Ornament

The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS, a homebirth midwife in Mountain View, CA

Ornament

Group B Strep (GBS)

Why women shouldn't fear home birth
by Mayim Bialik, Ph.D.
This short essay is humorous, honest, insightful and inspiring.

See also:

Subsections on this page:



News! Flash!  The Cochrane Collaboration Announces that
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 Disease.



Cochrane Database of Systematic Reviews: Plain Language Summaries.
Intrapartum antibiotics for known maternal Group B streptococcal colonization
First published: January 31, 2013; This version published: 2012; Review content assessed as up-to-date: November 10, 2012.

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.


Intrapartum antibiotics for known maternal Group B streptococcal colonization.
Ohlsson A, Shah VS.
Cochrane Database Syst Rev. 2009 Jul 8;(3):CD007467.

MAIN RESULTS: Three trials (involving 852 women) evaluating the effects of IAP versus no treatment were included. The risk of bias was high. The use of IAP did not significantly reduce the incidence of all cause mortality, mortality from GBS infection or from infections caused by bacteria other than GBS. The incidence of early GBS infection was reduced with IAP compared to no treatment (risk ratio 0.17, 95% confidence interval (CI) 0.04 to 0.74, three trials, 488 infants; risk difference -0.04, 95% CI -0.07 to -0.01; number needed to treat to benefit 25, 95% CI 14 to 100, I(2) 0%). The incidence of LOD or sepsis from organisms other than GBS and puerperal infection was not significantly different between groups.One trial (involving 352 women) compared intrapartum ampicillin versus penicillin and reported no significant difference in neonatal or maternal outcomes.
AUTHORS' CONCLUSIONS: Intrapartum antibiotic prophylaxis appeared to reduce EOGBSD, but this result may well be a result of bias as we found a high risk of bias for one or more key domains in the study methodology and execution. There is lack of evidence from well designed and conducted trials to recommend IAP to reduce neonatal EOGBSD.Ideally the effectiveness of IAP to reduce neonatal GBS infections should be studied in adequately sized double-blind controlled trials. The opportunity to conduct such trials has likely been lost, as practice guidelines (albeit without good evidence) have been introduced in many jurisdictions.

 

Neonatal GBS colonization is lower in babies born in water.

Neonatal group 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.



Current Guidelines



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.



News! Flash!  The Cochrane Collaboration Announces that

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 Disease.


Discussion of current GBS guidelines in the UK [2012]

ACOG Updates Routine Well-Woman Annual Screening Guidelines [3/21/11]



Garlic and GBS



Make History - Participate in a Simple Research Project re: Garlic to Treat GBS

Judy Cohain has published a protocol for using garlic to get a negative GBS culture.  She is trying to collect women's experiences and culture results after using  garlic to see if it really works.


Free Phone Consulting about Antibiotic Treatment for GBS



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 service!



Avoid Membrane Stripping in GBS Positive Mothers



Cervical Manipulations 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]



Different Approach to GBS Colonization



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!



Rapid GBS Screening



New for 2011!  Rapid Screening is becoming a research topic again.  These newer tests appear to be more accurate than from years ago.

Rapid Strep Test During Labor More Accurate Than Antepartum Culture (Medscape, 2/14/11)

Intrapartum PCR Screening for Group B Strep Is Cost-Effective [Medscape, 3/27/12]

Cepheid's Xpert 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 month.


IDI-Strep B 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.


STREP B OIA® - Rapid test for Group B Strep (21 minutes) from Thermo Electron Corp.


Perinatal screening for group B streptococci: cost-benefit analysis of rapid polymerase chain reaction. [full text]
Haberland CA, Benitz WE, Sanders GD, Pietzsch JB, Yamada S, Nguyen L, Garber AM.
Pediatrics. 2002 Sep;110(3):471-80.


Rapid detection 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.



Resources - About Group B Strep (GBS)



News! Flash!  The Cochrane Collaboration Announces that
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 Disease.



Group B Strep: what you need to know from Gloria Lemay's Wise Woman Way of Birth



Is CDC GBS Protocol for Performing Rectovaginal Culture for GBS at 35-37 Weeks of Pregnancy and Subsequent Antibiotic Prophylaxis for Full Term GBS Positive Women Biased? Critical Analysis of: Centers for Disease Control and Prevention of Perinatal Group B Streptococcal Disease. [free full text from webmedcentral.com]

Ms. Judy S Cohain

A review of the literature shows that birthing the fetus into water has the lowest rates of Early Onset Newborn GBS (EOGBS). A single case of early onset newborn GBS was reported among 4,432 hospital births into water in the absence of antibiotic prophylaxis (1,2) suggesting a 300% lower rate of EOS among low risk women giving birth into water compared to 1/1,450 currently for hospital births into air where CDC protocols are adhered to (3). Possible theories to explain this might be:
1) Inoculating the baby with mother’s intestinal flora at birth is protective;
2) Bath water dilutes GBS acquired during the descent among a multitude of competitive intestinal bacteria;
3) EOS is prevented by lower level of interventions and kangaroo care at water birth promoting maternal/fetal immune function.
From the data in hand, the most effective way to prevent EOS is to deliver a baby is into very warm water.

Midwife Informed Consent for GBS Screening and Midwife Informed Consent for Group B Strep Carriers (Positive Screen) by Ronnie Falcao, LM MS



What's the Deal with Group B Strep (GBS) by Eva Goodfriend-Reano, CNM, NP, RN

Midwest 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 Strep testing.


Early-Onset and Late-Onset Neonatal Group B Streptococcal Disease - United States, 1996-2004
MMWR.  2005;54(47):1205-1208.

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 GBS.]



Vaginal-perianal compared with vaginal-rectal cultures for identification of group B streptococci.
Jamie WE, Edwards RK, Duff P.
Obstet Gynecol. 2004 Nov;104(5 Pt 1):1058-61.

"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."

Vaginal-Perianal Cultures for Strep B Preferred in Pregnancy [8/10/11]


This is a great summary of the issues - GROUP B 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.

Risk Factors for Group B Streptococcal Genitourinary Tract Colonization in Pregnant Women.
Stapleton RD, Kahn JM, Evans LE, Critchlow CW, Gardella CM.
Obstet Gynecol. 2005 Dec;106(6):1246-1252.


Invasive Group 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:

Herbal Treatments for Group B

and another:

Treating Group B Strep: Are Antibiotics Necessary?
By Christa Novelli
Issue 121, Nov/Dec 2003

And here's a backup copy from the Holistic Pediatric Association.


Preventing Group B Strep Disease from the CDC, including links to patient education materials from the ACNM and ACOG.

Universal Screening Algorithm

Patient education brochure


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 (GBSA)


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 chlorhexidine during labour to prevent neonatal group B streptococcal infection (Cochrane Protocol)


An Update on Perinatal Group B Streptococcal Disease [11/14/02] [Medscape registration is free]


Group B Strep: A Patient/Provider Approach for Optimizing Care by James Allan McGregor, MD, CM,, from OBGYN.net


Prevention of early-onset invasive neonatal group B streptococcal disease in a private hospital setting: the superiority of culture-based protocols.
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."

The Influence 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.

Self-collection of 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.


Method for Culturing Group B Streptococci from Pregnant Women (from the AAFP site)


Procedure for collecting and processing clinical specimens for culture of group b Streeptococcus (from the CDC site) - search for "Table_B1"


Client Information & Consent  for Group B Streptococcal Infections from Faith Gibson


The March of Dimes has some information for parents:

and some information for Professionals and Researchers:

CDC document which is a client brochure which you can reproduce.


CDC's Prevention of Perinatal Group B Streptococcal Disease: A Public Health Perspective
MMWR 45(RR-7);1-24 - Publication date: 05/31/1996


Another GBS Parents Page and e-mail distribution list



Sources of GBS Infection



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.



GBS in Urinary Tract




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.



Misinterpretation of Midstream Urine Culture Results Leads to Inappropriate Treatment of UTI
by Sarah Bruyn Jones | December 4, 2013

 . . . 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.



Negative Effects of Antibiotic Therapy



See also: Bonding and Baby Birth Trauma / Effects of Antibiotics on Baby's Health


Association of 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.

Germs Take 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 against infections.


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.

Clinical Presentation 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.

Use of 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.


The importance of prenatal exposures on the development of allergic disease: a birth cohort study using the West Midlands General Practice Database.
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 Manual).


Rise in E. coli Is Found in Premature Infants

In a dangerous boomerang effect apparently caused by antibiotics, E. coli is on the rise among premature babies and has overtaken strep as the most common infection in such infants, a new study suggests.

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.

Changes in pathogens causing early-onset sepsis in very-low-birth-weight infants.
Stoll BJ, Hansen N, Fanaroff AA, Wright LL et al.
N Engl J Med 2002 Jul 25;347(4):240-7


Check related 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?



Lower Risk in Women with Antibodies



Some years ago, there was a lot of attention paid to trying to identify the Group B Strep carriers who were at greatest risk of passing on a serious infection to their baby.  There were some findings that it was the women with lowest antibody levels who were at greatest risk.  This may be the same effect as with neonatal herpes - if the infection is of recent origin and the mother hasn't built up antibody levels to pass on to the baby, the baby is going to be at greater risk.

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!

Prevalence of 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.

Group B 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.


A prospective study of group B streptococcal bacteriuria in pregnancy.
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.

Can group 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.

Danny Tucker's 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 infection.


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 info.  Thanks.


Well, at least these people are discussing the issue:

Measurement of human antibodies to type III group B Streptococcus. [Full-text article]
Kasper DL, Wessels MR, Guttormsen HK, Paoletti LC, Edwards MS, Baker CJ.
Infect Immun 1999 Aug;67(8):4303-5


Correlation of 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.


Reducing GBS Colonization with Alternative Treatments and GBS Treatment for Homebirth



See also: Lavage w/Chlorhexidine and Oral Antibiotics in Labor


Homeopathic Regimen

There hasn't been much discussion of homeopathic treatments for GBS, but naturopaths sometimes recommend a homeopathic form of penicillin in combination with a Candida treatment available from Natural Health Care: Pure Health Systems!

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


Probiotics

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


The Art of Midwifery: Good Digestive Flora for GBS and Alternative Protocols for Dealing with GBS from Midwifery Today


Alternate treatments to reduce strep - Midwifery Updates, Summer Conference 2002 - Gail Hart©


Group B 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 infection."


Reducing GBS Colonization with Alternative Treatments


Group B Strep (GBS) and Homebirth - a handout by Kate Adamson


GBS Treatment for Homebirth



Lavage w/Chlorhexidine




Hibiclens Discussion (for GBS+ women) from the Navelgazing Midwife Blog

In an informed consent/refusal form for group B strep, it is noted: "A new protocol calling for use of chlorhexidine as a vaginal lubricant or wash for GBS moms to prevent or reduce vertical transmission.  This surgical wash has proven effective against strep in dental use, and use of this product has been used in obstetric wards for many years, but not as a specific deterrent for strep."

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 works.


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.



One of the reasons I actually PREFER for my clients to choose chlorhexidine over antibiotics is that I believe it's more effective.  In particular, it sidesteps all the problems associated with infections from antibiotic resistant bacteria, and it allows for the normal colonization of newborn skin and gut that is supposed to happen at birth.

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.



Chlorhexidine vaginal flushings versus systemic ampicillin in the prevention of vertical transmission of neonatal group B streptococcus, at term.
Facchinetti F, Piccinini F, Mordini B, Volpe A.
J Matern Fetal Neonatal Med. 2002 Feb;11(2):84-8.

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.

Vaginal disinfection 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

Chlorhexidine versus sterile water vaginal wash during labor to prevent peripartum infection.
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.


Can group 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.


Chlorhexidine Vaginal Flush Protocol for GBS

Candidates: GBS positive women in labor or with ruptured membranes who have declined IV antibiotic prophylaxis.

Source abstracts

Int J Antimicrob Agents 1999 Aug;12(3):245-51(Department of Gynecology and Obstetrics, Aker Hospital, University of Oslo, Norway)
This prospective controlled trial demonstrated that vaginal douching with 0.2% chlorhexidine during labor 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.

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.

Oral Antibiotics in Labor



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 days.


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 hospital!


Treatment for GBS at a Homebirth in an Illegal State

I live in a state where midwifery isn't licensed.  I'm planning a homebirth but tested positive for GBS in a previous pregnancy.  I'm not at all sure what to do. My midwife can't prescribe antibiotics.  Do I have any alternatives other than planning  a hospital birth?

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 homebirth.



Antibiotic Injections for Mom or Baby



Efficacy of 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 given.


Persistence of penicillin G benzathine in pregnant group B streptococcus carriers.
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.



Protocols



Archival Pages about GBS Protocols from around the time the CDC/ACOG/AAP Consensus Guidelines were released in 1997?



Antibiotic Alternatives to Penicillin



[from ob-gyn-l]


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


Macrolide (erythromycine)


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 individuals.



Dangers of Penicillin



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 anaphylaxis.


There are studies that show the potential for causing asthma after exposure to ABX in pregnancy or early newborn life.
 

The prenatal 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.
 

Does the 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.



Repeat Pregnancies and GBS



[from ob-gyn-l]


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 treat her?


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.



Prolonged Rupture in GBS Negative Woman



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.



Saline in "Hep Locks"



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.



Breastfeeding/Nursing and GBS



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.



Evaluating Newborns for Risk of Becoming Ill from GBS Colonization



Prospective studies 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 baby!



GBS as a Sexually Transmitted Disease (STD) or Infection (STI)



In her book, Physiology in 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 effect.


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 pages 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 Pregnancy Association.


The relationship 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.


The epidemiology 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 from 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.


Colonisation of 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 pregnancy.



Historical Documents



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?



About 10 years ago.  I remember watching it happen.  In Woman's Day and Redbook there started appearing articles by women who said "My baby could have been saved if my doc had performed this simple test."  The medico-legal world responded to the "suage" (suits) by imposing this new standard.


Hopes for Vaccine



Intranasal Vaccine 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 Strep Vaccine!?!


Search for 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 devastating infection."


Italian team finds vaccine against strep infections
June 1, 1998


Immune response 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.

 




SEARCH gentlebirth.org

Main Index Page of the Midwife Archives

Main page of gentlebirth.org         Mirror site

Please e-mail feedback about errors of fact, spelling, grammar or semantics. Thank you.

Permission to link to this page is hereby granted.
About the Midwife Archives / Midwife Archives Disclaimer