Group B Strep
What is Group B Strep?
· 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 GBS 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!!
• 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
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.