early onset of neonatal group b streptococcus diseases zharif
TRANSCRIPT
Prevention Early onset of neonatal group B streptococcus diseases
Prepared by:Dr Ahmad Zharif HusseinRSMU
Background Group B streptococcus
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
Clinical Manifestation period “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
Neonatal GBS disease in the UK – age at onset
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.
Photo courtesy of Dr. Carol Baker Baylor College of Medicine, Houston, TX
US guidelines all women colonised with GBS at 35–37 weeks of
gestation should be offered IAP(intrapartum antibiotic prophylaxis
GBS Carrier’s
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
Risk factors for EOGBS infection
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
Antenatal screening
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
How to reduce risk of neonatal GBS
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)
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.
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
• 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)
Intrapartum
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
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
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
antibiotic
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
no evidence that intrapartum vaginal cleansing will reduce the risk of neonatal GBS disease
Summary IAP indicated
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
Summary IAP not indicated: Colonization with GBS during a previous
pregnancy • Unless another indication during the current pregnancy
GBS bacteriuria during a previous pregnancy• Unless another indication during the current pregnancy
Negative vaginal and rectal GBS screening test during the current pregnancy• Regardless of intrapartum risk factors
Cesarean delivery performed before labor onset on a woman with intact amniotic membranes• Regardless of maternal GBS test status
• Regardless of gestational age
Conclusion
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
Management for infants
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.
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
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.
It is not necessary to perform routine surface cultures or blood cultures on well infants
no evidence to discourage breastfeeding
Typical signs of early-onset GBS infection
• 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).
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);
• 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.
The Recommendatio
ns
MMWR, Vol 59(RR-10)
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Quiz 1
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 seenvx no cord no placent
UR mx??
Quiz 2
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?
Quiz 3
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?
Reference
CDC -Overview of CDC Prevention Guidelines, 2010▪ National Center for Immunization and
Respiratory DiseasesDivision of Bacterial Diseases
Green top guideline no 36 Prevention of early neonatal group B
streptococcushttp://www.gbss.org.uk/epetitio
Thank you