19]. This test is also cheaper than most others
available on the market. [Benitz, Gould, & Druzin, 1999,
p.10].
Using Chlorohexidine to prevent transmission of Group B
strep bacteria:
• For a family who chooses to have the GBS test done
at 36 weeks and tests positive or declines testing.
• Chlorohexidine – Strong antiseptic solution
which is diluted to a very mild.02% solution
• It is very cost effective
• Much less invasive and less adverse reactions
• Has been shown to be “as effective as ampicillin
in preventing vertical transmission of Group B streptococcus.”
• Treats for E. coli bacteria which ampacillan does
not.
• Chlorohexidine (hibiclense) is included in your birth
kit.
• To make the vaginal rinsing solution use a peri squirt
bottle and mix 1 part hibiclense to 9 parts water.
• Begin rinsing when your labor begins either with contractions
or with your bag of waters breaking.
• NO DOUCHING – rinse your inner and outer labia,
your peri – rectal area and your introitus.
• Rinse every 4 hours.
• Please take your temperature ever 4 hours and document
it.
Using Antibiotics to prevent transmission of GBS bacteria:
• The CDC recommends treating a woman who has tested
positive or has not been tested and has “risk factors”
with 4 hours of IV antibiotic therapy during labor.
• Risk factors include having a premature labor, having
your bag of waters broken longer than 18 hours, or having
a previous baby who had Group B Strep disease **Not just a
positive GBS test in past pregnancy***
• There is a question of when to treat using antibiotics.
• Antibiotics can be given to an infant whose mother
carries GBS.
• More than 60% of infants with GBS disease are already
symptomatic at, or shortly after, birth and are at high risk
of GBS complications and poor outcome.
• Effectiveness of oral antibiotics during pregnancy
is not established.
• There is a high rate of re-colonization (67%) by delivery
(even when sexual partners are also treated)
• Penicillin G can be used, at a dose of 5 million Units
every 6 hours. If there is a history of penicillin allergy,
erythromycin 500 mg every 6 hours or clindamycin 900 mg every
8 hours should be given intravenously.
• Ideally, antibiotics should be given at least 4 hours
before delivery to allow enough time for the antibiotics to
build up in the unborn baby’s circulation and amniotic
fluid.
• 1 in 10 chance, or lower, of having a mild allergic
reaction to penicillin (such as rash) [CDC, 2001, sec.7].
• 1 in 10,000 chance of developing a severe, life-threatening
allergic reaction to penicillin [ibid.].
Using Herbs to try to change status of GBS colonization:
• No known effectiveness
• The theory is attempting to change the GBS colonization
late in pregnancy by using herbs.
• GBS test at 35 weeks then if colonized trying the
herbal protocol & re-culturing at 37 weeks.
• If colonized positive in the 3rd trimester, even if
you get a negative test after the first positive test there
is a 67% chance of reoccurrence by birth.
No prevention can prevent all GBS illnesses.
• 1 in 25 women who are GBS positive and have risk factors
have an infected child [ACDM, 1999, par.14].
• 1 in 200 women who are GBS positive but have no risk
factors have an infected child [Midwifery Today, 2001, par.2].
• 1 in 1,000 women who are GBS negative and have risk
factors have an infected child [ACDM, 1999, par.14].
• 3 in 10,000 women who are GBS negative but have no
risk factors have an infected child [ibid.].
• With chlorhexidine or antibiotics given in labor,
a GBS positive woman with no risk factors has a 1 in 4000
chance of delivering a baby with GBS disease [CDC, 2001, sec.7].
• Maternal treatment with chlorhexidine or antibiotics
decreases the incidence of GBS disease when risk factors for
GBS infection are present at delivery. However, it is estimated
that this doesn’t prevent up to 30% of GBS infections
and 10% of the fatalities.
How would I know if my baby was getting sick with
GBS?
• Babies who show signs of a GBS infection after birth
must also be treated with antibiotics.
• 50% of babies with Early Onset GBS disease show signs
at birth like they have to work hard to breathe and might
need resuscitation.
• Many more show signs within the first ½ hour
after birth.
• 90% of Early onset GBS disease babies begin to get
sick within the 1st 24 hours.
• There are other types of infections that can look
similar to GBS disease but they should all be checked out!
• Grunting with inhales and exhales, flaring of the
nostrils, retractions of the ribs (where you can see the spaces
in between, bluing around the mouth and nose. The baby might
breathe very fast or very slow (normal respirations are 40-60
breaths per minute) and If the baby stops breathing for 15-20
seconds it is another warning sign. With early onset might
struggle to keep temperature normal but with late onset might
run a fever. The baby might be grayish, washed out or pale.
A sick baby could be blah and lethargic or more irritable
with jerkiness and seizures. If something doesn’t seem
right with your baby CALL!!
Works Cited:
• ACDM, (1999). Client information and consent for group
b streptococcal infections. <http://www.collegeofmidwives.org/prac_issues01/GBSinfo98a.htm>
(2002, March 23).
• Alkalay, A., (1998). Teaching Files: Group B Streptococcal
Infection in Newborns:Rationale Document for CSMC Clinical
Guidelines 94-092-G through 94-096-G. <http://www.neonatology.org/syllabus/gbs.html>
(2002, March 23).
• Benitz, W.E., Gould, J.B., Druzin, M.L., (1999). Preventing
early-onset group b streptococcal sepsis: strategy development
using decision analysis. Pediatrics, Volume 103, No. 6, Jun
1999. (!!) <http://www.thermo.com/eThermo/CMA/PDFs/Product/productPDF_12061.pdf>
(2002, March 23).
• CDC (Centers for Disease Control and Prevention),
(2001). Group B Streptococcal Disease (GBS). <http://www.cdc.gov/ncidod/dbmd/diseaseinfo/groupbstrep_g.htm>
(2002, March 23).
• Jesse Cause Foundation. Mothers of Babies Killed or
Disabled by Preventable Bacteria Travel to CDC Meeting in
Georgia to Urge Change in Group B Strep Protocol.
• <http://www.groupbstrep.com/prcdc.htm> (2002,
March 23).
• Midwifery Today, (1999). Midwifery Today E-news, Volume
1, Issue 28: Group B Strep. <http://www.midwiferytoday.com/enews/enews1n28.asp>
(2002, March 23).
• Midwifery Today, (2001). Midwifery Today E-news, Volume
3, Issue 37: Group B Streptococcus. <http://www.midwiferytoday.com/enews/enews3n37.asp>
(2002, March 23).
• SOGC, (1997). SOGC Clinical Practice Guidelines: Statement
on the prevention of early-onset group b streptococcal infections
in the newborn. Policy statement No.61, June 1997.
• J Matern Fetal Med 2002 Feb;11(2):84-8 Chlorhexidine
vaginal flushings versus systemic ampicillin in the prevention
of vertical transmission of neonatal group B streptococcus,
at term. Facchinetti F, Piccinini F, Mordini B, Volpe A. Department
of Gynecology, Obstetrics and Pediatric Sciences, University
of Modena and Reggio Emilia, Modena, Italy.
• Int J Antimicrob Agents 1999 Aug;12(3):245-51 Vaginal
disinfection with chlorhexidine during childbirth.
• Stray-Pedersen B, Bergan T, Hafstad A, Normann E, Grogaard
J, Vangdal M. Department of Gynecology and Obstetrics, Aker
Hospital, University of Oslo, Norway.
• Lancet. 1992 Sep 26;340(8822):791; discussion 791-2.
Prevention of excess neonatal morbidity associated with group
B streptococci by vaginal chlorhexidine disinfection during
labour.
• Eur J Obstet Gynecol Reprod Biol 1989 Apr;31(1):47-51
Prevention of group B streptococci transmission during delivery
by vaginal application of chlorhexidine gel.
• Eur J Obstet Gynecol Reprod Biol 1985 Apr;19(4):231-6
Chlorhexidine for prevention of neonatal colonization with
group B streptococci. III. Effect of vaginal washing with
chlorhexidine before rupture of the membranes.
To review the new complete guidelines, click here:
2002 Revised Guidelines for Prevention of Perinatal Group
B Streptococcal Disease
Archive at GentleBirth.org about GBS
Informed Consent for GBS
Group B Strep Association Resource Group
Normal Medical Proticols for Identifying and Treating Clients
with GBS
I. Risk factors for Neonatal Sepsis. Intrapartum chorioamnionitis,
maternal group B streptococcal (GBS) colonization in the rectum
or vagina, prolonged rupture of membranes, and prolonged monitoring
with an internal pressure catheter or fetal scalp lead.
II. Vertical Transmission of GBS. GBS is the number one cause
of neonatal sepsis and meningitis in the United States. Infection
occurs in 2 or 3 neonates per 1000 live births. Maternal colonization
can be transient, and 20% to 25% of pregnant females are carriers
at any given time. In addition to threatening the life of
a neonate, GBS is also an important risk factor for the development
of chorioamnionitis in the mother, thereby increasing morbidity
and the rate of intrapartum complications.
III. The CDC Recommends 2 Options for GBS.
A. Option 1.
1. Culture all women (rectal and vaginal) at 35-37 weeks.
If the patient’s recto-vaginal cultures are positive
for GBS, she should be offered intrapartum antibiotic
prophylaxis.
2. Treatment. Oral antibiotics are ineffective. The following
regimens may be used:
- Penicillin G 5 million units IV and then 2.5 million
units Q4h until delivery. Penicillin G is the preferred
antibiotic because of its narrow spectrum, making it
less likely to select for antibiotic-resistant bacteria.
- Ampicillin 2 g IV followed by 1 g Q4h until delivery.
- For penicillin allergy. Either clindamycin 900 mg
IV Q8h or erythromycin 500 mg IV Q6h may be given until
delivery.
B. Option 2. Screening cultures are not done, but antibiotic
prophylaxis is given if any of the following risk factors
are present:
1. Previously delivered neonate with GBS infection.
2. GBS bacteriuria during the current pregnancy.
3. Labor and delivery occur at less than 37 weeks of gestation
(attack rates for preterm infants are higher).
4. Membranes have been ruptured for >18 hours (12 hours
in some institutions).
5. Intrapartum temperature greater than or equal to 38.0°
C (100.4° F).
6. If PROM occurs at <37 weeks of gestation and the
patient is not yet laboring, GBS cultures should be collected
as above. Either of the following regimens may then be
used:
- Give IV antibiotics until culture results are known,
or
- Initiate antibiotic therapy only when culture result
confirms presence of GBS.
IV. Care of the infant of a mother who has had GBS prophylaxis.
A. Any infant with symptoms or signs of GBS and those infants
born at less than 35 weeks gestation must have a full work-up
(CBC, blood culture, CXR for pulmonary symptoms, LP if indicated).
They should be treated until culture results are negative.
B. For those >35 weeks without symptoms, approach is
stratified based on duration of labor after the administration
of antibiotics.
- If duration of labor after antibiotics is <4 hours,
infant should have CBC, blood culture, and 48 hours of
observation.
- If duration of labor after antibiotics is >4 hours,
observation for 48 hours is indicated.
|
