Assessment of maternal GBS colonization and early-onset neonatal disease rate for term deliveries: a decade perspective.

Objective To assess the maternal group B streptococcal (GBS) colonization rate and neonatal early-onset GBS (EOGBS) disease in term deliveries, a decade apart. Methods This was a retrospective computerized study between 2005 and 2016. A universal GBS culture-based approach gradually replaced the GBS risk-oriented screening. A vaginal-rectal culture taken at 35-37 weeks was recorded at admission for delivery. Results We identified 149,910 term deliveries during the study period. GBS status was recorded in 53,879 (35.9%) cases. The GBS screening rate constantly increased from 20% in 2005 to 47.5% in 2016. GBS colonization rates significantly decreased, from 50.3% in 2005 to 31.7% in 2016, P<0.001. Overall, EOGBS disease was diagnosed in 37 term neonates (0.25 per 1000 live births.). The rate of EOGBS in neonates decreased dramatically from 0.361 per 1000 deliveries between 2005 and 2009 to 0.19 per 1000 deliveries between 2010 and 2016 (P<0.05). During the latter period, over 35% of the deliveries were screened for GBS. Remarkably, 64.9% of the EOGBS originated in the non-screened population. Conclusion The universal screening policy was associated with a significant decrease in neonatal EOGBS and therefore should be adopted. Further national surveillance studies should be performed in order to validate this approach.

Accuracy of a rapid intrapartum group B Streptococcus test: A new immunochromatographic assay.

OBJECTIVES: To decrease the incidence of early-onset group B streptococcal (GBS) disease, a culture-based screening of all pregnant women at 35-37 weeks is recommended. This gold standard test requires 24-72hours culture. This delay precludes its use for intrapartum screening. This study assesses a new immunoassay, the DIMA test, for identifying GBS-positive patients in the labor ward. MATERIALS AND METHODS: This was a prospective observational study of 195 pregnant women presenting with full-term labor at a single site in France between June and August 2012. We assessed the diagnostic accuracy of intrapartum DIMA testing as compared to intrapartum GBS culture and prenatal screening at 35-38 weeks. RESULTS: The DIMA test sensitivity and specificity were 57.1% and 83.2%, respectively, as compared to 42.9% and 97% for prenatal culture screening. CONCLUSION: The DIMA test assay is a rapid and inexpensive test for the detection of maternal GBS colonization in the labor ward. Its sensitivity is higher than antepartum culture but its specificity is lower. Its performance was inferior to that reported for rapid polymerase chain reaction assays.

An area-based study on intrapartum antibiotic prophylaxis for preventing group B streptococcus early-onset disease: advances and limitations.

INTRODUCTION: The prevalence of maternal group-B-streptococcus (GBS) colonization and risk factors (RFs) for neonatal early-onset disease (EOD) in Europe are poorly defined. Large-scale information concerning adherence to recommendations for preventing GBS-EOD are lacking. MATERIALS AND METHODS: This was a 3-month retrospective area-based study including all regional deliveries ≥35 weeks' gestation (in 2012). The sensitivity, specificity, positive and negative predictive values, odds ratio and receiver operating characteristic (ROC) curve for intrapartum antibiotic prophylaxis (IAP) among full-term and preterm deliveries and prolonged membrane rupture (PROM) were calculated. RESULTS: Among 7133 women, 259 (3.6%) were preterm (35-36 weeks' gestation). Full-term women were 6874, and 876 (12.7%) had at least 1 RF. Most women (6495) had prenatal screening and 21.4% (1390) were GBS positive. IAP was given to 2369 (33.2%) women (preterm, n = 166; full term, n = 2203). Compared to full-term, preterm women were less likely to receive IAP when indicated (73.2% versus 90.3%, p < 0.01). Full-term women represented the largest area under the curve (AUC, 0.87). PROM showed the highest sensitivity (98.6%), but the lowest specificity (6.9%) and AUC (0.53). CONCLUSIONS: Large-scale prenatal screening and IAP are feasible. Women delivering preterm are less likely to receive IAP when indicated. Most unnecessary antibiotics are given in cases of PROM.

The ongoing quandary of defining the standard of care for neonates.

UNLABELLED: Despite extensive use of the term 'standard of care' (SOC), there is no such medical definition. How are neonatal therapies accepted as SOC with huge centre-to-centre variation? What defines SOC? We will consider paths to acceptance of multiple therapies (antenatal corticosteroids, preventing GBS, others). We conclude single-centre trials drive care, but are not consistently predictive for multicentre trials. Innovation/quality improvement initiatives also alter care, despite strong evidence practice changes take time. Furthermore, there are powerful medico-legal implications if a therapy is designated SOC. CONCLUSION: Defining SOC is a quandary with more legal implications than medical, but what's most critical is keeping current in a rapidly changing field.

Effectiveness of a prematurity-based protocol for management of infants born to mothers with Group B Streptococcus colonisation.

The aim of this study was to validate the efficacy of a protocol for the management of infants born to colonised mothers with Group B Streptococcus (GBS). We studied a cohort of newborns admitted at the A. Gemelli University Hospital between May 2006 and December 2009. A total of 1,108 were newborns of mothers with GBS; 178 were children of mothers with unknown GBS status. Newborns were managed according to the care protocol in use at our division. Infected infants were born to mothers who underwent inadequate intrapartum antibiotic prophylaxis (IAP). No mother with complete IAP had an infected newborn. The incidence of invasive GBS infection in newborns of mothers with GBS was 0.4% and in newborns of mothers with unknown GBS status was 2.2%. Only 17.4% of newborns of mothers with GBS had risk factors. The complete IAP should always be performed regardless of the presence or the absence of risk factors. The care protocol applied offers successful management of the newborns of mothers with GBS, based on the correct execution of IAP, considering as a primary risk factor, the gestational age of < 35 weeks.

Which is the optimal algorithm for the prevention of neonatal early-onset group B streptococcus sepsis?

The incidence of neonatal early-onset group B streptococcus (GBS EOS) sepsis has declined during the last decade since the implementation of intrapartum antibiotic prophylaxis endorsed by Centers for Disease Control and Prevention (CDC) guidelines. All the CDC guidelines versions provide recommendations for neonatal management. The neonatal algorithm of CDC has not been universally accepted and hence different algorithms have been suggested. Since all approaches to disease prevention are still imperfect, an optimal algorithm for GBS EOS prevention is still lacking; the development of improved diagnostic methods of distinguishing at-risk infants may contribute to improve the clinician's approach.

[Streptococcus agalactiae late-onset neonatal infections in Barcelona (1996-2010)]. / La infección neonatal tardía por Streptococcus agalactiae en el área de Barcelona (1996-2010).

OBJETIVE: To study the characteristics and evolution of group B Streptococcus (GBS) late-onset diseases, over a period of 15years in 8hospitals the Barcelona area and analyze the possible impact of prophylactic measures for the prevention of early-onset neonatal infections. METHODS: Retrospective review of all patients diagnosed with late-onset neonatal disease due to GBS from 1996 to 2010. RESULTS: A total of 143 patients were diagnosed. Of these, 51 were born in others hospitals. The overalll incidence was 0.42 per 1000 live births, varying between 0.14‰ in the year 2000 and 0.80‰ in 2009. A slight but sustained tendency of increased risk was observed over the years, 6.9% in the overall disease (with no statistical significance). Sepsis/bacteremia was detected in 63.6% of the newborns, meningitis in 32.8%, and arthritis/osteomyelitis in 3.5%. In cases with known obstetrics dates, 53% of mothers had been colonized by GBS during pregnancy, 53.8% received intrapartum antibiotic prophylaxis, and 41.2% had some obstetric risk factors, particularly premature birth in 35.9%. There was a 2.8% mortality rate in the neonates, and predominant serotypes were III and Ia. CONCLUSIONS: The incidence of GBS late-onset disease has not decreased despite the control practices of early-onset disease, and possibility of this appearing must be taken into account.

[Epididymo-orchitis in a newborn: rare illness revealing late-onset Streptococcus agalactiae meningitis]. / Orchi-épididymite néonatale : une affection rare révélatrice d'un sepsis secondaire à streptocoque du groupe B.

Acute scrotum is unusual during the neonatal period. Testicular torsion is a surgical emergency aimed at salvaging the affected testis. Epididymo-orchitis is the main differential diagnosis, but few cases have been described in the newborn. Here, we report the case of a late-preterm infant who presented with late-onset group B streptococcal sepsis revealed by unilateral epididymo-orchitis.

[Acute osteomyelitis of the clavicle in the newborn infant: a case report]. / L'ostéomyélite aiguë de la clavicule chez le nouveau-né : à propos d'un cas.

Acute osteomyelitis of the clavicle accounts for less than 3% of osteomyelitis cases, with its usual location in the middle third. It may be hematogenous, due to contiguity, or secondary to catheterization of the subclavian vein or neck surgery. The diagnosis is often delayed, and clinical symptoms may simulate obstetric brachial plexus palsy in young children. We report a new case of osteomyelitis of the clavicle in a 30-day-old newborn.

Effectiveness of intrapartum antibiotic prophylaxis for prevention of early-onset group B streptococcal disease.

OBJECTIVE: To estimate the effectiveness against early-onset group B streptococcal (GBS) disease of intrapartum antibiotic prophylaxis among term and preterm deliveries, deliveries with fewer than 4 hours of antibiotics, and deliveries receiving clindamycin regimens. METHODS: We performed a secondary analysis of the Birthnet cohort, a survey of 7,691 births to residents of the Active Bacterial Core surveillance system from 2003 to 2004. We used propensity score matching on covariates associated with prophylaxis and early-onset GBS disease to evaluate the effectiveness (1-risk ratio) of specific intrapartum antibiotic prophylaxis regimens against the disease end point. RESULTS: The effectiveness of 4 or more hours of prophylaxis with penicillin or ampicillin was high among term (91%, 95% confidence interval [CI] +63% to +98%) and preterm (86%, 95% CI +38% to +97%) neonates. Effectiveness was significantly lower for clindamycin (22%, 95% CI -53% to +60%). The effectiveness of 2 or fewer to fewer than 4 hours of prophylaxis with penicillin or ampicillin before delivery (47%, 95% CI -16% to +76%) and the effectiveness of prophylaxis with penicillin or ampicillin fewer than 2 hours before delivery (38%, 95% CI -17% to +67%) were both lower than the effectiveness of prophylaxis durations at 4 or more hours. CONCLUSION: Beta-lactam prophylaxis given 4 or more hours before delivery is highly effective for prevention of early-onset GBS disease. Prophylaxis of shorter durations or with clindamycin is less effective, reinforcing the need for health care providers to adhere to prevention recommendations, particularly for preterm deliveries, penicillin-allergic women, and neonates exposed to fewer than 4 hours of prophylaxis.

Institutional prevention policies and rates of Group B Streptococcus infection among HIV-infected pregnant women and their infants in Latin America.

OBJECTIVE: To describe Group B Streptococcus (GBS) prevention policies at 12 Latin American sites participating in the NICHD (Eunice Kennedy Shriver National Institute of Child Health and Human Development) International Site Development Initiative (NISDI) Longitudinal Study in Latin American Countries (LILAC) and to determine rates of rectovaginal colonization and GBS-related disease among HIV-infected pregnant women and their infants. METHODS: Site surveys were used to assess prevention policies and practices administered cross-sectionally during 2010. Data collected in NISDI from 2008 to 2010 regarding HIV-infected pregnant women were used to determine rates of colonization and GBS-related disease. RESULTS: Of the 9 sites with a GBS prevention policy, 7 performed routine rectovaginal screening for GBS. Of the 401 women included in the NISDI study, 56.9% were at sites that screened. The GBS colonization rate was 8.3% (19/228 women; 95% confidence interval [CI], 5.1%-12.7%). Disease related to GBS occurred in 0.5% of the participants (2/401 women; 95% CI, 0.1%-1.8%); however, no GBS-related disease was reported among the 398 infants (95% CI, 0.0%-0.9%). CONCLUSION: Improved efforts to implement prevention policies and continued surveillance for GBS are needed to understand the impact of GBS among HIV-infected pregnant women and their infants in Latin America.

How useful is routine amniotic fluid and neonatal surface swab microbiology at Caesarean section?

BACKGROUND: Our aim was to evaluate the clinical impact of routine amniotic fluid and neonatal surface swab microbiology at Caesarean section. MATERIALS AND METHODS: Microbiology data from 1 537 neonates delivered by Caesarean section were analysed in the light of clinical outcome. RESULTS: 1 340 (87%) neonates had non-pathogenic bacteria or negative culture results from both amniotic fluid and surface swab samples. Of the 197 (13%) neonates with pathogenic bacteria, 22 (1.4%) were diagnosed with infection, but only in 6 (0.4%) were the bacteria presumed to be responsible for the infection. Amniotic fluid and surface swab culture had sensitivities of 54% and 35%, and positive predictive values of 14% and 17%, respectively, for detecting a neonate at risk of infection. CONCLUSION: Amniotic fluid and neonatal surface swab microbiology at Caesarean section contributes little if anything to postnatal management and can be safely dropped from operative routine.

Efficacy of intrapartum chemoprophylaxis less than 4 hours duration.

OBJECTIVE: Current guidelines for prevention of group B streptococcus (GBS) early-onset infection recommend to administer antibiotic during labor at least 4 h prior to delivery (adequate prophylaxis). We aimed to determine if neonatal GBS colonization may be significantly decreased in case of inadequate (<4 h) duration of ampicillin prophylaxis. METHODS: In prospective, cohort study, 167 infants born to 167 GBS culture-positive mothers without additional risk factors were enrolled. Cultures were collected both, at 10-24 h after birth (admission) and at discharge. RESULTS: Among 137 infants born to mothers who received inadequate prophylaxis, 5 (3.6%, C.I. = 0.5-6.8) were colonized (≥1 sites) at admission, at discharge, or both, at admission and discharge. Eighty-two women received prophylaxis <2 h before delivery and two infants (2.4%) were colonized at discharge. Eighteen (60.0%, C.I. = 42.5-77.5) of 30 infants who were not exposed to prophylaxis were colonized at admission or both, at admission and discharge. Colonization was significantly more frequent among infants born to untreated mothers with respect to infants born to women who received inadequate prophylaxis (either <2 or <4 h). CONCLUSIONS: In this selected group, inadequate prophylaxis significantly interrupted vertical colonization. This effect was evident even if prophylaxis started <2 h before delivery.

Group B streptococcal disease in infants: progress in prevention and continued challenges.

The burden of early-onset disease caused by group B Streptococcus (GBS) has decreased dramatically in the United States over the past 20 years. Universal culture-based screening at 35 to 37 weeks gestational age and use of intrapartum antibiotic prophylaxis are the cornerstones of prevention measures that have led to this decline. GBS, however, remains the leading cause of early-onset neonatal sepsis in the United States. Revised guidelines for prevention of perinatal GBS are planned for issuance in 2010. This article discusses implementation challenges for clinicians caring for pregnant women and newborns and presents an updated algorithm for neonatal management.

Spontaneous tachysystole as sign of serious perinatal conditions.

We present three cases of spontaneous tachysystole, related to severe myometrium infection and to atypical partial placental abruption. Tachysystole was, in all three cases, associated with repetitive and frequent late decelerations, displaying a pseudo-sinusoidal fetal heart rate (FHR) pattern. Tachysystole, with a pseudo-sinusoidal FHR pattern, may be a sign of a critical perinatal condition and recognition may be of vital importance.

[Evaluation of 6 years of group B streptococcus (GBS) screening in near-term pregnant women]. / Bilan bactériologique de six ans de dépistage du streptocoque de groupe B (SGB) au cours du dernier trimestre de la grossesse.

Streptococcus agalactiae (GBS) is a significant cause of morbidity and mortality among newborns. Colonization frequently occurs in pregnant women, nearly all international recommendations suggest that all pregnant women must be screened for vaginal colonization at 34 to 37 weeks of gestation. The microbiological diagnostic modalities used to combat GBS had to be accurate and in short time frame. We reported a 6 years experience of GBS screening, comparing results of culture swab of prenatal vaginal specimens and newborns colonization or infection. The carriage rate of 13 to 14% of GBS in newborn was unchanged during all the study period.

Perinatal infections and fetal/neonatal brain injury.

PURPOSE OF REVIEW: Fetal and newborn brain injury causes lifelong morbidity for the survivors, with high emotional costs to the individual and the family plus a heavy economic burden for society. This is timely and relevant. Techniques are now available to prevent, detect, and treat those central nervous injuries that result from infection. If instituted, these would have beneficial results for both newborn survival and morbidity. RECENT FINDINGS: The new developments and prevention of adverse impacts of maternal infections due to Rubella, Group B Streptococcus, cytomegalovirus, toxoplasmosis, and chorioamnionitis are discussed. SUMMARY: Rubella immunization has been a success in the USA with virtual elimination of wild virus infection. Broader screening policies need to be instituted to lower the morbidities associated with cytomegalovirus and toxoplasmosis. Alternatives to maternal antibiotic prophylaxis in newborn Group B Streptococcus infection need to be evaluated and implemented when proven effective. The most beneficial treatment protocol for chorioamnionitis needs to be determined by prospective study and then instituted. To date, the combination of maternal antibiotics and steroids appears most promising.

Perinatal infection with Group B streptococci.

Group B streptococcus (GBS) is a major cause of severe bacterial infection in newborns. Early neonatal GBS infection can be prevented by identifying high-risk pregnancies and administering intrapartum antibiotics. In the USA, a screening strategy has been introduced resulting in a reduction in early-onset GBS infection, but no decrease in late-onset neonatal GBS disease has been noted. In many European countries, a risk-based strategy is recommended. Vaccination may, in the future, be an alternative in preventing GBS infection in newborns.