Issues Involved in the Management of Women Who Are Group B Streptococcus Positive - Literature review Example

GBS IN PREGNANCY Name : LeeAnne Smith Student Number : 30052248 Course : HCMDW 6912 Word Count : 2832 Date :6/9/2012 Introduction Universal screening for Group B Streptococcus (GBS) in pregnancy is offered to all Australian women and is carried out routinely at about 36 weeks (Walker, 2012). GBS, also referred to as streptococcus agalactiae, is arguably one of the leading causes of life-threatening bacterial infections presently screened for, and affects between 10-30 percent of the Australian pregnant women population. About one out of every three women carries the infection within their bowel, and it colonizes the vagina in every one out of four women (RANZCOG, 2011). According to Walker, (2012) the vertical disease transmission rate in unborn babies is lower in the sense that 12 out of 1000 newborns of infected mothers develop early signs of GBS. Nevertheless, GBS causes a great deal of health implications on a newborn baby. If the infection is not treated, it approximated that one out of each 200 babies born with an infected mother, is likely to suffer from life threatening complications such as neonatal sepsis, blood poisoning, meningitis and pneumonia. Some recent evidence suggests that increasing the use of antibiotics for treatment of GBS in pregnancy may lead to complications of antibiotic resistance and subsequent difficulties in treating infection (McIntosh, 2011, Novelli, 2003). This academic paper will firstly define GBS and antenatal screening, followed by identification and critical analysis of current evidence of the issues involved in the management of women who are GBS positive. GBS is defined a bacterial infection caused by a bacterium referred to as Streptococcus agalactiae. The infection affects women during pregnancy essentially those women who are not frequently treated using antibiotics. GBS can categorically be linked to the same family bug as that of the sore throats. However, the bacterium that causes GBS is not similar to the one that causes the sore throats (RANZCOG, 2011). On the other hand, universal screening entails screening of every individual in a particular category for instance in terms of age. Universal screening for GBS therefore involves performing tests in order to detect the existence of Streptococcus agalactiae bacterium in pregnant women (Walker, 2012). GBS infection is usually characterized by a number of (multiplicities) of clinical features; but the typical discovery is the quickly developing areflexic ascending motor paralysis of the extremities. A two-sided facial paralysis has also been reported as the initial sign in approximately 50 percent of the GBS patients (Iannello, 2004).Another characteristic of GBS is reduced or lacking profound reflexes of the tendon and slight sensory symptoms may as well be seen. On the other hand, a number of GBS patients can display significant weight loss in addition to cranial nerve deficits impairing oral intake (very uncommon signs). They are thus argued to be often hypercatabolic and hypermetabolic due to the endocrine, contagious, and inflammatory components of the infection (Iannello, 2004). Issues involved in the Management of Women who are GBS Positive Lack of adherence to guidelines According to the Agency for Healthcare Research and Quality (2011), during the year 2002, the Center for Disease Control and Prevention came up with guidelines urging pregnant women to be screened for GBS between the 35th and 37th of their pregnancy. The guidelines also recommended that if the results prove positive, then the pregnant mothers are to be given intravenous antibiotics four or more hours prior to the delivery of their babies in order to avoid passing the GBS to it. However, according to the Agency for Healthcare Research and Quality (2011), this has not been the case. This is supported by Lockwood (2011), who argues that one of the significant issues involved in the management of women who are GBS positive is the lack of adherence to the prenatal GBS screening and treatment guidelines. Recent studies by Rodriguez, (2011) carried out to determine the current adherence to screening and treatment guidelines in Tennessee, for instance, have revealed that while 85% of the women were screened for this infection, the tests were often carried out too early and not all the women who tested positive for the GBS were given the antibiotics prior to their delivery. Employing the use of a random sample of 877 births, a recent study carried out to determine the current adherence to screening and treatment guidelines as issued by the Centers for Disease Control and Prevention revealed that 26% of the women had the GBS test carried out before the 35th week (Healthcare Research and Quality, 2011). According to the Agency for Healthcare Research and Quality (2011), early screening of the GBS may imply that the providers are not familiar with the guidelines issued by the Center for Disease Control and Prevention. Further, out of the 27% of the women who proved positive for GBS, 39% were not given the recommended antibiotics prior to delivery. Unluckily, out of 40 cases identified, 21 cases occurred in babies whose mothers tested negative for GBS. The Agency for Healthcare Research and Quality (2011) argues that these cases are may be attributed to incorrect-negative tests, early screening or even improper collection of specimens. A recent study in Australia, by Kok and Gilbert (2011) also discloses that although the country has adopted universal screening, 61.4 % of infants born with EOGBS, were born to mothers who had negative screening results. This basically implies that there is lack of proper adherence to the guidelines in the screening of GBs among pregnant women. Resistance Issue Another emerging concern involved in the management of women who are GBS is the alarming increase in the antibiotic resistance strains of the bacteria. According to McIntosh (2011), bacteria are gradually becoming resistant to antibiotics, a disturbing situation that could sooner or later take us back to a similar position when antibiotics had never been discovered. However, according to Davies (2002), no findings have been achieved concerning the resistance of GBS to ampicillin or penicillin. Despite this, more recently there are increasing reports of the GBS resistance to erythromycin and clindamycin recorded in the United States and Canada with levels ranging from 7 percent to 25 percent for erythromycin to 3 percent to 15 percent for clindamycin. Recent research conducted in Alberta, Canada also revealed resistance rates of about 3.0 percent and 5.6 percent to clindamycin and erythromycin respectively (Davies, 2002). Novelli (2003) highlights that existing evidence shows that the frequent use of antibiotics leads to increasing resistance of bacteria. When a pregnant woman is given the antibiotics when undergoing labour in order to treat the GBS infection, the antibiotics cross the placenta and move into the amniotic fluid. McIntosh (2011) supports this and concludes that even though the antibiotics might possess the desired effect of doing away with the bacteria, some of the GBS bacteria may survive and turn out to be difficult or impossible to kill when traditionally-used antibiotics are employed. Similarly, other bacteria, such as the E.coli, present in the infant’s mother or the infant may turn out to be resistant to the antibiotic treatment (Novelli, 2003). The antibiotic resistance strains of the bacteria can lead to infections such as Klebsiella, Pseudomonas and E.Coli in the newborn babies that are difficult to treat (Novelli, 2003). While a number of research have found out that giving out antibiotics during labour to pregnant women who are found positive for GBS reduces the GBS infection rates among the newborns, research is currently revealing that this benefit is being overshadowed by increases of other types of infections (Novelli,2003). For instance, a study investigating blood infection rates among the infants for six year period found out that the use of antibiotics during labour reduced cases of the GBS infection in infants but increased the occurrence of other forms of blood infections such as sepsis, meningitis (infection of the fluid and brain lining, and pneumonia. The general effect was that the frequency of infant blood infection stayed unchanged (Novelli, 2003). According to Davies (2002), another issue of significant concern involved in the management of women who are GBS positive is the issue concerning the probability of a rise in the prevalence of initial inception of sepsis owing to ampicillin-resistant, Esherichia coli or Gram-negative pathogens other than GBS, including the resistant ones. Davies (2002), however, argues that this issue of concern has not come out as a problem. Davies (2002) highlights further that a large number of research, including the population-based ones, are suggesting a stable or declining rates of the non-GBS early onset sepsis with increased usage of intrapartum antibiotic prophylaxis. While various single hospital studies have revealed increased cases (rates) of neonatal sepsis brought about by the Esherichia coli, ampicillin-resistant pathogens, these seem to be limited to low birthweight deliveries. Davies (2002), nonetheless, argues that this area requires a continued monitoring. Timing to recommend the screening The accurate or precise timing to recommend the screening tool forms another major issue involved in the management of women who are GBS positive. The Royal Australian and New Zealand College of Obstetricians and Gynecologists (2012) highlights that if it is recommended around the 35th -37th weeks of pregnancy, then this only makes up a subgroup of pregnant women in the population, as a consequence, it might not fully cover all women with the carrier status. The Royal Australian and New Zealand College of Obstetricians and Gynecologists (2012) argues that the current tool used for screening may take between 16-72 hours before a report is made available in order to give treatment to the patient. This might not be practical for patients who are in labour. Another issue of significant concern involved as far as the management of women who are GBS positive is concerned is that when pregnant women are screened for GBS and treated using the intrapartum antibiotics, it only lowers the risk of early onset of the neonatal GBS infection. Early onset GBS is normally associated with septicemia and pneumonia and the mechanism may be birth-related such as with the infection ascending from the parental genital tract (Gibbs et.al 2004). Conversely, the late onset of the GBS infection is most likely associated with meningitis while the associated acquisition is by means of nosocomial or vertical transmission (Gibbs et.al 2004). The Royal College of Obstetricians and Gynecologists (2012) therefore argues that if there would be a perfect tool for screening, a tool with a higher sensitivity as well as sensitivity, then it could help eradicate the early onset of the GBS neonatal infection. Critical Analysis of the Current Evidence to Support Universal Screening According to Steer (2011), universal screening should be made a routine prenatal practice for pregnant women. This argument can be supported by the fact that there have been significant reductions seen with regards to the rate of early onset of the GBS infection in all the Western countries that have introduced the practice. Kok and Gilbert, (2011) also argue that although a controversy still exists in Australia concerning universal screening versus risk based screening, in terms of the effectiveness of universal screening in the prevention of GBS, Kok and Gilbert, (2011) highlight that compared to the risk based approach, the adoption of universal screening has actually lead to the reduction incidents of GBS among infants and thus according to the two authors universal screening is an effective strategy. Nations such as Germany, Spain, USA, Italy and Australia have been associated with significant falls in death rates resulting from the EOGBS disease since their respective adopting of the screening practice. Steer (2011) argues further that there is no nation known to have presented before and after data that has not revealed a significant fall in the prevalence of the GBS infection after the practiced was introduced. On the contrary, however, Steer (2011) continues to suggest that pregnant women should not to be provided with the regular antenatal screening for the GBS infection since evidence or proof of its clinical as well as cost effectiveness is still uncertain and that more research into its effectiveness and cost effectiveness is needed. Steer (2011) argues that a consistent review of the randomized controlled trials (RCTs) of the intrapartum antibiotics meant for reduction of the perinatal GBS infections have not yet proved any effect on the neonatal deaths from infection. The UK prevalence of the initial inception of Group B Streptococcal has, for instance, risen from the time when the risk-based prevention guidelines were issued by the Royal College of Obstetricians & Gynecologists during the year 2003 and is continuing to do so. As highlighted by McCartney (2012), the Health protection Agency has also found out that the voluntarily or willingly testified cases of GBS screening at 35 to 37th weeks of pregnancy within Northern Ireland, Wales and England have gone up from 229 in the year 2003 to 302 during the year 2010.The prevalence rate of the initial Group B Streptococcal in England, Northern Ireland and Wales is currently 0.4 per 1000 live births. This is higher compared to the United States post universal screening (0.34 per 1000 live births (McCartney, 2012). Rodriguez (2011) also supports the practice of universal screening arguing that most neonatal Group B streptococci infections can be inhibited through screening practices offered to pregnant women at the 35th to the 37th weeks of pregnancy as well as the use of the intrapartum antimicrobial prophylaxis. Rodriguez (2011) further argues that current data reveals that the screening practice actually saves a lot of money in America since the costs incurred in treating the newborns for GBS is usually very high with a number of insurance firms covering the test. However in the Australian context insurance firms may not cover the costs incurred in the management of GBS. According to Rodriguez (2011), the Center for Disease Control estimated the direct medical expenses of neonatal disease prior to prevention to be approximately $294 million yearly. Rodriguez (2011) argues as well that the CDC has come up with prevention guidelines with significant input from the American Congress of Obstetricians and Gynecologists (ACOG), the American Congress of Obstetricians and Gynecologists and the American College of Nurse-Midwives (ACNM). Rodriguez (2011), however, argues that a great number of practitioners are today not executing the recommendations and the preventive strategies citing the risk of adverse or harmful effects of chemoprophylaxis in addition to cost factors. Similarly, Sharma (2011) argues that the universal screening and the treatment for the GBS should not be recommended because there are possible risks of medicalization of the labour and neonatal period, risks of serious anaphylaxis in addition to infection with resistant organisms. In addition, Sharma (2011) also argues that the number of pregnant women that needs to be treated with antibiotics in order to prevent one neonatal death is on the increase. Nevertheless the positive aspect is that universal screening in Australia is cost-effective for the pregnant women, based on the fact that they do not have to pay for the screening. According to McCartney (2012), universal screening to test for the GBS infection should also be carried out as this will enable pregnant women who have been screened, and are GBS positive to have an antibiogram (a method of testing the effectiveness of the antibiotics) in addition to knowing the best antibiotics that are adapted to their situations. In addition to this, McCartney (2012) also highlights that universal screening will enable women with the vaginal Streptococcus B to benefit from induced labour should the amniotic membranes be prematurely raptured since the fetus is expose to the ascending genital infection. McCartney (2012) argues that in France, for instance, screening is recommended between the 34th to the 37th of pregnancy and the results of the screening obtained within 48 hours. According to McCartney (2012), normally there is no antepartum treatment since this particular treatment does not normally inhibit recurrences. Until the labour pain commences pregnant women having the vaginal Streptococcus B were given antibiotics (usually penicillin A or G in the absence of any known allergy) in order to protect the fetus from the genital ascending infection when the amniotic membranes rupture. The antibiotics are stopped postnatally if it is found out that there are no any signs of infection in the newborn baby. Verani et.al (2010), on the other hand, argues that there is incomplete evidence to support universal screening in a number of key areas related to GBS infection prevention, including strategies to inhibit the early-onset of the GBS infection among infants, the role of bacteriuria as a significant risk factor in this era of universal routine screening, the effectiveness of the recommended or the suggested intrapartum antibiotic prophylaxis agents for penicillin-allergic pregnant women who are at risk for anaphylaxis, the effect and effectiveness of the recommendations for secondary prevention of the early-onset GBS infection among the neonates, in addition to the factors contributing towards the higher rate of the early-onset GBS infection cases witnessed among newborn babies born to women with negative prenatal GBS screens. On the other hand, Back et.al (2012) supports the idea of universal screening to test for the GBS infection arguing that this practice has been a significant public health success. Back et.al (2012) further argues that according to the Centers for Disease Control and Prevention (CDC) the prevalence of the neonatal GBS infection, a significant cause of morbidity and mortality (death), has significantly gone down over the last 15 years, from approximately 1.7 cases for each 1000 live childbirths during the early 1990s to approximately 0.34 to 0.37 cases for each 1000 live deliveries in recent years. In contrast, Verani et.al (2010) argues against the current evidence to support universal screening arguing that it has had no measurable impact on the prenatal-onset of the disease (including miscarriages and stillbirths), the late-onset of the GBS infection or the GBS infection among the non-pregnant women. Verani et.al (2010) argues that as a result of the declines in initial stages of GBS infection, the burden that comes with the late-onset infection is currently similar to that of early-onset disease. Verani et.al (2010) also argues that the burden of the prenatal-onset GBS disease has also not been adequately assessed, and that no effective tools for prevention have been identified before the intrapartum period. In addition to this, Verani et.al (2010) argues that GBS infection among non-pregnant women has also increased in recent years. Verani et.al (2010) thus recommends that more research on various preventive measures against the late onset is required. Kok and Gilbert (2011) and Walker (2012) support notion that universal screening of GBS should be performed as a routine based on the fact that it has significantly assisted in the prevention of GBS infections in newborns. Nevertheless Levine et al (1999) argue that the screening should not be routine due to risk factors such as maternal risk issues for instance delivering a neonate who is exposed to the risk of EOGBS. Levine et al (1999) further highlight that ; although universal screening reduces the rate of GBS infection, in the sense that infected mothers can take preventative antibiotics, nevertheless, the use of antibiotics many cause other forms of blood infections in newborns. The Royal Australian and New Zealand College of Obstetricians therefore recommends that in order to implement best practice, there is need to make an introspective comparison of the universal screening of GBS with other methods. This will enable healthcare stakeholders to evaluate whether there is need for combination of the universal screening approach with other approaches. Conclusion This academic paper has found that in spite of an era of noticeable success with universal routine screening, Group B Streptococcus continues to be a major cause of the infectious morbidity and mortality among the newborn babies, and therefore remains a major public health issue. There is also no doubt from the empirical evidence that the current preventive strategies have led to a significant decline in both the GBS as well as other neonatal sepsis rates. It is also clear that important challenges still remain. It may be concluded that continued efforts are required in order to sustain as well as improve on the progresses attained in as far as the prevention of the GBS infection is concerned. There is also the need to examine other potential adverse effects of intrapartum antibiotic propphylaxis, for instance, the emergence of the resistance bacterial anti-microbial or the increased prevalence or severity of the non-GBS neonatal pathogens. States should also be urged to monitor the GBS disease prevalence rate to promote various activities that improve prenatal GBS disease prevention and education, in addition to assessing progress towards national objectives for disease reduction. References Agency for Healthcare Research and Quality. (2012) .Women's Health: Prenatal screening for Group B streptococci often fails to live up to current screening and treatment guidelines. Back, E, Grady, E.J and Back, J. (2012).’’High Rates of Perinatal Group B Streptococcus Clindamycin and Erythromycin Resistance in an Upstate New York Hospital. Journal of Antimicrobial Agents and Chemotherapy. 56(2): 739–742. Davies, H.D. (2002).Preventing Group B Streptococcal Infections: New recommendations, Journal of Pediatrics & Child Health. 7(6): 380–383. Gibbs, R.S, Schrag, S & Schuchat, A. (2004). Perinatal Infections due to Group B Streptococci, Lippincott Williams & Wilkins. Garland, S.M, Cottril, E, Markowski & Pearce, C. (2011). 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