A nationwide survey of the opinions of paediatricians regarding the management of neonates born to women with group B Streptococcus in Japanese maternity homes.

OBJECTIVE: The Japanese Midwifery Association (JMA) guidelines allow midwives to manage group B Streptococcus (GBS)-positive women during pregnancy and labour at maternity homes. However, no guidelines exist to manage neonates born to GBS-positive women in Japan. We aimed to investigate the opinions of paediatricians regarding optimal management strategies for neonates born to GBS-positive women in maternity homes. A questionnaire was sent to paediatricians at 396 Japanese perinatal medical centres. We examined opinions regarding examinations and routine clinical tests for neonates born to GBS-positive women in maternity homes. RESULTS: Of 235 paediatricians, only 11.2% considered that paediatric examinations were unnecessary for neonates born to GBS-positive women in maternity homes. Moreover, 20.5%, 13.2%, and 11.1% of paediatricians considered culture test of the nasal cavity, serum C-reactive protein level analysis, and blood cell count analysis, respectively, necessary for neonates born to GBS-positive pregnant women with intrapartum antibiotic prophylaxis (IAP), whereas 36.3%, 56.2%, and 40.6% of paediatricians considered these tests necessary in cases without IAP. The JMA guidelines had low penetration rates among paediatricians in Japan. To manage neonates born to GBS-positive women in maternity homes, midwives should engage with commissioned paediatricians in more detail and develop appropriate strategies to increase awareness and cooperation.

Management of Contacts of Patients With Severe Invasive Group A Streptococcal Infection.

BACKGROUND: Conflicting recommendations regarding antibiotic prophylaxis for contacts of patients with invasive group A streptococcal (GAS) infection exist. Close contacts of patients with such severe and rapidly progressive disease often strongly appeal to the treating clinicians for antimicrobial treatment to prevent additional cases. We aimed to use an approach based on pharyngeal culture testing of contacts and targeted antibiotic prophylaxis. METHODS: A large throat swab survey including 105 contacts was undertaken after a fulminant and fatal case of GAS necrotizing fasciitis. GAS strains were characterized by emm typing and antimicrobial susceptibility to 7 antibiotics. The presence of 30 virulence determinants was determined by polymerase chain reaction and sequencing. RESULTS: The GAS isolate recovered from the index patient was an M1T1 GAS clone susceptible to all antimicrobial agents tested. The same clone was present in the throat of 36% of close contacts who had exposure to the index patient (family households and classroom contacts) for >24 hours/week, whereas the strain was present in only 2% of the other contacts. CONCLUSIONS: Although the study does not allow firm conclusions to be drawn as to whether antibiotic prophylaxis is effective, we describe a practical approach, including an educational campaign and targeted antibiotic treatment to close contacts who have been exposed to an index patient for > 24 hours/week before the initial disease onset.

Aortic graft infection and mycotic aneurysm with Streptococcus equi zooepidemicus: two cases with favorable outcome of antibiotic treatment.

Infections with Streptococcus equi zooepidemicus are rare and are associated with contact with animals or animal products. There are very few reports about infected vascular grafts or aneurysms with this etiology. We present two patients. The first is a 77-year-old man with an infected bifurcated graft four years after an open operation for an abdominal aortic aneurysm (AAA). The second is a 72-year-old man with a symptomatic mycotic AAA, treated with endovascular aneurysm repair. Both received prolonged treatment with bactericidal antibiotics and responded well. Follow-up time at present is 5.5 years for the first, and 4.5 years for the second, patient.

Choice of antibiotic for group B streptococcus in women in labour based on antibiotic sensitivity testing.

OBJECTIVE: To determine whether pregnant women testing positive for Group B Streptococcus (GBS) are receiving appropriate antibiotic prophylaxis in labour based on sensitivity testing. METHODS: We performed a retrospective chart review of all women who delivered at our institution from January 1 to December 31, 2008. We identified all GBS-positive women, and then abstracted data regarding demographic characteristics, method of GBS detection (recto-vaginal or urine culture), prevalence, and antibiotic use. The main outcome measure was the proportion of GBS-positive women who were managed appropriately. RESULTS: During the study period 628 (22%) of 2878 women were identified as having GBS-positive cultures. Sensitivity testing was available for 481 of the recto-vaginal cultures. All were sensitive to penicillin. The rates of resistance for recto-vaginal culture were 22% for erythromycin, 19% for clindamycin, and 18% for both. Four hundred eighty-one women (93%) were treated with penicillin, 30 (6%) with clindamycin, three with cefazolin, and two with vancomycin. One hundred nine women (17%) who were GBS-positive did not receive antibiotics. Forty-four women (9%) did not receive appropriate antibiotic prophylaxis based on sensitivity testing. CONCLUSION: Most GBS-positive women at our institution received an appropriate antibiotic during labour based on sensitivity testing. Our population reflects the Canadian GBS-positivity rate, which is similar to those observed in published studies from other populations. Future work should focus on developing strategies that re-emphasize GBS testing and treatment guidelines for prenatal care providers and on systems to ensure GBS-positive women are given the appropriate antibiotics during labour.

Homologous whole bacterin vaccination is not able to reduce Streptococcus suis serotype 9 strain 7997 transmission among pigs or colonization.

Streptococcus suis (S. suis) is an important porcine pathogen worldwide, and antibiotics are often applied to treat or prevent clinical signs. Vaccination could be an alternative measure to reduce the abundant use of antimicrobials. The aim of this study was to determine the effect of vaccination with homologues whole bacterin vaccine containing S. suis serotype 9 strain 7997 on transmission of this serotype among pigs and on mucosal colonization. Caesarean derived, colostrum deprived pigs (N=50) were housed pair wise. Thirteen pairs were vaccinated intramuscularly with 2-3×10(9) colony forming units (CFU) inactivated S. suis serotype 9 per dose and α-tocopherolactetaat as adjuvant at 3 and 5 weeks of age; twelve pairs served as non-vaccinated controls. At 7 weeks of age, one pig of each pair was intranasally inoculated with 1-2×10(9)CFU of the homologues strain, whereas the other pig of each pair was contact-exposed. Tonsil brushings and saliva swabs were collected for 4 weeks, and tested for the presence of S. suis by bacteriological culture. No differences in number of S. suis in the tonsils or saliva samples or in clinical signs were observed between vaccinated and control pigs. In all pairs, transmission between inoculated and contact exposed pigs occurred, and no difference was observed in rate at which this occurred. The estimated transmission rate parameter ß between vaccinated pigs was ß(v)=5.27/day, and for non-vaccinated pigs ß(nv)=2.77/day (P=0.18). It was concluded that vaccination against S. suis serotype 9 did not reduce transmission, nor colonization and that there were no indications that protection against clinical signs was induced.

Survival and biofilm formation by Group B streptococci in simulated vaginal fluid at different pHs.

The Group B Streptococcus (GBS, Streptococcus agalactiae) is an important cause of neonatal and maternal infection. GBS is a commensal organism of the lower gastrointestinal and vaginal tract. A frequent mode of neonatal infection is vertical transmission from pregnant women to their foetus or neonate. The aim of this study was to evaluate the survival and biofilm production of 10 GBS strains in simulated vaginal fluid at pH 4.2, 5.5 and 6.5. GBS survived longer at higher pH than at normal vaginal pH. At pH 4.2, with the exception of two isolates that were recovered up to 48 and 72 h, viable GBS numbers declined below the limit of detection by 24 h. At higher pH, GBS survived between 3 and 15 days. All isolates investigated were biofilm producers but biofilm production was greater in tryptone soy broth compared to simulated vaginal fluid. The quantity of biofilm produced increased with the rise in the pH. This study suggests that high vaginal pH may influence both GBS survival and biofilm production and thus could be a risk factor for GBS infection.

Interpretation of 2002 Centers for Disease Control guidelines for group B streptococcus and evolving provider practice patterns.

We investigated if clinicians were altering their care of group B streptococcus (GBS)-positive women in labor to achieve 4 hours of intrapartum antibiotic prophylaxis based on their interpretation of the 2002 Centers for Disease Control (CDC) guidelines on prevention of perinatal GBS disease. We surveyed all clinicians with privileges on the labor floor at our institution about their interpretation and clinical application of the 2002 CDC guidelines. Seventy of 96 eligible clinicians (72.9%) completed our survey. In our survey, only 22.9% of clinicians reported not altering their management of labor in GBS-positive pregnancies that achieved less than 4 hours of prophylaxis. These alterations included "laboring down" or delaying pushing; turning off or decrease an oxytocin infusion; or delaying or avoiding artificial rupture of membranes. Clinicians are altering their management of labor to attempt to achieve 4 hours of intrapartum prophylaxis. The 2002 CDC guidelines do not specifically recommend prolonging labor and are being interpreted differently in the clinical setting than the authors may have intended. The effects and consequences of this interpretation are unknown.

The strange destiny of Caterina de' Medici and a case of puerperal fever in the sixteenth century.

The aim of this study is the reconstruction of a case of puerperal fever, which affected the mother of Caterina de' Medici, the future Queen of France, in 1519. Only unpublished data found in the Archives were used, to follow the onset and the development of the disease, offering a glimpse into medical perception of the time. The description of the case provides interesting points of contact with modern medicine.

Inappropriate use of vancomycin for preventing perinatal group B streptococcal (GBS) disease in laboring patients.

OBJECTIVE: The 2002 CDC guidelines for the prevention of perinatal group B streptococcus (GBS) stipulate that vancomycin is reserved for penicillin-allergic women at high risk for beta-lactam anaphylaxis with resistance to clindamycin or erythromycin. Our objective was to evaluate practitioner adherence to these guidelines. METHODS: This is a retrospective chart review of patients admitted to labor and delivery who received vancomycin for GBS prophylaxis from January 1st, 2005 to June 1st, 2007. Identification and documentation of allergic reactions to beta lactams and performance of GBS sensitivities at the time of screening were recorded. RESULTS: Eighty-seven patients reporting a penicillin allergy received vancomycin during labor. In 71 patients screened at 35-37 weeks, sensitivities were not performed for 55 patients, of which 10 reported an anaphylactic-like reaction to penicillin. Of 15 patients who had sensitivities performed at the time of screening and were resistant to clindamycin and/or erythromycin, only two patients, however, described an anaphylactic-like reaction to penicillin. Fourteen patients received vancomycin due to an unknown GBS status at <35 weeks of gestation and only three patients from this group reported an anaphylactic-like reaction to penicillin. There were deviations from the CDC protocol in 82 (94%) of 87 patients who received intrapartum vancomycin there were deviations in the CDC protocol. CONCLUSION: Most patients receiving intrapartum vancomycin for perinatal GBS prophylaxis either did not have a culture with sensitivities performed at the time of GBS screening due to a history of anaphylactic-like reactions to penicillin or received vancomycin for a mild or unknown allergy. Physician adherence to the CDC guidelines with regards to the use of vancomycin is far from optimal.

[A midwife involved in patients with puerperal fever in three different hospitals]. / Een verloskundige betrokken bij patiënten met kraamvrouwenkoorts in drie verschillende ziekenhuizen.

In three hospitals three women aged 34, 33 and 25 years respectively, developed fever following delivery; in two of them a beta-haemolytic streptococcus of Lancefield group A (GAS) was cultured. Between the time of transmission of the infective agent of the first and the third patients there was a period of ten days. Because the intervals between the emergence of cases were relatively long, the suspicion of a common vector, i.e. the midwife, was raised only after some time. The midwife who had been present at all three deliveries turned out to be negative for GAS carriership on three occasions. However, cultures taken from her son and partner were positive for GAS carriership. A number of typing systems were unable to distinguish the GAS-isolates from the first two patients and from the son. After the midwife and her family members had been treated, no new cases occurred. This case illustrates the importance of keeping midwives as well as the department of public health informed of a rise in the number of cases of puerperal fever, whether the cases involve more than one hospital or not, in order to prevent a potential epidemic. Only then can a common source be looked for and the epidemic contained.

Primera visita del bebé al consultorio odontológico / First visit of the baby to the dental office

Se sostiene que la primera visita del niño debe ser durante el embarazo de su mamá, éste debe recibir la primera revisación de su boca con la aparición del primer diente, si se retrasara, no debe pasar de los 12 meses de vida para hacerlo. La atención desde temprana edad constituye una forma raacional de prevención primaria, porque permite adelantarse a la historia de enfermedad bucal del niño. Se presenta una sistematización de actividades a realizar en esta primera visita, tanto en el embarazo como en el niño. Se discute la necesidad de evaluar el riesgo cariogénico de los padres utilizando modelo propio y se presenta un modelos para niños en su primera infancia basado en recomendaciones internacionales y en experiencias del equipo

Primera visita del bebé al consultorio odontológico / First visit of the baby to the dental office

Se sostiene que la primera visita del niño debe ser durante el embarazo de su mamá, éste debe recibir la primera revisación de su boca con la aparición del primer diente, si se retrasara, no debe pasar de los 12 meses de vida para hacerlo. La atención desde temprana edad constituye una forma raacional de prevención primaria, porque permite adelantarse a la historia de enfermedad bucal del niño. Se presenta una sistematización de actividades a realizar en esta primera visita, tanto en el embarazo como en el niño. Se discute la necesidad de evaluar el riesgo cariogénico de los padres utilizando modelo propio y se presenta un modelos para niños en su primera infancia basado en recomendaciones internacionales y en experiencias del equipo (AU)

Group B strep: prevention is better than cure.

We believe that the key issue for prevention of EOGBS infection is knowledge-if a pregnant woman knows she carries GBS, or has other risk factors present that increase the risk of her baby developing EOGBS infection, she can be offered IAP to protect her baby from this potentially devastating condition. Of course, women don't have to accept the recommended intravenous antibiotics in labour (or an ECM test, either privately or if available on the NHS) if they choose not to. But surely they should have access to good-quality information so they can make an informed choice about what is right for them and for their unborn baby? And midwives are in the perfect position to ensure that pregnant women have such information, resulting in appropriate treatment, which will minimise the number of babies suffering needlessly from EOGBS infection.

Awareness, knowledge and attitudes of lead maternity carers towards early-onset neonatal group B streptococcal disease.

AIM: To determine awareness, knowledge and attitudes of lead maternity carers (LMCs) towards early-onset neonatal group B streptococcus (GBS) infection and its prevention. METHODS: An anonymous, self-administered questionnaire was sent to the 155 practising LMCs in Wellington and Hutt Valley. RESULTS: Completed questionnaires were returned by 84 (54%) LMCs (59 midwives). 66 (79%) believed perinatal GBS infections were important, 70 (85%) supported antenatal screening, while 68 (81%) were confident of determining risk factors for GBS infection and counselling women. However, less than one-third nominated major risk factors, none identified all five high-risk criteria and only 22 (26%) regularly discussed GBS with clients. When asked to name high-risk criteria, midwives were more likely than doctors to disclose they had incomplete knowledge or not to answer this item (53% vs 20%; p < 0.006). Of the 48 (57%) LMCs routinely employing GBS prevention strategies, 34 (71%) used culture-based screening, relying mainly upon high-vaginal swabs from the first-trimester. CONCLUSIONS: Despite widespread awareness of perinatal GBS disease, only 57% of surveyed LMCs practised prevention strategies and none completely followed published recommendations. A New Zealand consensus or improved dissemination of local guidelines is required to achieve further reductions in neonatal GBS sepsis.

[A fatal case of streptococcal toxic shock-like syndrome probably caused by acupuncture].

A 41-year-old male received acupuncture in the right shoulder for the sake of arthralgia. Three days after acupuncture he was admitted due to severe epigastralgia. Erythematous change and swelling were observed around the right shoulder. A study by magnetic resonance showed an increased signal intensity in a portion of the right subscapular muscle. Four hours after admission he became hypotensive. The erythematous and necrotic change in the right shoulder skin rapidly spread. Excisional debridement in the right lateral chest wall was immediately done. However, the patient died one day after admission despite administration of a high-dose ampicillin and other supportive therapies. Bacteriological and histological examinations confirmed severe streptococcal myositis. This is a case report of toxic shock-like syndrome probably caused by acupuncture.

[Systemic infection caused by Streptococcus suis]. / Systemische Infektion durch Streptococcus suis.

Streptococcus suis type 2 was isolated from blood and cerebrospinal fluid in a 49-year-old butcher as the causative organism of a generalized septic infection with meningeal involvement. High-dosage penicillin G treatment quickly terminated the fever and all neurological signs disappeared completely. Streptococcus suis type 2 causes a zoonosis, which usually occurs as an occupational disease among those handling pigs or pork (farmers, butchers etc.). Sequelae of such infection not rarely are damage to the VIIIth cranial nerve, especially loss of hearing.