Early onset Group B streptococcus disease (EOGBSD)



Canberra Hospital and Health Services

Clinical Procedure

Early Onset Group B Streptococcus Disease (EOGBSD) (Maternity)

|Contents |

Contents 1

Purpose 2

Scope 2

Section 1 – Background 2

Section 2 – Antepartum 3

Detection and Screening 3

Pre-labour rupture of membranes at term 3

Intrapartum Intravenous Antibiotic Prophylaxis - See Attachment 1 4

Section 3 – Postpartum 4

Management of Term babies – See Attachment 2 4

Implementation 6

Related Policies, Procedures, Guidelines and Legislation 6

References 6

Search Terms 7

Attachments 7

Attachment 1 – Neonatal Minimisation of Early Onset of Group B Streptococcal Infection 8

Attachment 2 – Group B Streptococcal Management of the Neonate 9

|Purpose |

The purpose of this procedure is to facilitate a consistent approach to the prevention and early detection of Early Onset Group B Streptococcal Disease (EOGBSD) in babies.

|Scope |

This document pertains to women and babies in the antepartum, intrapartum and postpartum periods who have risk factors for Group B Streptococcus (GBS) or who have been found to be positive for GBS after culture based screening and for whom intrapartum chemoprophylaxis is recommended. This document also pertains to babies of mothers who have risk factors for EOGBSD.

This document applies to the following Canberra Hospital Health Services (CHHS) staff working within their scope of practice:

• Midwives and Nurses

• Medical Officers

• Students under direct supervision.

|Section 1 – Background |

1. EOGBSD is recognised as the most common cause of early onset neonatal sepsis in developed countries

2. In Australia, approximately 20-24% of women will be asymptomatic carriers of Group B Streptococcus

3. Up to 70% of babies born to GBS colonised women will become colonised with GBS, and approximately 1% of these babies will go on to develop EOGBSD

4. The risk of a preterm baby developing EOGBSD is greater than a full term baby as preterm babies are immunologically more prone to sepsis

5. Contention as to the optimal prevention strategy exists due to a paucity of high-level evidence from which to draw conclusions

6. Two main prevention strategies are currently recommended; a risk based approach and routine antenatal culture based screening

7. In a risk based approach women with the following risk factors should receive Intrapartum antibiotic prophylaxis:

• Gestation ≤ 37 weeks duration

• Rupture of membranes ≥ 18 hours

• Maternal fever ≥ 38◦C

• Previous GBS infected baby

• GBS bacteruria ( of any count) during current pregnancy

• Known carriage of GBS in current pregnancy

8. GBS colonisation is transient and culture based screening at 35-37 weeks has the highest predictive value for maternal GBS colonisation in labour

9. Intrapartum antibiotic prophylaxis is recommended to women with identified risk factors (in the risk based approach) and to those who culture positive for GBS (in the routine antenatal culture based screening approach)

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|Section 2 – Antepartum |

Women should be recommended routine culture based screening at 35-37 weeks gestation.

Those who decline routine culture based screening or where for whatever reason, a culture was not obtained or a result is not available should be managed according to the risk factors.

Detection and Screening

Discuss and recommend low vaginal swab (LVS) to screen for GBS (see Attachment...):

• Between 35 and 37 weeks gestation

• With preterm pre-labour ruptured membranes

Do not offer screening to women with GBS Urinary Tract Infection (UTI) during current pregnancy or to women with a previous GBS affected baby. These women should be recommended intrapartum intravenous antibiotic prophylaxis.

Perform LVS (by the woman or by the clinician):

• Insert swab 2cm into vagina and sweep over perineum. Do not touch cotton end with fingers, ensure cap fits firmly. Refer to the Pathology Requests and Specimens procedure which can be found on the policy register ().

Confirm and document the GBS status at following antenatal visit and discuss intravenous antibiotic prophylaxis where necessary and offer GBS Information sheet, which can be found on the policy register ()

If the woman should decline LVS, recommend that she be treated with intrapartum intravenous antibiotic prophylaxis if she develops any risks factors, document reasons for declining screening in antenatal records.

Screening for GBS is not required for women for whom a planned elective caesarean section is to be performed.

|PRACTICE NOTE: |

|As screening cultures take 24-48 hours to become positive, cultures are not useful in the initial management of labour 6. |

Pre-labour rupture of membranes at term

For those women who test positive for GBS on antenatal culture, those with a history of a baby affected by GBS and anyone with GBS bacteruria in the current pregnancy:

• Pre labour rupture of membranes at term - Intravenous antibiotic prophylaxis is unnecessary prior to labour. Refer to ‘Prelabour Rupture of Membranes’ (PROM) guideline

• Known risk for GBS with preterm PROM and in labour – give intravenous antibiotic prophylaxis.

• Suspicion of chorioamnionitis - offer intravenous antibiotic prophylaxis and consider induction of labour.

• Induction of labour should be offered soon after a diagnosis of ruptured membranes is confirmed. If the woman declines immediate induction advise re setting a time limit for expectant management if she does not go into labour and document same. Development of infection or other complications is an indication for delivery by the most appropriate method for the clinical situation12. The decision for induction is based on the risk factors and the individual clinical situation.

Intrapartum Intravenous Antibiotic Prophylaxis - See Attachment 1

All women with risk factors for GBS or with GBS positive screening should be advised to have intrapartum intravenous antibiotic prophylaxis. This is defined as antibiotics ≥ 4 hours prior to birth 3, 6. Benzylpenicillin is preferred over ampicillin because of its narrower spectrum of activity.

|MEDICATION |DOSE |ROUTE |FREQUENCY |DURATION |

|Benzylpenicillin 3 |3.0gram stat |Intravenous |4 hourly |Intrapartum |

| |then 1.8gram | | | |

|Clindamycin (if anaphylaxis to |900mg in 100mls |Intravenous |8 hourly |Intrapartum |

|penicillin) | | | | |

|Cephazolin (if non-anaphylaxis to |2 gram stat |Intravenous |8 hourly |Intrapartum |

|penicillin) |Then 1 gram | | | |

Note:

For elective Caesarean section (not in labour, no rupture of membranes) no additional prophylaxis is recommended, irrespective of carriage.

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|Section 3 – Postpartum |

Management of Term babies – See Attachment 2

|PRACTICE NOTE: |

|Babies whose mothers were not screened for GBS will follow the Neonatal Early Warning pathway i.e. normal care if there are no risk |

|factors and no signs of infection and observations as above if risk factors present. |

| |

|All babies will have a risk assessment done and a NEWS chart (including recommended observations) commenced. |

RISK FACTOR 1:

Adequate intrapartum antibiotic prophylaxis

Babies of women with risk factors for GBS or testing positive for GBS in the antenatal period and for whom there was adequate intrapartum antibiotic prophylaxis (>4 hours before birth)are observed for 24 hours with 4 hourly observations (temperature, respiratory rate, oxygen saturations and heart rate) then if mother remains an inpatient, 8 hourly observations until discharge.

RISK FACTOR 2:

Inadequate intrapartum antibiotic prophylaxis

Babies for whom there was inadequate intrapartum antibiotic prophylaxis (18 hours or who are < 37 weeks

regardless of intrapartum antibiotic prophylaxis, are observed in hospital for at least 48 hours with 4 hourly observations (temperature, respiratory rate, oxygen saturations and heart rate). Babies with a sibling affected by Early Onset Group B Streptococcus Disease (EOGBSD), of women with chorioamnionitis, born ................
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