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PAPERS: Sam Oddie and Nicholas D Embleton Risk factors for early onset neonatal group B streptococcal sepsis: case-control study BMJ 2002; 325: 308 [Abstract] [Full text]

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Prevention of early-onset GBS sepsis

philip owen   (13 August 2002)

Risk Factors for Group B streptococcus

Kathryn Beardsall   (24 August 2002)

Prophylaxis does not seem to have been widely used

Sam J Oddie   (27 August 2002)

Prevention of early-onset GBS sepsis 13 August 2002
philip owen, consultant obstetrician Princess Royal maternity Unit, Glasgow,Scotland Send response to journal: Re: Prevention of early-onset GBS sepsis	Editor-Oddie & Embleton rightly highlight the dangers of and risk -factors for early onset group B streptococcal (GBS) sepsis(1). When their data is retrospectively analysed they estimate that most affected cases (78%) could have received effective antenatal/intra-partum prophylaxis but accept that this interpretation might be an overestimate. Our maternity unit recently introduced a protocol for selective intra -partum GBS prophylaxis based upon recognised clinical risk-factors(2) and subsequently audited our practice with respect to whether eligible women received adequate prophylaxis or not. Over an initial 4 week period 10.3% of 359 women were eligible for antibiotic prophylaxis but only 32% of those eligible received adequate prophylaxis. Following minor changes to the protocol and staff education, a re-audit over a subsequent 4 week period identified 13% of 378 women eligible with 42% of those eligible receiving adequate prophylaxis(3). This represents but a modest improvement. This audit represents actual clinical practice in a teaching hospital delivery suite. When guidelines for GBS prophylaxis are being designed, the difference between what might be achieved (78%(1)) and that which is achieved (32 to 42%(3)) needs to be recognised. Philip Owen MD MRCOG Consultant Obstetrician Princess Royal Maternity Unit, Alexandra Parade, Glasgow, Scotland philipowen1@hotmail.com References. 1.Oddie S, Embleton ND Risk factors for early onset neonatal group B streptococcal sepsis:case-control study BMJ 2002;325:308-11. 2.American Academy of Pediatrics Committee on Infectious Diseases, Committee on Fetus and newborn. Revised guidelines for prevention of early -onset Group B streptococcal (GBS) disease. Pediatrics 1997;99:489-96. 3.McCord N,Owen P, Powls A, Lunan B A complete audit cycle of intrapartum group B streptococcus prophylaxis. Health Bulletin.2001;59:263 -267.
Risk Factors for Group B streptococcus 24 August 2002
Kathryn Beardsall, Clinical Research Fellow University of Cambridge Send response to journal: Re: Risk Factors for Group B streptococcus	I read with interest the article by the Northern Neonatal Network on the risks for early onset neonatal group B streptococcal sepsis. I would like to question the basis for some of the authors’ conclusions. Since the revised American guidelines for treatment of group B streptococcus were published in 1997 (1) there has been increasing medical awareness of the problems of this perinatal infection, and introduction of treatment regimens by obstetricians. This study was performed over a period from April 1998 to 2000 and therefore during a period in which most hospitals will have had some kind of obstetric guidelines in place. The authors do not comment on what constituted their local guidelines or how widely they were being implemented during the study period. The implementation of guidelines and use of antibiotics in the maternal population will of course have significant impact on disease in the neonatal population. For example, if all pyrexial mothers were treated with intravenous antibiotics then the probability of an infant from one of these pregnancies having positive blood cultures is very small. This will reduce the prevalence of pyrexia as a risk factor in the neonatal population, and the calculated odds ratio for this risk factor will be artificially low. My concern as to there being a problem of potential cases that will have been “missed” due to maternal prophylaxis is supported by the reported incidence of 0.57/1000 live births. Previous reports in the United Kingdom, prior to the implementation of group B streptococcal prophylaxis regimens, but using similarly strict criteria for case definition, have reported incidences of up to 1.15/1000 live births (2). It would be interesting to know what percentage of the obstetric population were treated with prophylactic antibiotics? I would agree that odds ratios for a British population will help in developing prophylactic guidelines but we must be cautious in over interpreting data that is obtained in a period when prophylaxis is already being used. By doing so we will obtain inaccurate information on true risks, and are in danger of targeting the wrong population. Yours sincerely Dr Kathryn Beardsall Clinical Research Fellow University of Cambridge Addenbrookes Hospital Hills Road Cambridge CB2 2QQ 1. American Academy of Pediatrics Committee on Infectious diseases and committee on fetus and Newborn. Revised guidelines for prevention of early onset group B streptococcal (GBS) infection. Pediatrics 1997;99:489-96. 2. Beardsall K, Thompson MH, Mulla RJ. Neonatal group B streptococcal infection in South Bedfordshire, 1993-1998. Arch Dis Child Fetal Neonatal Ed 2000;82(3):F205-7.
Prophylaxis does not seem to have been widely used 27 August 2002
Sam J Oddie, Higher Specialist Trainee in Neonatology Royal Victoria Infirmary, Victoria Road, Newcastle upon Tyne NE1 4LP Send response to journal: Re: Prophylaxis does not seem to have been widely used	We would like to thank Dr Beardsall for drawing attention to the possibility that use of intrapartum antibiotic prophylaxis might have been sufficiently widespread to have affected our measurement of a birth prevalence of early onset group B streptococcal disease. We were very conscious of this possibility, and indeed with prophylaxis becoming more widespread, we were conscious that the timing of our study allowed us an opportunity to perform a population based study, based on examination of the clinical records of prospectively collected cases from various sources, before the use of intrapartum antibiotics became any more widespread. We surveyed senior midwives and obstetricians to determine presence or absence and content of policies on intrapartum antibiotic prophylaxis. As stated in the text only 11 of the 13 units had a policy at all. The content of the policies suggested that some well recognised risk factors would not have led to the use of intrapartum antibiotics. With specific regard to intrpartum fever, 2 of 13 responding units believed their policy did not mandate intrapartum antibiotic prophylaxis where there was intrapartum fever. Furthermore in only 8 of the 13 responding hospitals did either a midwife or a senior doctor believe that the use of intrapartum antibiotics would certainly follow intrpartum fever on their delviery suite. Indeed as someone who has examined large numbers of records for this and similar studies, I would caution that intrapartum temperature is not always all that frequently recorded. Finally from the controls it is possible to get some impression of how widely intrpartum antibiotics were actually used during the study period. The drug chart of each case and control woman was examined for evidence of antimicrobial therapy. Four of 147 control women appear to have had antibiotics (last sentence of results section). We must be cautious in interpreting this figure, as the numbers are small, and the controls are not strictly speaking necessarily representative of the background population of the region. However that intrapartum antibiotics were used so infrequently in the controls suggests that their use was not widespread in the region in the study period. Yours sincerely Sam Oddie