GBS in Saudi Arabia

Nawaf Al-Dajani, 2008

Discolsure

• History• Introduction • Milestone of the guidelines• GBS carriage during pregnancy in

KSA• Current practice• Future plans• Conclusions

History

• 1930s, GBS ass’ mastitis in Cows.

• 1935, Lancefield isolated GBS from adult female patients.

• 1970’s GBS emerged as major pathogen in neonates

Postnatal Sepsis: Change in Etiology in North America

1900 1950 2000

GASGBSE. coli

GBS proph

revised GBS proph

Introduction

GBS Maternal ColonizationGBS Maternal Colonization

• GBS Carriers10% - 30% of women

higher in African Americans and nonsmokers

clinical signs not predictivedynamic condition

• Risk factor for early-onset disease: GBS colonization at deliveryprenatal cultures late in pregnancy can

predict delivery status

Additional Risk Factors for Additional Risk Factors for Early-Onset GBS DiseaseEarly-Onset GBS Disease

• Obstetric: prolonged rupture of membranes, preterm delivery, intrapartum fever

• GBS bacteriuria• Previous infant with GBS disease• Demographic (African American race,

young age)• Immunologic (low antibody to GBS

capsular polysaccharide)

Mother to Infant Mother to Infant TransmissionTransmission

GBS colonized mother

Non-colonized newborn

Colonized newborn

Asymptomatic Early-onset sepsis, pneumonia, meningitis

50% 50%

98% 2%

GBS Disease in Infants GBS Disease in Infants Before Prevention EffortsBefore Prevention Efforts

0102030405060708090

< 1wk

1-3wk

1 2 3 4 5 6 7 8 9 10 11

Age (months)

Percent of cases

A Schuchat. Clin Micro Rev 1998;11:497-513.

Early-Onset Early-Onset Neonatal GBS Neonatal GBS Disease Before Prevention Disease Before Prevention EffortsEfforts

0102030405060708090

0 1 2 3 4 5 6

Age (days)

Percent of cases

A Schuchat. Clin Micro Rev 1998;11:497-513.

Milestone of the guidelines

0

0.5

1

1.5

2

2.5

1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000

Year

Cases per 1000 live births

Early-onset Late-onset

Rate of Early- and Late-onset GBS Rate of Early- and Late-onset GBS Disease in the 1990s, U.S.Disease in the 1990s, U.S.

Consensus guidelines

1st ACOG & AAP statements

Group B Strep Association formed CDC draft

guidelines published

Schrag, New Engl J Med 2000 342: 15-20

Rates of Early-Onset GBS Disease by Rates of Early-Onset GBS Disease by Prenatal Colonization & Risk FactorsPrenatal Colonization & Risk Factors

40.8

5.10.9 0.3

0

5

10

15

20

25

30

35

40

45

Col+,RF+ Col+,RF- Col-,RF+ Col-,RF-

Cases per

1000

live births

Col: prenatal vag/rect cultureRF: risk factors (gest. <37 wks, ROM >12 hr, fever > 37.5 C)

Boyer & Gotoff, Antibiot Chemother 1985.

0

0.2

0.4

0.6

0.8

1

Hospitals w/ newpolicy

Hospitals w/outpolicies

Cases per 1000 births

1996 1997

Change in incidence of early-onset GBS disease in hospitals w/ and w/out new policies

Factor, Obstet Gynecol 2000;95:377-82

GBS partners meeting to re-evaluate the GBS partners meeting to re-evaluate the 1996 guidelines, November 1-2, 20011996 guidelines, November 1-2, 2001

• Recommendation: Universal prenatal screening at 35-37 wks’ gestation

• Risk based strategy reserved for women with unknown GBS culture status at the time of labor

MMWR, VOLUME 51 (RR-11), 2002

Schrag et al, NEJM 2002, 347:233-9

Screening !!

• Boyer et al, 1986• RCT of selective IPC, < 37 wk,

PPROM > 12hrs, 83 (85) received Abx vs 77(79)

• NC vs EOD.• NC 8/85 vs 40/79 p < 0.001• EOD 0/85 vs 4/79 p 0.052

Screening !!

• Matorras et el, 1991• RCT, 121 pt. 57 received ampicillin, 64 placebo. EOD 0/60 vs 3/65, p= 0.137.• In Summary:• Relative risk reduction 0.21, CI 0.04-1.17• No statistically significant.

• Gilson et al, 2003, J Perinatol,• Case control study• 420 vs 470• 0/420 vs 4/470, p 0.04

GBS carriage rate in KSA

• Uduman et al, 1985, J Gynaecol Obstet. 1985 Feb ;23 (1):21-4 260 pt in labour, 24 had +ve GBS, 9.2% 3 neonate screened +ve, 12.5%

• Aguis et al, 1987 3% colonised @ term

• Al-Suleiman et al, 1991. 1939 pt. screened in 3rd trimester. 17.2% were colonized with GBS

• El-Kersh et al, 2002, Saudi medical journal. 217 pt. screened 27.6 % colonised

Current Practice

• Majority of regional hospital are not following the recommendation for screening.

• Few hospital have a policy for screening.

• Obstetricians vary among them self.• Hospitals following screening

approach doing various other approaches.

Northwestern territories:3 hospitals, no screening, one

trying!!Western territories:8 hospitals, one screening, one ++.Southwestern territories:2 hospitals, one have a policy.Middle:One +/-, one +, two ++

Why there is disparity and diversity?

Lack of adequate time!!Lack of administrative

support.Limited resources.Unbooked mothers.Different opinions.

What is the incidence of GBS ENOSAlMuneef et al,29601 live birth, 1990-199423 had GBS spsis0.8/ 1000 >>>> 0.64/1000

Others

Many neonatologists feel it is a rare.

During survey:A- no confirmed case per 7000 B- no confirmed case per > 5000C- one case per 6000 (unbooked)D- no case last few yr, 1300/ yrE- one case in 34 wk, 5000

Why it is rare?

Underdetection. Intrapartum antimicrobial

exposure. Different serotypes. Different scale of colonization. False believe?

Future plan!!

Depends on:Incidence of GBS EONS.Patients characteristics.? Colonization rate.Available resources.

Accurate incidence of EONS due to GBS is unknown in Saudi Arabia.

Mohle-Boetani et al, JAMA,1993: Risk-based approach is not cost

effective unless incidence is > 0.6/1000

Screening not cost effective unless it is 1.2/1000

Strickland et al, 1990, Colonization rate has to be > 10%

Allardice et al, 1982, 16 women NNT to prevent on EONS

Garland et al, 1991, 2059 colonized women NNT to

prevent one case of EONS.

Conclusions Screening approach is probably is

better than risk based approach based on cohort study, level II evidence (fair).

Probably is not cost effective if the neonatal infection is rare or uncommon.

The incidence of EONS due to GBS is probably rare or low in Saudi Arabia.

Hospital with adequate resources may follow the guidelines for booked pt.

Hospital with limited resources may follow the risk based approach.

Self collection is an option for busy clinics.

Rapid testing can be useful for unbooked mothers

Vaccines