SD16 - Detection, Prevention and Treatment of Group B Streptococcus Infection (GBS)


Executive Summary:
Since its emergence in the 1970's;group B streptococcal (GBS) disease has been the leading bacterial infection associated with illness and death among newborns in the United States. A protocol would provide guidance to health care professionals and women of childbearing age on how to adequately detect, prevent and treat GBS infection. The Virginia Center for Health Statistics reports seven infants died from GBS infection from 1990-1994. According to Virginia Health Information (VHI), in 1994 there were 139 cases of hospitalized neonates under 30 days old, with 129 of these cases being infants under 8 days old, with the diagnosis of GBS infection. A hospital neonatal chart review from Region 5 Northern Virginia Regional Perinatal Coordinating Council (RPCC) indicates that GBS infections may be under reported as a causative factor in infant deaths. From this chart review, GBS infection was listed as a contributing factor in 7 infant deaths in 1992, 5 deaths in 1993 and 5 deaths in 1994. GBS was not listed as the underlying cause of death in any of these reviews. Individual chart reviews and VHI data may more accurately capture the incidence of GBS infection, because GBS is often listed as a contributing cause of death, with sepsis listed as the cause of death on the death certificates. Sepsis is a broader term that encompasses all types of infection, while GBS is the specific organism that causes the infection.

Senate Joint Resolution (SJR) 51 passed by the 1996 General Assembly, requests the Commissioner of Health to assemble a panel of experts to develop a protocol for the detection, prevention and treatment of Group B Streptococcus (GBS). The Commissioner is further requested to include representatives on this panel from the Virginia Chapters of the American Academy of Pediatrics (AAP), the American College of Obstetricians and Gynecologists (ACOG), the Virginia Perinatal Association (VPA), and the Medical Society of Virginia.

The panel of experts met on June 10, 1996 to review GBS incidence and mortality data and the current GBS protocols of professional organizations. The Centers for Disease Control and Prevention (CDC) document published May 31, 1996 is endorsed by the AAP and ACOG. ACOG's Committee Opinion (Number 173, June 1996) on Prevention of Early-Onset Group B Streptococcal Disease in Newborns was distributed and discussed at the meeting. ACOG supports the CDC guidelines which is reflected in the Committee Opinion. AAP will be publishing its Policy Statement on Group B Streptococcus in Newborns in July 1996. Guidelines for Perinatal Care, 4th Edition published by AAP and ACOG, will be printed with the CDC guidelines for GBS in the new text. The professional organizations have agreed to adopt the CDC guidelines and their own publications reflect this position. The panel acknowledged the extensive research CDC has devoted to the development of the guidelines and agreed that the state of Virginia should adopt them. The panel recommends supporting the CDC protocol but not legislating the protocol. A brief overview of the CDC recommendations follows:

Screening-Based Approach

All pregnant women should be screened at 35-37 weeks' gestation for vaginal and rectal GBS colonization. Patients should be informed of screening results and of potential benefits and risks of intrapartum antimicrobial prophylaxis for GBS carriers. Information systems should be developed and monitored to ensure that prenatal culture results are available at the time and place of delivery. Intrapartum chemoprophylaxis should be offered to all pregnant women identified as GBS carriers by culture at 35-37 weeks' gestation. Women who develop rupture of membranes or labor before 37 weeks, in the absence of a negative GBS culture, should be given intrapartum chemoprophylaxis as well.

Risk-Factor Approach

A prophylaxis strategy based on the presence of intrapartum risk factors alone (e.g., 37 weeks' gestation, duration of membrane rupture greater than or equal to 18 hours or temperature greater than or equal to 100.4F) is an acceptable alternative. Women who develop membrane rupture without labor, before 37 weeks' completed gestation should have a vaginal and rectal culture collected and may be treated with antimicrobial prophylaxis until culture results become available.

The panel recommends supporting the CDC protocol but not legislating the protocol. By publicizing the long awaited CDC guidelines, it will decrease some of the confusion that health care providers currently have. The panel supported the CDC recommendations with the prenatal screening at 35-37 weeks algorithm. The panel agreed that the screening-based approach which prevents 86% of early-onset neonatal GBS disease is preferable to the risk-factor approach which prevents only 68.8% of early-onset neonatal GBS disease (Appendix 4). The panel strongly encourages women to discuss this issue with their health care provider and supports proper testing procedures for obtaining specimens and proper lab medium.

The utilization of improper culture mediums and inappropriate site of cultures was discussed by the panel at length. It was agreed that lack of information and knowledge by health care providers and laboratories about the appropriate culture media and correct culture sites is evident. Insurance coverage for these cultures needs to be investigated. Both CDC approaches listed above, require laboratories to use appropriate culture methods for collection of GBS from vagina-rectal swabs. Some insurance companies pay for a screening test but not a culture, or require a screening test before reimbursing for a culture. Due to the low specificity of GBS screening tests, with none of them having greater than 80% accuracy, the screening test is not considered reliable.

The panel also recommended that a statewide educational campaign on GBS and the new CDC guidelines is necessary. A campaign to educate women of childbearing age about GBS will also increase the amount of women who will talk to their health care provider about this disease. The campaign will reflect a preference for the screening-based approach over the risk-factor based approach. Educating the laboratories, insurance companies and hospitals about these state supported guidelines will increase their compliance with the accepted manner of testing individuals for GBS colonization.

The statewide campaign should include:

• A fact sheet on the diagnosis, prevention and treatment of GBS with a letter from the Commissioner to be mailed to health care providers, labs, hospitals, and insurance companies. The letter would include advising all perinatal care providers to discuss GBS infection with pregnant women and employ the prevention strategies recommended by the CDC.

• A brochure to be developed in cooperation with the Group B Streptococcus Association to educate women of childbearing age.

The cost to implement this statewide campaign would be approximately $17,000.00. Funding would have to be sought either through public/private partnership or Virginia Department of Health support.

The panel also recommended developing a method for collecting data about GBS infection in Virginia in order to document progress in educating the public on GBS and the CDC guidelines. If progress in educating both professionals and women of childbearing age is successful, GBS infections and deaths of Virginia's newborns should be decreased. Working in cooperation with Virginia Health Information to track this data is an important strategy. In addition, the panel recommended insurance companies cover the cost of GBS cultures with no prerequisite for initial GBS screening test.