The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS, a homebirth midwife in Mountain View, CA
Campaign for the passage of California AB1306
Enables equal partnerships between nurse-midwives and obstetricians
Special page for California physicians and birth practitioners to join in support
News! Flash! The Cochrane Collaboration
Intrapartum Antibiotics for GBS is not evidence based.
"There is lack of evidence from well designed and conducted trials to recommend IAP to reduce neonatal EOGBSD."
Translated: There is lack of evidence from well designed and
conducted trials to recommend Intrapartum Antibiotics
Prophylaxis to reduce neonatal Early-Onset Group B Strep
Very few of the women in labor who are GBS positive give birth to babies who are infected with GBS and antibiotics can have harmful effects such as severe maternal allergic reactions, increase in drug‐resistant organisms and exposure of newborn infants to resistant bacteria, and postnatal maternal and neonatal yeast infections. This review finds that giving antibiotics is not supported by conclusive evidence.
Neonatal GBS colonization is lower in babies born in water.
B streptococcus colonization in water births.
Zanetti-Dällenbach RA, Holzgreve W, Hösli I.
Int J Gynaecol Obstet. 2007 Jul;98(1):54-5. Epub 2007 May 1.
2010 Guidelines for the Prevention of Perinatal Group B Streptococcal (GBS) Disease from the CDC
The foundations of prevention in 2010 remain unchanged from the 2002 guidelines.
Here's a summary: Improved guidelines for laboratories.
Better dosing of penicillin (we use ampicillin out of habit where
I work (which is less specific and probably contributes to more
antibiotic resistance)...only the midwives and residents use
penicillin). Testing of women allergic to penicillin
to determine what antibiotic will be most appropriate.
Treating of women who are GBS-negative but have risk
factors. Less aggressive testing in newborns who appear
well. Overall, I hope this means that fewer women will test
positive based on the new lab guidelines and fewer infants will be
poked unnecessarily. Better care, I hope.
Intrapartum Antibiotics for GBS is not evidence based.
"There is lack of evidence from well designed and conducted trials to recommend IAP to reduce neonatal EOGBSD."Translated: There is lack of evidence from well designed and conducted trials to recommend Intrapartum Antibiotics Prophylaxis to reduce neonatal Early-Onset Group B
Routine Well-Woman Annual Screening Guidelines [3/21/11]
The midwife who used to be available for free phone consulting
about antibiotic treatment for GBS is no longer able to offer this
service. We can hope that she will be able to resume this
service soon. Best wishes, KN, and thanks for your years of
Linked to Perinatal Sepsis: Consider GBS-specific
chemoprophylaxis - Eight Case Reports
Avoid membrane stripping in GBS positive mothers: Studies
using ultrasound contrast media show "facilitated transport" of
vaginal fluid into the lower uterine segment during cervical
manipulation. We have reported three perinatal deaths after
membrane stripping in GBS positive mothers at term. GBS
vaginitis is well reported.* [From a handout about The Jesse Cause]
It's well known that the percentage of babies who actually benefit from intrapartum antibiotics is very small. And, increasingly, the routine use of chemoprophylaxis (antibiotics) during labor is causing problems with resistant GBS or resistant e. coli.
So, in this area, some OBs and pediatricians have a new approach;
for cases of prolonged rupture of membranes, they're only giving
antibiotics if the mom runs a fever. Otherwise, they just do
a simple blood test on the baby (can be done from cord blood or a
heelstick if they miss the cord blood opportunity) to check for
C-reactive protein. This is an indicator of an acute
infection. If it's negative, everyone can be reassured that
baby's fine, even though mom didn't get antibiotics; if it's
positive (for whatever reason!), then baby will be appropriately
treated for an acute infection. This has great potential for
focusing the treatment where it is most needed and not exposing
all the others to unnecessary side effects and increased risks
from resistant bacteria. HURRAY for progress!
New for 2011! Rapid
Screening is becoming a research topic again. These newer
tests appear to be more accurate than from years ago.
GBS(TM) Test for Group B Streptococcus - "GBS results can be
available in as quickly as 30+ minutes". This is a useful test for
women at term who were not screened for GBS prenatally, for
whatever reason. However, this test is not useful for
preterm births, as the Cepheid literature claims, since ACOG
protocols call for antibiotics for all preterm births. (And,
in case you're wondering, this is because a preterm baby's immune
system is weaker than a newborn at term, and the preterm baby is
already going to be stressed by other factors, and the mother's
placental downloading of antibodies happens mostly in the last
is the only non-culture test cleared by the FDA and by Health
Canada capable of identifying Group B Streptococcus in pregnant
women at the time of delivery or at any other stage of their
pregnancy. Based on real-time PCR technology and Cepheid's
Smart Cycler instrument, IDI-Strep B test results are available
less than one hour after collecting a vagino-rectal sample,
thereby paving the way to optimal treatment for both mother and
newborn if necessary.
OIA® - Rapid test for Group B Strep (21 minutes) from Thermo Electron Corp.
for group B streptococci: cost-benefit analysis of rapid
polymerase chain reaction. [full
Haberland CA, Benitz WE, Sanders GD, Pietzsch JB, Yamada S, Nguyen L, Garber AM.
Pediatrics. 2002 Sep;110(3):471-80.
of group B streptococci in pregnant women at delivery.
Bergeron MG, Ke D, Menard C, Picard FJ, Gagnon M, Bernier M, Ouellette M, Roy PH, Marcoux S, Fraser WD
N Engl J Med 2000 Jul 20;343(3):175-9
Summary: Pregnant women colonized with GBS at the time of
delivery can be rapidly and reliably identified by a PCR assay of
combined anal and vaginal secretions.
News! Flash! The Cochrane Collaboration
Intrapartum Antibiotics for GBS is not evidence based.
"There is lack of evidence from well designed and conducted trials to recommend IAP to reduce neonatal EOGBSD."
Translated: There is lack of evidence from well designed and
conducted trials to recommend Intrapartum Antibiotics Prophylaxis
to reduce neonatal Early-Onset Group B
B Strep: what you need to know from Gloria Lemay's Wise
Woman Way of Birth
Infants with early-onset GBS disease generally present with respiratory distress, apnea, or other signs of sepsis within the first 24--48 hours of life (3,31). The most common clinical syndromes of early-onset disease are sepsis and pneumonia; less frequently, early-onset infections can lead to meningitis. The case-fatality ratio of early-onset disease has declined from as high as 50% in the 1970s (5) to 4%--6% in recent years, primarily because of advances in neonatal care (17,19). Mortality is higher among preterm infants, with case-fatality rates of approximately 20% and as high as 30% among those ≤33 weeks' gestation, compared with 2%--3% among full-term infants (17,19).Footnote references:
Midwife Informed Consent for GBS Screening
and Midwife Informed Consent for Group B
Strep Carriers (Positive Screen) by Ronnie Falcao,
Cancer Screening and Pathology is pleased to offer discount
pricing to Nurse Midwives for Cytology services for pap and HPV
screening in addition to prenatal panels or any clinical testing
required. Our toll free # 888-299-1937. They offer Beta
Late-Onset Neonatal Group B Streptococcal Disease - United
In 2002, CDC, the American College of Obstetricians and Gynecologists (ACOG), and the American Academy of Pediatrics (AAP) issued revised guidelines for prevention of perinatal invasive group B streptococcal (GBS) disease.[1,2] These guidelines recommend universal screening of pregnant women for rectovaginal GBS colonization at 35--37 weeks' gestation and administering intrapartum antimicrobial prophylaxis to carriers. To assess the impact of the guidelines on multistate trends in neonatal GBS disease incidence, CDC analyzed data from the Active Bacterial Core surveillance (ABCs) system from 1996--2004. This report summarizes the results of that analysis, which determined that incidence of GBS disease in infants aged 0--6 days (i.e., early-onset disease) in 2004 had decreased by 31% from 2000--2001, the period immediately before universal screening was implemented. Incidence of GBS disease in infants aged 7--89 days (i.e., late-onset disease) remained unchanged during the 9-year period reviewed. Continued monitoring is needed to assess the impact of the 2002 guidelines on early-onset disease and the long-term effect of widespread intrapartum use of antimicrobial agents on neonatal GBS disease.
. . . No strategies exist to prevent late-onset disease, although
more than half of reported cases of neonatal GBS disease now occur
during the late-onset period. In addition, concern continues among
health officials that widespread intrapartum antimicrobial use
might delay, rather than prevent, GBS disease onset, resulting in
increased rates of late-onset disease. . . . [Ed. The
best strategy to prevent late-onset GBS disease is to keep
babies out of the hospital, since exposure to GBS in the
hospitals is the most common transmission route for late-onset
"CONCLUSION: The group B streptococci detection rate from
vaginal-perianal specimens is not significantly different from the
detection rate from vaginal-rectal specimens. Therefore, pregnant
women do not need to be subjected to the discomfort of collection
of a rectal specimen."
This is a great summary of the issues - GROUP
STREPTOCOCCAL MENINGITIS from The Meningitis Research
Foundation of Canada. Note that GBS is just one of the many
microbial causes of meningitis - it just happens to be the leading
cause of neonatal sepsis at this time. There is no evidence
that routine hospitalization for administration of antibiotics has
better outcomes than homebirth, where the overall infection rate
is 25% of that in the hospital.
The Jesse Cause -
this is a summary of the pro-intervention approach that is easy to
read. Unfortunately, it ignores the risks associated with
treatment. They are also affiliated with www.groupbstrepinternational.org
Some women prone to carry strep in pregnancy [12/8/05] - Black women, health care workers, and overweight women are at increased risk for carrying group B streptococcus (GBS) during pregnancy, new research suggests.
"Women in health care occupations with a high frequency of direct patient contact faced a 22 percent increased risk of GBS colonization" - Hmmm, there are people who've observed that women are often negative with their first pregnancy but positive with their second pregnancy. Could they be acquiring it from the healthcare workers? It makes sense that GBS may just be one of the many hospital-acquired infections.
for Group B Streptococcal Genitourinary Tract Colonization in
Stapleton RD, Kahn JM, Evans LE, Critchlow CW, Gardella CM.
Obstet Gynecol. 2005 Dec;106(6):1246-1252.
B Streptococcal Infections in Finland: A Population-based Study
(from the CDC web pages)
Outi Lyytikäinen,* J. Pekka Nuorti,* Erja Halmesmäki,† Petteri Carlson,† Jukka Uotila,‡ Risto Vuento,‡ Tapio Ranta,§ Hannu Sarkkinen,§ Martti Ämmälä, Anja Kostiala, and Anna-Liisa Järvenpää†
"We analyzed surveillance data on group B streptococcus (GBS) infection in Finland from 1995 to 2000 and reviewed neonatal cases of early-onset GBS infection in selected hospitals in 1999 to 2000. From 1995 to 2000, 853 cases were reported (annual incidence 2.2-3.0/100,000 population). We found 32-38 neonatal cases of early-onset GBS disease per year (annual incidence 0.6-0.7/1,000 live births). In five hospitals, 35% of 26 neonatal cases of early-onset GBS infection had at least one risk factor: prolonged rupture of membranes, preterm delivery, or intrapartum fever. Five of eight mothers screened for GBS were colonized. In one case, disease developed despite intrapartum chemoprophylaxis. Although the incidence of early-onset GBS disease in Finland is relatively low, some geographic variation exists, and current prevention practices are suboptimal. Establishing national guidelines to prevent perinatal GBS is likely to reduce the incidence of the disease."
Of interest - their overall incidence is lower than in the U.S., and they note geographic variation within their own country. Does this reflect the sexually transmitted nature of the disease or genetic inability to make antibodies to GBS?
The only neonatal death was a premature infant, born at 25 weeks,
whose mother was GBS negative.
This is a fabulous article from Mothering Magazine:
B Strep: Are Antibiotics Necessary?
By Christa Novelli
Issue 121, Nov/Dec 2003
And here's a backup
copy from the Holistic
Preventing Group B Strep Disease from the CDC, including links to patient education materials from the ACNM and ACOG.
Universal Screening Algorithm
Prevention of Early Onset Neonatal Group B Streptococcal Disease - from The Royal College of Obstetricians and Gynaecologists.
Although it seems that most UK hospitals recommend that women have IV antibiotics during labour if they test positive for GBS antenatally, in fact the RCOG recommendation is just that antibiotics be 'considered' in this situation, and that the risks of medicalisation of labour and allergic reaction in the mother, plus risks of antibiotic-resistant infections developing in the baby, are balanced against any possible benefit of IV antibiotics in labour. To quote:
"Antenatal screening and treatment have not yet demonstrated an
effect on all cause neonatal mortality, and may carry
disadvantages for the mother and baby. These include
potentially fatal anaphylaxis, the medicalisation of labour and
the neonatal period, and infection with resistant organisms."
(Page 1, Section 2)
GROUP B STREP SUPPORT - a
charity in the UK
Group B Strep Association
From the Cochrane Collaboration:
Main results: Five trials were included. Overall quality was poor, with potential selection bias in all the identified studies. Intrapartum antibiotic treatment reduced the rate of infant colonization (odds ratio 0.10, 95% confidence interval 0.07 to 0.14) and early onset neonatal infection with group B streptococcus (odds ratio 0.17, 95% confidence interval 0.07 to 0.39). A difference in neonatal mortality was not seen (odds ratio 0.12, 95% confidence interval 0.01 to 2.00).
Reviewers' conclusions: Intrapartum antibiotic treatment of women colonized with group B streptococcus appears to reduce neonatal infection. Effective strategies to detect maternal colonization with group B streptococcus and better data on maternal risk factors for neonatal group B streptococcus infection in different populations are required."
They also make reference to Vaginal
during labour to prevent neonatal group B streptococcal
infection (Cochrane Protocol)
Update on Perinatal Group B Streptococcal Disease [11/14/02]
[Medscape registration is free]
Strep: A Patient/Provider Approach for Optimizing Care by
James Allan McGregor, MD, CM,, from OBGYN.net
early-onset invasive neonatal group B streptococcal disease in a
private hospital setting: the superiority of culture-based
Main EK, Slagle T
Am J Obstet Gynecol 2000 Jun;182(6):1344-54
Summary: A culture-based treatment protocol for GBS prophylaxis
significantly reduced the incidence of early-onset GBS infections
compared with a risk-based protocol and no protocol.
Signs, Symptoms of Neonatal GBS Infection Unaffected by Intrapartum Antibiotics [Medscape Summary]
"Antibiotic exposure also does not delay the onset of clinical signs of infection . . . The findings imply that, for at-risk infants exposed to intrapartum antibiotics, a 48-hour stay is not required to monitor those who remain asymptomatic at 24 hours."
of Intrapartum Antibiotics on the Clinical Spectrum of
Early-Onset Group B Streptococcal Infection in Term Infants.
Bromberger P, Lawrence JM, Braun D, Saunders B, Contreras R, Petitti DB
Pediatrics 2000 Aug;106(2):244-250
Conclusions. Exposure to antibiotics during labor did not change the clinical spectrum of disease or the onset of clinical signs of infection within 24 hours of birth for term infants with EOGBS infection. A 48-hour stay is not required to monitor asymptomatic term infants exposed to intrapartum antibiotics for onset of GBS infection.
antepartum anogenital group B streptococcus cultures.
Torok PG, Dunn JR
J Am Board Fam Pract 2000 Mar-Apr;13(2):107-10
In conclusion, the findings of our study suggests self-collection of GBS cultures is an accurate and potentially cost-saving alternative for implementing the CDC screening guidelines for perinatal GBS colonization. Because a small majority of patients preferred collecting the culture swab themselves, pregnant patients could be given that option either in the clinic or at home during their 35th to 37th week of gestation.
Group B Strep is Lancefield group B beta-hemolytic streptococcus. There is no such thing as "group beta". The "B" doesn't stand for "beta". In fact, there are other groups of beta-hemolytic streptococci - presumably Lancefield groups A,C,D,E,F,G,H,I,J,K,L,M,N,O,P,Q,R . Check out Bacteriology 330 Lecture Topics: Streptococcus pyogenes.
Historically , the definitive identification of streptococci has rested on the serologic reactivity of cell wall polysaccharide antigens as originally described by Rebecca Lancefield. Eighteen group-specific antigens (Lancefield groups) were established.
There's no perfect answer. In most cases, a mom who has GBS will also have GBS antibodies that are passed to the baby through the placenta. [ref: Williams Obstetrics] Nature's not stupid. In rare cases of either very high colonization or unhealthy mom or baby, the baby could be overwhelmed and then require antibiotic treatment.
However, the treatment carries risks of its own - 10% of moms have a mild allergic reaction to the antibiotics - 1 in 10,000 experience anaphylactic shock, which is life-threatening to both the mom and baby.
In addition, 4% of strains of GBS are now antibiotic-resistant. Again, nature's not stupid.
If you carry a resistant strain of GBS, the antibiotics will kill off all the innocuous, normal bacteria that would keep the antibiotic-resistant GBS in check, so that the only thing left is the resistant strain, which tends to be more virulent than the regular strain. This is a horrible situation for a newborn with an immature immune system.
In addition, of course, receiving antibiotics in labor is one of the dominoes in the cascade of interventions and increases overall risk due to the compounded risks of the cascade.
There's no perfect answer. Alternative approaches to
reducing colonization may be the most sensible solution.
Culturing Group B Streptococci from Pregnant Women (from the
collecting and processing clinical specimens for culture of
group b Streeptococcus (from the CDC site) - search for
& Consent for Group B Streptococcal Infections
from Faith Gibson
The March of Dimes has some information for parents:
which is a client brochure which you can reproduce.
of Perinatal Group B Streptococcal Disease: A Public Health
MMWR 45(RR-7);1-24 - Publication date: 05/31/1996
GBS Parents Page and e-mail distribution list
Any caregiver can introduce GBS also. I have watched docs and midwives when they do vaginals. They lube up and then do this little wipe of the vulva with their fingers (almost like foreplay) to lube up the woman. During that wipe they can easily pick up GBS and insert it with their fingers. And it is not unusual for anyone who has delivered in hospital to have GBS.
As everyone knows, docs do vaginals on the first visit of a pregnancy (for pelvimetry and STD checks). I believe that with that first vaginal they can introduce GBS to the cervix and all too often do.
If a caregiver is going to do a vaginal in early pregnancy (& even in late) then the vulva should be wiped first with a microbial swab.
Far better to avoid GBS then have to treat it.
I think the most obvious source of a GBS vaginal infection is the
woman herself. Even when women are scrupulous about wiping
front-to-back, there are many routes of transport from the rectum
to the vagina - the woman's handling of a tampon in a public
toilet where she doesn't have a chance to wash her hands before
tampon insert; the tampon string itself.
It's very possible that a diagnosis of GBS in the urinary tract is a false positive due to vaginal secretions getting into the urine sample. Especially in late pregnancy, there is a lot of vaginal discharge, and any GBS in the vagina can easily find their way into the urine sample. A diagnosis of GBS in the urinary tract should be confirmed with a very clean midstream catch. In my homebirth practice, a diagnosis of GBS in the urine can make the difference between a transfer of care to a hospital-based provider so the woman can receive IV antibiotics during labor and an unmedicated homebirth where sensible precautions can reduce GBS colonization and infection.
This is what I do when labwork shows GBS in the urine sample and
we need to retest with a very clean sample.
I direct the woman to take a thorough shower with special
attention to the urogenital area. This includes a vaginal wash with
hydrogen peroxide. I encourage her to drink a fair
amount of fluid so she has a good volume of urine. Then I
accompany her to the lab and go into the restroom with her.
I provide gloves for her and wear them myself also, of
course. I ask her to hold the labial folds open so the
urethral area is not blocked. Then I use a 30cc syringe to
squirt regular-grade hydrogen peroxide around the urethral area
and then dab it dry with sterile gauze. Then I direct her to
start urinating, and I move the collection cup into the urine
stream to get the midstream sample.
I've only needed to do this a few times, but every time, the
result has come back negative. This precludes unnecessary
(and expensive) treatment during labor and birth and helps the
woman to have the birth experience she has planned.
. . . midstream urine cultures from which moderate or high
concentrations of enterococci or group B streptococci are
isolated probably represent false positive tests for cystitis.
If the midstream urine culture is to remain useful for the
diagnosis of uncomplicated cystitis, it may need to be refined.”
From Understanding Diagnostic Tests in the Childbearing Year by Anne Frye: "Urinary tract infections: GBS in maternal urine > 10,000 cfu/cc is associated with infants who are at greater risk of preterm birth, colonization and infection. (Gilstrap & Faro, 1990, p. 56). In most of these women, vaginal and cervical cultures are also positive. Ampicillin can be given to the mother to help prevent complications and the development ot pyelonephritis (kidney infection). (Bobbitt, 1992)
Women with a healthy immune system and normal genetics will not
get GBS growing in the urinary tract. Mothers with a
genetically inherited inability to develop antibodies against the
capsid of the GBS bacterium or with systemic immune problems may
not develop adequate antibodies to keep GBS from growing in the
urinary tract. They also will not have adequate antibodies
to pass to the baby through the placenta, which is why GBS in the
urinary tract is a serious risk factor for newborn GBS disease;
these women should receive antibiotics in labor.
See also: Bonding and Baby
Birth Trauma / Effects of Antibiotics on Baby's Health
intrapartum antibiotic exposure and late-onset serious bacterial
infections in infants.
Glasgow TS, Young PC, Wallin J, Kwok C, Stoddard G, Firth S, Samore M, Byington CL.
Pediatrics. 2005 Sep;116(3):696-702.
CONCLUSIONS: After adjusting for potential confounders, infants
with late-onset SBI were more likely to have been exposed to IPA
than noninfected control infants. Pathogens that cause late-onset
SBI were more likely to be resistant to ampicillin when the infant
had been exposed to intrapartum antibiotics.
Scientists find host of antibiotic-eating germs - Several strains of bacteria in the soil can make a meal of the world's most potent antibiotics, researchers said on Thursday, in a startling finding that illustrates the extent to which these germ-fighting drugs are losing the war against superbugs.
a Bite Out of Antibiotics - A broad survey of soil microbes
shows that numerous species devour even the most potent drugs,
researchers report on page 100 of this week's issue of Science,
fueling worries about the dwindling power of our main weapons
Community-acquired MRSA emerging in obstetric populations
"This raises the question of whether community-acquired MRSA carriage actually originated in a prior pregnancy as a result of prophylactic antibiotic administration," write the authors, led by Vanessa Laibl, from the University of Texas Southwestern Medical Center in Dallas, USA.
of Community-Acquired Methicillin-Resistant Staphylococcus
aureus in Pregnancy.
Laibl VR, Sheffield JS, Roberts S, McIntire DD, Trevino S, Wendel GD Jr.
Obstet Gynecol. 2005 Sep;106(3):461-5.
In comparison with the general obstetric population, patients with MRSA were more likely to be multiparous and to have had a cesarean delivery.
Conclusion: Community-acquired MRSA is an emerging problem in our obstetric population. Most commonly, it presents as a skin or soft tissue infection that involves multiple sites. Recurrent skin abscesses during pregnancy should raise prompt investigation for MRSA. Level of Evidence: II-3.
Intrapartum antibiotics predispose to nursing-linked yeast infection [7/20/05]
Use of intrapartum antibiotics appears to raise the risk of thrush and breast candidiasis in nursing infant-mother pairs, researchers warn. Within 1 month of delivery, thrush or breast candidiasis were detected in 46 (10.6 percent) mother-infant pairs. Both the breast and oral infection were more common in individuals exposed to antibiotics postpartum, with odds ratios of 2.1 and 1.87, respectively; however, only the former relationship reached statistical significance.
intrapartum antibiotics and the incidence of postnatal maternal
and neonatal yeast infections.
Dinsmoor MJ, Viloria R, Lief L, Elder S.
Obstet Gynecol. 2005 Jul;106(1):19-22.
Conclusions: Neonatal thrush and maternal breast candidiasis are
common early postnatal complications. The higher rates of thrush
and breast candidiasis in antibiotic-exposed mother-infant pairs
merits further study. Level of Evidence: II-2.
of prenatal exposures on the development of allergic disease: a
birth cohort study using the West Midlands General Practice
McKeever TM, Lewis SA, Smith C, Hubbard R.
Am J Respir Crit Care Med 2002 Sep 15;166(6):827-32
About 4% of GBS isolates demonstrate penicillin tolerance (from Merck
The shift is worrisome because E. coli bacteria can be more deadly than streptococcus germs.
The rate of Group B streptococcus blood infections in premature newborns fell by nearly three-quarters during the 1990's, probably because more women in labor took antibiotics to keep from passing the bacteria on to their babies during delivery, the researchers said.
But they added that during that same period, the rate of E. coli infections doubled, apparently because ampicillin, the antibiotic commonly used to wipe out strep, gave E. coli room to flourish.
The study, financed by the National Institutes of Health, is to be published today in The New England Journal of Medicine. It was led by Dr. Barbara J. Stoll of the Emory University School of Medicine.
pathogens causing early-onset sepsis in very-low-birth-weight
Stoll BJ, Hansen N, Fanaroff AA, Wright LL et al.
N Engl J Med 2002 Jul 25;347(4):240-7
articles for lots more
The March 1, 1999 Ob.Gyn.News reports a presentation at the Society for Maternal-Fetal Medicine which found ampicillin resistance in 45% of septic neonates who had been exposed to antibiotics in the prepartum or intrapartum period. Their retrospective study included 8593 births at 6 hospitals between 7-97 and 2-98, and looked at the 96 neonates who were clinically ill with a positive blood or cerebrospinal fluid culture. 70% of these had been exposed to either prepartum or intrapartum antibiotic tx.
Sepsis was 19.3 times more common in preterm babies (57 vs 3.1/1000). Ampicillin resistance was found in 50.1% of preterm babies, vs 20.6% of term babies. Intrapartum exposure was more likely to result in resistance than prepartum exposure (56.7 vs 16.7%) Most common organisms for early onset sepsis were GBS and e coli; for late onset, staph, e coli and candida.
There were 11 early onset GBS cases (1.4/1000), which the presenter commented was about the same incidence as is usually reported. (So does that mean that even though 70% had antibiotics, the rate of GBS was no different than if nobody got them, or does it mean that the 1.4/100 is what is expected when antibiotics are given?) They did find less GBS in those who had intrapartum antibiotics vs those who had prepartum antibiotics (10% vs 32%). It still leaves me wondering if this experiment (lots of antibiotics to a wide range of moms in the name of prevention, vs tx) is really working out when you look at the big picture, or will this too fall by the wayside as more is known?
Sufficient amounts of GBS capsular polysaccharide type-specific serum IgG in mothers have been shown to protect against invasive disease in their infants (51,115--118)
From Prevention of Perinatal Group B Streptococcal Disease, Revised Guidelines from CDC, 2010
Baker CJ, Edwards MS, Kasper DL. Role of antibody to native type III polysaccharide of group B Streptococcus in infant infection. Pediatrics 1981;68:544--9.
Baker CJ, Kasper DL. Correlation of maternal antibody deficiency with susceptibility to neonatal group B streptococcal infection. N Engl J Med 1976 Apr 1;294:753--6.
Baker CJ, Edwards MS. Group B streptococcal conjugate vaccines. Arch Dis Child 2003;88:375--8.
Heath PT, Feldman RG. Vaccination against group B Streptococcus. Expert Review of Vaccines 2005;4:207--18.
Edwards MS. Group B streptococcal conjugate vaccine: a timely
concept for which the time has come. Human Vaccines 2008;4:444--8.
Why do we not test pregnant women who carry GBS to measure their levels of GBS capsular polysaccharide type-specific serum IgG? The infants of those women are already protected against GBS and need not receive antibiotics.
Presumably, these would be the women with recent exposures, compromised immune systems or a genetic inability to make antibodies to GBS.
We could drastically reduce the unnecessary exposure of 30% of laboring women to antibiotics through a more intelligent approach. This would be accompanied by a drastic reduction in cost, as well as the unpleasant side effects of antibiotics.
Given the increasing problems with antibiotic-resistance with both GBS and e. coli, I think it would make a lot of sense to put more effort into investigating this correlation. If only women with low levels of antibodies are at risk, then the rest of the cases can be treated normally unless obvious problems arise, such as fever during labor.
It is well accepted that maternal antibodies are protective for
the baby; this is the basis for research into a GBS vaccine.
Wow! It looks as if the Chinese are studying this seriously. Good for them!
antibodies against group B streptococcal capsular
polysaccharides in healthy Chinese neonates.
Shen X, Yang Y, Zhang J, Berg S, Lagergard T, Trollfors B.
Pediatr Infect Dis J 1997 Dec;16(12):1179-80
It looks as if the idea is catching on again - Double HURRAY! You can also check out the related articles, which might be newer.
streptococcal colonization and serotype-specific immunity in
pregnant women at delivery.
Campbell JR, Hillier SL, Krohn MA, Ferrieri P, Zaleznik DF, Baker CJ.
Obstet Gynecol. 2000 Oct;96(4):498-503.
CONCLUSION: Colonization with group B streptococcus can elicit a systemic immune response, with a cumulative increase in the prevalence of capsular polysaccharide-specific IgG with increasing age. Conversely, low antibody levels in colonized teenagers might account in part for the reported increased risk of group B streptococcal disease in neonates born to these patients.
prospective study of group B streptococcal bacteriuria in
Wood EG, Dillon HC
Am J Obstet Gynecol 1981 Jul 1;140(5):515-20
Bacteriuria in pregnancy was prospectively studied in 569 women, with specific reference to group B streptococcal infection. Forty-six patients (8%) had bacteriuria, including 14 with group B streptococcal infection; group B streptococci (GBS) were exceeded in frequency only by Escherichia coli. Two thirds of the bacteriuric patients remained asymptomatic. The outcome of pregnancy was studied in 41/46 bacteriuric patients, including all those with group B streptococcal infection. Two pregnancies ended in intrauterine fetal death, and one neonate developedgroup B streptococcal sepsis; all three complications occurred in the 14 women with group B streptococcal bacteriuria. Diabetes mellitus appeared to increase the risk of group B streptococcal bacteriuria. This study revealed that group B streptococcal bacteriuria is more common in pregnancy than was previously suspected and suggests that culture methods to detect GBS should be used in bacteriuria screening programs done in pregnancy. In terms of perinatal infection risk, screening for group B streptococcal bacteriuria at or near the time of delivery may be more meaningful than other group B streptococcal surveillance culture studies.
B streptococci cause symptomatic vaginitis?
Honig E, Mouton JW, van der Meijden WI.
Infect Dis Obstet Gynecol 1999;7(4):206-9
We hypothesize that GBS-vaginitis may be a possible disease entity. Although at present it is not clear why some patients become symptomatic, we speculate that the immunologic response is somehow selectively hampered in such patients.
web page about GBS is very instructive: Oddly, the
rates of newborn illness from GBS disease are significantly lower
in the UK than in the US, even for babies born to GBS-positive
mothers. The overall rate in the US is 10 times higher than
in the UK, and, in the UK, treating GBS-positive mothers without
risk factors does not appear to have much benefit. Wouldn't
it be interesting to know more about this difference? Is it
the case that British women are more likely to have an immune
system that is highly effective against GBS? Again, this is
strong support for the argument that the presence or absence of
antibodies is the most relevant risk factor, and that the other
risk factors are indicators of an immune system that is not able
to mount an effective response against GBS, or of a recent
Mothers with a genetically inherited inability to develop antibodies against the capsid of the GBS bacterium. Because of this possibility, mothers who have previously delivered GBS-affected neonates have a much higher chance of delivering a similarly affected infant. [From Physicians Insurance page on "Minimizing Obstetrical Risk: Prevention of Perinatal Group B Beta Strep"]
Is there any way to test for this genetic tendency and/or for the
mother's level of antibodies to GBS? Please e-mail me
Well, at least these people are discussing the issue:
human antibodies to type III group B Streptococcus. [Full-text
Kasper DL, Wessels MR, Guttormsen HK, Paoletti LC, Edwards MS, Baker CJ.
Infect Immun 1999 Aug;67(8):4303-5
maternal antibody deficiency with susceptibility to neonatal
group B streptococcal infection.
Baker CJ, Kasper DL
N Engl J Med 1976 Apr 1;294(14):753-6
We investigated the role of maternal antibody in neonatal Group B streptococcal infection with a radioactive antigen-binding assay employing a purified polysaccharide antigen with both Type III and Group B determinants. Serums from seven women who gave birth to infants who had invasive Group B streptococcal infection with Type III strains were all deficient in antibody. In contrast, serums from 22 of 29 pregnant Type III vaginal carriers whose infants were healthy contained antibody with a prevalence significantly different from that in women delivering infants with Type III disease (P less than 0.01). Three healthy neonates born to women with antibody in serums had demonstrable antibody in umbilical-cord serum. These data suggest that transplacental transfer of maternal antibody protects infants from invasive Group B streptococcal infection with Type III strains.
See also: Lavage w/Chlorhexidine
and Oral Antibiotics in Labor
A basic regimen:
SanPharma Notatum (Penicillium notatum), 10 Caps, 4X, taken every other day
A suggested expanded regimen:
SanPharma Notatum (Penicillium notatum), 10 Caps, 4X, taken every
other day, alternating with
SanPharma Candida (Candida parapsilosis), 10 Caps, 4X, taken every other day.
If your hope is to have a negative result on the initial test, then the above regimen should be completed a week before being tested, so you would need to start around 31 weeks pregnancy if your practitioner does the initial GBS swab at 35 weeks. Otherwise, you could start this protocol anytime you want to reduce GBS colonization levels.
Although it probably won't affect your GBS status at the birth if you do the above regimen close to your due date, you could followup the above regimen with
SanPharma Mucor (Mucor racemosus), 10 Caps, 4X, taken every other day, starting after you complete the Notatum and Candida regimen.
This is especially recommended if you do the Notatum and Candida regimen early in pregnancy and want the results to last until the birth.
NOTE - There is no scientific evidence that homeopathic regimens
are an appropriate treatment for GBS in pregnancy, and it is also
the AMA position that homeopathics cannot do any harm.
However, the goal here is to eradicate the GBS so that your baby
isn't exposed to GBS. If you choose an alternative form of
treatment, it is still important to be tested and to seek
appropriate treatment for a positive result.
Group B Strep and
Home Birth from homebirth.org.uk
Garden of Life and Jarodopholis each make a probiotic that is
targeted towards vaginal flora.
Florastor - we really don't
know if it helps but it cannot hurt.
It seems clear that boosting the mom's immune system can only
help reduce GBS infections in babies. See: Lower Risk in Women with Antibodies
of Midwifery: Good Digestive Flora for GBS and Alternative
for Dealing with GBS from Midwifery Today
to reduce strep - Midwifery Updates, Summer Conference 2002
- Gail Hart©
strep: prevention is better than cure.
Plumb J, Holwell D.
Pract Midwife. 2004 Mar;7(3):17-21.
"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
Reducing GBS Colonization with Alternative
Group B Strep (GBS) and Homebirth -
a handout by Kate Adamson
GBS Treatment for Homebirth
Hibiclens (or Dyna-hex) is 4% of the solution. (At a birth
center where i did an internship, if a woman was sensitive to
betadine, we would use hibiclens in a bowl of warm water to clean
the blood off her lower area. Not important info, just interesting
to me that it's been around a long time, but haven't made the
connection to GBS...)
The chlorhexidine used for vaginal antisepsis is topical
chlorhexidine gluconate (Hibiclens) used full strength. If waters
are broken, it is especially important that you do not wash
bacteria up into the cervical area. It makes most sense to
have the woman do the vaginal wash herself in a standing
position. This is a very effective means of washing the
outer half of the vagina, where bacteria are most likely to
reside. I have my clients use a 30cc syringe, as for a
vaginal wash with hydrogen peroxide for BV.
This may be a dumb question but I wonder why these washes are
thought to be better than an IV dose of PCN G. We know the PCN G
Well, no, actually, the PCN G protocols are NOT 100% effective,
and the attendant risks of anaphylaxis and death from resistant
GBS or e. coli are increased with antibiotics.
I especially like being able to get SOMETHING effective going for
a mom who's about to give birth imminently. The antibiotics
have to be on board 4 hours in advance, and most moms don't take
that long to birth a second or subsequent baby.
Yes, I agree. There's a big difference between systemic antibiotics, which kill off all but the strongest, most resistant bacteria, and local disinfection, which is a completely different mechanism. Let's start with something simple, such as heat, which no bacteria have ever become resistant against. (I know there are some really strange ones at the bottom of the ocean that live in very hot water jets, but I am very certain they're not a threat to humans!) The heat simply makes the environment so hostile that they can't live, kind of like salt water or alcohol, or other things that destroy the cell membrane. Antibiotics work on a different principle. There haven't been any documented cases of resistance to chlorhexidine, although I did find some references to the need for higher concentrations with some strains of bacteria.
However, when it comes to the choice of antibiotics or
chlorhexidine for GBS, there's a huge difference in the way the
baby's skin is colonized. Systemic antibiotics affect your
skin colonies and the timing of the baby's skin/gut colonization
and creates the opportunity for colonization with resistant
bacteria. Since the chlorhexidine isn't systemic, it doesn't
affect your skin colonization (except for where it might drip down
your legs), and it doesn't affect the baby's receptivity to your
normal skin bacteria at birth.
with chlorhexidine during childbirth.
Stray-Pedersen B, Bergan T, Hafstad A, Normann E, Grogaard J, Vangdal M.
Int J Antimicrob Agents 1999 Aug;12(3):245-51
"Vertical transmission of microbes occurred in 43% of the reference deliveries. In the double blind study, vaginal douching with chlorhexidine significantly reduced the vertical transmission rate from 35% (saline) to 18% (chlorhexidine),. . . . This prospective controlled trial demonstrated that vaginal douching with 0.2% chlorhexidine during labour can significantly reduce both maternal and early neonatal infectious morbidity. The squeeze bottle procedure was simple, quick, and well tolerated. The beneficial effect may be ascribed both to mechanical cleansing by liquid flow and to the disinfective action of chlorhexidine."
Fortunately, there is a fair amount of recent research about this subject. For the latest studies, see Related articles
sterile water vaginal wash during labor to prevent peripartum
Sweeten KM, Eriksen NL, Blanco JD.
Am J Obstet Gynecol 1997 Feb;176(2):426-30
"CONCLUSIONS: Our findings suggest that a one-time 0.4%
chlorhexidine vaginal wash does not decrease the incidence of
infectious morbidity in parturients, compared with the use of
sterile water." [Ed. It would have been nice if they'd
mentioned how effective sterile water is!]
J Matern Fetal Med 2002 Feb; 11(2):84-8 (Department of
Gynecology, Obstetrics and Pediatric Sciences, University of
Modena and Reggio Emilia, Modena Italy)
Conclusion: In this carefully screened target population, intrapartum vaginal flushings with chlorhexidine in colonized mothers display the same efficacy as ampicillin in preventing vertical transmission of group B streptococcus. Moreover, the rate of neonatal E. coli colonization was reduced by chlorhexidine.
B streptococci cause symptomatic vaginitis?
Honig E, Mouton JW, van der Meijden WI.
Infect Dis Obstet Gynecol 1999;7(4):206-9
"After emergence of resistance to antibiotics, local application
of chlorhexidine appeared to be the only useful treatment"
I have been doing a private study on hibiclens and GBS. I test my
ladies @ 35-36 weeks. If positive we do the wash once a week, then
the next day wash with apple cider vinegar, then the next week do
the hibiclens and the next day reseed good flora with active
yogurt. The next week we test and there is no GBS. HOWEVER, the
week after that I tested again and it was present. The reason
being?... You have to treat the husband as well. Seems just like
yeast, they can give it back. Since I have been treating the
husband.. no recurrence.
Just a reminder that chlorhexidine (Hibiclens) is not intended to
eradicate GBS prenatally. It is not an antibiotic, it is a
local antiseptic. It's only researched use is to temporarily
(for several hours) minimize or eliminate GBS from the vaginal
canal during labor. There is no sense in using it
repetitively during the prenatal period and it probably only
disrupts natural vaginal flora.
I know that oral antibiotics are not acceptable protocol and the
reasoning is that the antibiotics don't get across the placenta in
a timely fashion. Does anyone use them anyway, and is there
any place I can look to find out how long it does take to get the
antibiotics to get into the placenta? My understanding, a
while back, is that it is not used, and hasn't really been
studied, but I don't know if that is still true.
I do, start about a week before and hope she goes into labor in
the time frame but can continue another round.
I am a homebirth midwife and here is my method for detecting and dealing with strep.
I culture at 36 weeks, if the mom is positive I give Amoxicillin
500 mg q 6h for 10 days. If she goes overdue I will reculture at
41 weeks. Depending on the situation (i.e. PROM, long labor, lots
of checks) I may or may not culture Mom at the beginning of labor
but it is an option while closely observing baby for the next few
The good news is, IV antibiotics are NOT required. My CNM is
putting me on oral antibiotics. I will take 3 a day starting at
week 37 (today!) and then one a day until labor begins. When labor
begins, I will take one every 4-6 hours until the baby is born. It
seems like a lot, but it is better than being stuck in the
One option would be to follow the common protocol of treating only for risk factors, even for women who are GBS positive.
Other options would be to find an MD who would prescribe oral antibiotics for you. It's probably easier to get a pediatrician or family practice doc to do this than an obstetrician. Since the pediatrician is interested in your baby's well-being and doesn't care much about how well you conform to obstetric protocols, some are happy to do this.
A third option is to connect with some nice pregnant woman in Mexico who would buy the antibiotics for you and ship them to you. Antibiotics are available without prescription in Mexico, i.e. you can buy over the counter the way we buy Robitussin or aspirin. I've been told it's completely legal to have them shipped to you in the U.S., but I'm not a lawyer and can't say I know for sure.
Or you could take a little vacation south of the border. :-)
And, by the way, it's entirely possible that the increased risk
of your baby's getting GBS through exposure in a hospital nursery
is greater than the risk of getting GBS directly from you at a
intramuscular penicillin in the eradication of group B
streptococcal colonization at delivery.
Pinette MG, Thayer K, Wax JR, Blackstone J, Cartin A.
J Matern Fetal Neonatal Med. 2005 Ma
CONCLUSION: The large number of persistent carriers suggests that
2.4 million units of intramuscular benzathine penicillin G
suspension (Bicillin L-A) is insufficient as sole therapy.
However, the decline in group B streptococcal carriers might
lessen the risk of failed or insufficient intrapartum treatment.
Intramuscular benzathine penicillin G suspension (Bicillin L-A)
may be useful as an adjunctive treatment for patients at risk for
rapid delivery, before adequate intrapartum prophylaxis can be
penicillin G benzathine in pregnant group B streptococcus
Weeks JW, Myers SR, Lasher L, Goldsmith J, Watkins C, Gall SA.
Obstet Gynecol. 1997 Aug;90(2):240-3.
For those of you on the list who saw my request for info on GBS and the possibility of continuing with homebirth plans AND treating the GBS...here is an update.
I will be continuing with plans to birth my 2 clients at home.
After trying to make arrangements for a home IV (a royal pain for
all!) we opted (we, as in I the client and my back-up doc and his
new CNM partner) to treat with antibiotics IM. Both clients went
in this week for their pre-birth injections. I did not have to
deal with giving them the meds during labor (for which I am
grateful) and they are covered for 30 days after the
injections (yes, 4 injections were needed to give the full
dose!!). I researched the exact med and dosage and relayed that to
my back-up and they then ordered up the meds and my clients called
and went in for their injections. I now have a new client due in
Dec. who is GBS+ and we will have a plan of action already in
place for her. I am glad to have a workable solution to this
dilemma! Thanks to the person who posted the abstract on IM
coverage for GBS, we used that formula. Hope you all can use this
info if you come up against this problem.
Those women with risk factors (PROM >18 hours, +cultures or
hx) we do treat for Group B Strep we give IM ampicillin 1 gram q12
hours (loading dose 2 grams). Two shots in the butt, less invasive
than an IV, more effective then PO. My moms prefer doing that than
risking the baby.
Archival Pages about GBS Protocols from
around the time the CDC/ACOG/AAP Consensus Guidelines were
released in 1997?
Secondly, what antibiotic do you use in labor for a woman who you
know has vaginal Group B Strep and is allergic to Penicillin?
I would use clinda in the pen allergic patient. If not pen
allergic, I would use Pen G load with 2.4 million units IV and
then 1.2 million units iv q hr until delivery.
I have searched for some time for the dosage of Cleocin used for
group B strep positive women. Is there a reference for Cleocin
900mg IV q 8hours.
Clindamycin 900mg iv q8hr
I would use clinda in the pen allergic patient. If not pen
allergic, I would use Pen G load with 2.4 million units IV and
then 1.2 million units iv q 4 hr until delivery.
In addition to treating the patients with known risk factors, I
now culture (vaginal and rectal) all women between 35 and 37
weeks, treating those who are positive for Group B strep.
Clindamycin is the drug of choice for penicillin sensitive
We have a patient at our hospital who went into labor at 35 weeks. Was 4 cm dilated. No history of Penicillin allergy. Given a dose of Penicillin and immediately went into shock. Emergency C-section, DIC. Mother developed acute tubular necrosis and is on dialysis.
Let's not forget Penicillin can be a dangerous drug. And if we
culture everyone, we will be exposing a lot of women to possible
There are studies that show the potential for causing asthma
after exposure to ABX in pregnancy or early newborn life.
use of antibiotics and the development of allergic disease in
one year old infants. A preliminary study.
Jedrychowski W, Galas A, Whyatt R, Perera F.
Int J Occup Med Environ Health. 2006;19(1):70-6.
CONCLUSIONS: The study suggests that maternal use of antibiotics
during pregnancy may prove to be a risk factor for persistent
wheezing and development of allergy in early infancy.
use of antibiotics in early childhood increase the risk of
asthma and allergic disease?
Droste JH, Wieringa MH, Weyler JJ, Nelen VJ, Vermeire PA, Van Bever HP.
Clin Exp Allergy. 2000 Nov;30(11):1547-53.
CONCLUSION: Early childhood use of antibiotics is associated with
an increased risk of developing asthma and allergic disorders in
children who are predisposed to atopic immune responses. These
findings support recent immunological understanding of the
maturation of the immune system.
Women laboring with saline locks for periodic administration of
antibiotics tell me that the needle hurts a lot and limits their
movements and positions. They say it hurts to be on hands
and knees, and she can't move freely in the birthing tub if she
needs to keep the saline lock above water.
1) If a patient has been treated for carriage state in a prior
pregnancy would you treat her in subsequent pregnancies? Would you
even culture her? If you did and she was negative would you not
Would culture her in current pregnancy at 36 weeks. If negative,
I would not treat.
If someone is a known carrier, and even if treated, I would still
treat her in labor, and find no reason to ever culture her again.
Yes. Carrier status doesn't always culture pos. If you culture
her neg, fail to treat, and then her baby gets GBS; legally &
guilt-wise you are fried.
If a GBS neg mom is ruptured 18+ hrs, would you treat her?
If afebrile, no.
If someone who is culture negative is ruptured for 18 hours, I
would re-culture then, and treat, because this is a high risk
situation for GBS passage, and we all know that some of the people
who are negative at the 36 week culture are positive later.
Culture first and then treat. What caused the rupture?? At least
if baby gets sick you have a culture done for the Peds.
Are hep locks still used at all? I've been told they've been
replaced by saline locks, whatever those might be. Can you really
place an IV and then disconnect it without heparin? If so, how
long can you go in between flushing it?
Heplocks are still used...however we've started flushing them with saline (like stuff for contact lenses) instead of heparin. Works just as well, costs much much less, and doesn't expose mom and baby to that minute amount of heparin.
Yes, we often place HLs (like if the mom needs antibiotics for some reason--Mitral Valve Prolapse, Group B Strep Carrier etc.) and don't hook them up to an IV. Only needs to be flushed every 8-12hrs with saline to keep it open, and after medication is administered through it. And a HL DOESN'T have to be placed in an inconvenient place like the back of the hand, wrist or inner elbow. it can easily be placed on the forearm out of the way. it can be covered with saran wrap and be immersed in tub/shower. And there is NO needle left in an IV or HL....so no fear of re-poking with mvnt.
Actually an "acceptable" choice for someone who wants no
intervention, but needs IV medication.
I'm curious about research regarding the different outcomes for
GBS babies who were breastfed normally after birth.
One of my clients had a baby who nearly died from GBS even though
she was nursed a lot. Problems didn't show up until around
18 hours; first signs were expiratory grunting.
One of my clients had a baby who was fine until 24 hours, when he
turned blue and stopped breathing. Mom had had a negative
culture, but the baby was cultured positive. Mom
nursed/pumped very often, and baby was off the ventilator in 5
days and home again within 8 with no further problems. The
medical staff were amazed at how quickly and well he recovered.
of group B streptococcal infections in infants.
Pass MA, Gray BM, Khare S, Dillon HC Jr.
J Pediatr. 1979 Sep;95(3):437-43.
I believe it was this study in which she stated that the risk of
infection was only increased if at least 3 of 4 superficial
cultures (throat, umbilical stump, ear canal, rectum) are
positive. I've heard that this approach was abandoned
because of the expense of the cultures. This surprises me,
since it seems to be based on an assumption that there is no
"cost" associated with receiving antibiotics for the mother and
In her book, Physiology
Childbearing with Anatomy and Related Biosciences, Dorothy
Stables classifies GBS as a Sexually Transmitted Disease.
(see p. 170). I can't find the source for this
classification, but it seems clear that GBS can be transmitted
between people in a variety of ways, just as most other bacteria
can be transmitted in a number of different ways. I can't
find a copy of Gut Reactions right now, but I think it
says that a sexually intimate couple will share 90% of their gut
flora within six months? (or a year?) of being together.
It's not clear how much the sexual contact increases the sharing
over regular household contact, but I would expect it to have some
To the extent that a recent exposure to GBS is more dangerous
than an established colonization, it's important to know how much
having a new sexual partner increases your chance of having a
recent exposure to GBS. On the other hand, it might be
prudent not to emphasize sexual contact as a mode of transmission
if it would add a stigma to GBS diagnosis and treatment.
From the web
of the Los Olivos Women's Medical Group about GBS, which
includes perinatologists, their web page states unequivocally,
"Group B strep colonization is not a sexually transmitted disease
(STD)." So does the American
between abuse, sexually transmitted diseases, & group B
streptococcus in childbearing women.
Winn N, Records K, Rice M.
MCN Am J Matern Child Nurs. 2003 Mar-Apr;28(2):106-10
RESULTS: Abuse was significantly related to STDs, and ethnicity emerged as a significant variable for the Hispanic women participating in this study. Findings indicated that infection with group B was also related to abuse status ( r=.60, p < or =.002) and to presence of herpes simplex virus-2 (r =.468, p<or =.01). Total prevalence of STDs was positively related to abuse ( r=.78, p <or =.000). Abused Hispanic women were more likely to be positive for STDs than were their nonabused counterparts ( p <or =.03). CLINICAL IMPLICATIONS: The findings support previously published results that abuse is widespread in the United States and that abused women are at increased risk for STDs. These results highlight the need for regular screenings for abuse during healthcare, for abuse is a critical variable to consider when screening for STDs and GBS. STD screening typically occurs during the first prenatal visit and may need to be repeated for high-risk groups.
This study shows an association between abuse and STDs, and an
association between abuse and GBS, but that does not mean that GBS
is an STD.
of vaginal colonisation with group B streptococci in a sexually
transmitted disease clinic.
Honig E, Mouton JW, van der Meijden WI.
Eur J Obstet Gynecol Reprod Biol. 2002 Nov 15;105(2):177-80.
CONCLUSIONS: In our study, vaginal colonisation with GBS was not
correlated with any of the epidemiological variables previously
reported. Sexual contact does not seem to be the principal way
of transmitting GBS. Our findings confirm the general
opinion that vaginal colonisation with GBS usually does not cause
any vaginal symptoms.
On the denial end of the spectrum, we have Ask-An-Expert
peacehealth.org saying about GBS, "There is no evidence that
this bacterium is transmitted through sexual contact." This
implies that GBS cannot be transmitted through sexual contact,
which simply makes no sense.
babies and their families by group B streptococci.
Weindling AM, Hawkins JM, Coombes MA, Stringer J.
Br Med J (Clin Res Ed). 1981 Dec 5;283(6305):1503-5.
A high incidence of group B streptococcal disease of the newborn
in West Berkshire led to a prospective study of the condition.
Cultures taken from 1090 babies shortly after birth showed that 65
(6%) were colonised with the streptococcus. Thirty of these babies
were assigned to group 1. Bacteriological samples were taken from
babies and mothers at birth and at four, eight, and 12 weeks, and
also from fathers and siblings. Fifty uncolonised babies and their
families were similarly studied and served as controls (group 2).
In group 1,28 of the 30 mothers and 14 of the 28 fathers examined
were colonised by group B streptococci. In group 2 the
streptococci were isolated from three babies, 12 mothers, and 11
out of 45 fathers during follow-up. These findings suggest that
group B streptococci are carried predominantly in the lower
gastrointestinal and genitourinary tracts. Most families are
lightly colonised, but in others maternal colonisation is stable
and heavy and the incidence of paternal colonisation high. Results
of serotyping suggest that sexual transmission occurs, which may
explain the difficulty in eradicating the organism during
These old links are preserved here because sometimes it can be
helpful to look back and see how protocols have changed.
New Group B Strep Prevention Guidelines
On May 31, 1996, the Center for Disease Control & Prevention (CDC) published guidelines for the prevention of early-onset group B streptococcal (GBS) disease in newborn infants and post-delivery associated infection in their mothers. CDC, the American College of Obstetricians & Gynecologists (ACOG), the American Academy of Pediatrics (AAP) and other groups, including the Group B Strep Association developed these more comprehensive guidelines, and ACOG and AAP support their implementation by physicians caring for pregnant women and newborns.
Revised Guidelines for Prevention of Early-onset Group B Streptococcal (GBS) Infection (RE9712)
AMERICAN ACADEMY OF PEDIATRICS - Policy Statement
Volume 99, Number 3, March 1997
Committee on Infectious Diseases and Committee on Fetus and Newborn
When did testing all women for strep b, and then treating with
antibiotic become standard of care?
Effective in Murine Model [February 6, 2001]
The availability of an effective GBS vaccine would be terrific, but I am struck by the amount of effort that is going into finding pharmaceutical approaches that can be applied across all populations, instead of identifying those women at risk, i.e. women who have a genetic tendency not to mount an effective immune response against GBS. In particular, if women who are carrying GBS naturally are unable to mount an effective immune response, why would their exposure to a vaccine suddenly enable them to do so? If you have any insights or information about this to share with me (and other readers of this page), please contact me. Thank you.
A Group B
In Search of a Group B Strep Vaccine. - "Transplacentally
acquired maternal antibodies to CPS protect newborns against GBS
disease." and "A vaccine that elicits high concentrations of
transplacentally transmissible IgG makes third-trimester
immunization feasible as a strategy for preventing this
finds vaccine against strep infections
June 1, 1998
to type III group B streptococcal polysaccharide-tetanus toxoid
conjugate vaccine. [The
full-text article is available free]
Kasper DL, Paoletti LC, Wessels MR, Guttormsen HK, Carey VJ, Jennings HJ, Baker CJ.
J Clin Invest. 1996 Nov 15;98(10):2308-14.
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