Appropriateness of Intrapartum Antibiotic Prophylaxis to Prevent Neonatal Group B Streptococcus Disease

Abstract

The aims of this study were to describe the adherence to CDC guidelines for intrapartum antibiotic prophylaxis (IAP) and to identify possible factors influencing noncompliance with guidelines. We conducted a retrospective study in Italy. Our cohort included women in whom antenatal Group B Streptococcus (GBS) screening was not performed, was performed, but results were not available at the time of labor or delivery and women who were positive for GBS colonization. The indications for complete execution of IAP according to revised CDC guidelines was evaluated. It was considered adequate when performed with a recommended antibiotic at least four hours prior to delivery. The cohort included 902 women. Among those who had performed rectal and vaginal swabs (or recto-vaginal swabs), results were available in 86.9% of vaginal swabs and in 87.1% of rectal swabs and GBS was detected in 59.8% of vaginal swabs and in 71% of rectal swabs. 49.2% women had indication for GBS prophylaxis. Among these, 91.1% received an antibiotic during labor. Totally appropriate IAP was performed in 36.3% deliveries, an inappropriate antibiotic was administered in 10.4% women, the remaining 45.3% women received partially appropriate IAP; of these, 15.5% had received antibiotics through an inappropriate route of administration, 18.2% an inappropriate dosage regimen. Overall, 27.5% women received intrapartum ampicillin with inappropriate timing. Multivariate analysis showed that totally appropriate prophylaxis was significantly more likely in women who had no previous live birth, who had vaginal delivery, and a positive result at antenatal GBS screening. Despite satisfactory GBS screening implementation, there is still a substantial gap between optimal and actual IAP. We hypothesize that the complexity of the CDC guidelines may partially explain this shortcoming. Future efforts will include initiatives focused at enabling and reinforcing adherence to evidence-based prevention practices.

Group B Streptococcus ( Streptococcus agalactiae )

“…Since the institution of intrapartum antibiotic prophylaxis in the US, the incidence of invasive early onset GBS disease has declined from 1.7 cases/1,000 live births in 1993 to 0.76–0.77 cases/1,000 live birth in 2005–2008 and an estimated 0.21 cases/1,000 live births in 2015 (111, 150, 151). However, while 87% of women in the US undergo cultures to screen for GBS, only an estimated 36% of women in 2016 received care fully compliant to intrapartum antibiotic prophylaxis guidelines; challenges relate to appropriate timing of screening culture collection, appropriateness of intrapartum antibiotic selection, and appropriateness of intrapartum antibiotic dosages and timing (152).…”

Immunization Against Group B Streptococci vs. Intrapartum Antibiotic Prophylaxis in Peripartum Pregnant Women and their Neonates: A Review

“…Currently, 90% of women are screened for GBS with 62% screened between 35-37 weeks gestation (the others being tested before the 35-week recommendation). Results were available at delivery in 98% of cases [ 9 ]. While screening is provided in a high percentage of the patients, early testing is concerning for late GBS colonization.…”

“…While guidelines recommend delivering after intrapartum antibiotic prophylaxis (IAP) for at least four hours, in practice, only about 50% of patients receive the full four hours of treatment. When considering the combination of appropriate drug choice, route of administration, dosage, and timing, only 36% of pregnant women received the correct treatment [ 9 ]. While penicillin is an effective treatment IAP for four hours, the lack of consistent and appropriate use demands stricter regulations or is a potential opportunity for vaccines to take out some of the human error.…”

Towards accurate exclusion of neonatal bacterial meningitis: a feasibility study of a novel 16S rDNA PCR assay

“…The clinical signs of neonatal meningitis are very nonspecific [1] and the current UK practice is to test cerebrospinal fluid (CSF) for meningitis in all newborn babies with suspected sepsis and raised C-reactive protein [2]. With many babies exposed to antibiotics intrapartum [3] and with nearly all babies receiving antibiotics before the lumbar puncture [2], a negative result in CSF bacterial culture does not rule out bacterial meningitis [4][5][6]. CSF pleocytosis can be indicative of meningitis, but CSF microscopy can be difficult to interpret: (i) up to 50% of neonatal lumbar punctures result in blood-stained CSF [7,8], (ii) there is uncertainty as to what constitutes a normal CSF white cell count in healthy babies [9,10], and (iii) "normal" CSF microscopy does not exclude bacterial meningitis [11].…”