Prevention of Early-onset Group B Streptococcal Disease (Green-top Guideline No. 36)

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Post category

Corresponding Author

the Royal College of Obstetricians, Gynaecologists

Publish date

09/13/2017
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Comment count

Executive summary

Information for women

What information should women be given about group B streptococcal (GBS) colonisation of the mother and the risk of neonatal infection, during pregnancy and after delivery?

All pregnant women should be provided with an appropriate information leaflet. [New 2016]

Grade of recommendation: ✓

Antenatal screening

Should all pregnant women be offered bacteriological screening for GBS?

Universal bacteriological screening is not recommended.

Grade of recommendation: D

What are the clinical risk factors that affect the risk of GBS disease?

Clinicians should be aware of the clinical risk factors that place women at increased risk of having a baby with early-onset GBS (EOGBS) disease. [New 2016]

Grade of recommendation: ✓

Should women be offered intrapartum antibiotic prophylaxis (IAP) if GBS was detected in a previous pregnancy, irrespective of carrier status this pregnancy?

Explain to women that the likelihood of maternal GBS carriage in this pregnancy is 50%. Discuss the options of IAP, or bacteriological testing in late pregnancy and then offer of IAP if still positive. [New 2016]

Grade of recommendation: B

If performed, bacteriological testing should ideally be carried out at 35–37 weeks of gestation or 3–5 weeks prior to the anticipated delivery date, e.g. 32–34 weeks of gestation for women with twins. [New 2016]

Grade of recommendation: C

Should women with a previous baby affected by GBS disease be offered IAP irrespective of carrier status this pregnancy?

IAP should be offered to women with a previous baby with early- or late-onset GBS disease.

Grade of recommendation: D

What screening tests (if any) should be offered if a woman requests testing for carrier status?

A maternal request is not an indication for bacteriological screening. [New 2016]

Grade of recommendation: D

Antenatal care

How should GBS bacteriuria in the current pregnancy be managed?

Clinicians should offer IAP to women with GBS bacteriuria identified during the current pregnancy.

Grade of recommendation: C

Women with GBS urinary tract infection (growth of greater than 10 5 cfu/ml) during pregnancy should receive appropriate treatment at the time of diagnosis as well as IAP. [New 2016]

Grade of recommendation: C

Should women be treated before the onset of labour if GBS carriage is detected incidentally earlier in the pregnancy?

Antenatal treatment is not recommended for GBS cultured from a vaginal or rectal swab.

Grade of recommendation: C

Should the management differ if the detection of GBS is incidental or following intentional testing, and if so, how?

Where GBS carriage is detected incidentally or by intentional testing, women should be offered IAP. [New 2016]

Should being a GBS carrier influence the method of induction?

Method of induction should not vary according to GBS carrier status. [New 2016]

Grade of recommendation: ✓

Is being a GBS carrier a contraindication to membrane sweeping?

Membrane sweeping is not contraindicated in women who are carriers of GBS. [New 2016]

Grade of recommendation: D

How should planned caesarean section in women with known GBS colonisation be managed?

Antibiotic prophylaxis specific for GBS is not required for women undergoing planned caesarean section in the absence of labour and with intact membranes.

Grade of recommendation: C

Management of term labour (including rupture of membranes) to reduce the risk of EOGBS disease

How should rupture of membranes in a woman at term (37+0 weeks of gestation) with known or unknown GBS carrier status be managed?

Women who are known GBS carriers should be offered immediate IAP and induction of labour as soon as reasonably possible.

Grade of recommendation: C

In women where the carrier status is negative or unknown, offer induction of labour immediately or expectant management up to 24 hours. Beyond 24 hours, induction of labour is appropriate. [New 2016]

Grade of recommendation: A

How should labour in a woman with a temperature of 38°C or greater and without known GBS colonisation be managed?

Women who are pyrexial (38°C or greater) in labour should be offered a broad-spectrum antibiotic regimen which should cover GBS in line with local microbiology sensitivities.

Grade of recommendation: C

How should preterm labour be managed in women without known GBS colonisation?

IAP is recommended for women in confirmed preterm labour. [New 2016]

Grade of recommendation: D

IAP is not recommended for women not in labour and having a preterm planned caesarean section with intact membranes. [New 2016]

Grade of recommendation: D

Is there a role for polymerase chain reaction or other near-patient testing at the onset of labour?

Polymerase chain reaction or other near-patient testing at the onset of labour is not recommended. [New 2016]

Grade of recommendation: C

Can GBS-positive women have a water birth?

Birth in a pool is not contraindicated if the woman is a known GBS carrier provided she is offered appropriate IAP. [New 2016]

Grade of recommendation: D

Management of preterm labour (including rupture of membranes) to reduce the risk of EOGBS disease

Women with preterm rupture of membranes

How should known or unknown GBS carrier status be managed in women with preterm prelabour rupture of membranes?

Bacteriological testing for GBS carriage is not recommended for women with preterm rupture of membranes. IAP should be given once labour is confirmed or induced irrespective of GBS status. [New 2016]

Grade of recommendation: D

For those with evidence of colonisation in the current pregnancy or in previous pregnancies, the perinatal risks associated with preterm delivery at less than 34 +0 weeks of gestation are likely to outweigh the risk of perinatal infection. For those at more than 34 +0 weeks of gestation it may be beneficial to expedite delivery if a woman is a known GBS carrier. [New 2016]

Grade of recommendation: D

Bacteriological considerations

What are the appropriate swabs if testing for carrier status is to be undertaken?

When testing for GBS carrier status, a swab should be taken from the lower vagina and the anorectum. A single swab (vagina then anorectum) or two different swabs can be used. [New 2016]

Grade of recommendation: D

How quickly should the swabs be transported to the laboratory, in what medium and at what temperature?

After collection, swabs should be placed in a non-nutrient transport medium, such as Amies or Stuart. Specimens should be transported and processed as soon as possible. If processing is delayed, specimens should be refrigerated. [New 2016]

Grade of recommendation: B

What culture medium should be used if testing for GBS carriage is to be undertaken?

Enriched culture medium tests are recommended. The clinician should indicate that the swab is being taken for GBS. [New 2016]

Grade of recommendation: B

Which antibiotic should be used for IAP?

For women who have agreed to IAP, benzylpenicillin should be administered. Once commenced, treatment should be given regularly until delivery.

Grade of recommendation: B

Which antibiotic should be used in women with known or suspected penicillin allergy?

Provided a woman has not had severe allergy to penicillin, a cephalosporin should be used. If there is any evidence of severe allergy to penicillin, vancomycin should be used. [New 2016]

Grade of recommendation: ✓

How should known GBS colonisation in women who decline IAP be managed?

Women with known GBS colonisation who decline IAP should be advised that the baby should be very closely monitored for 12 hours after birth, and discouraged from seeking very early discharge from the maternity hospital. [New 2016]

Grade of recommendation: ✓

What are the adverse effects of IAP (maternal anaphylaxis, altered neonatal bowel flora and abnormal child development)?

Clinicians should be aware of the potential adverse effects of IAP. [New 2016]

Grade of recommendation: C

Should vaginal cleansing be performed in labour and does this differ according to GBS carrier status?

There is no evidence that intrapartum vaginal cleansing will reduce the risk of neonatal GBS disease.

Grade of recommendation: C

How should a newborn baby be managed?

If there have been any concerns about early-onset neonatal infection, what signs should prompt parents and carers to seek medical advice?

Parents and carers should seek urgent medical advice if they are concerned that the baby:

Grade of recommendation: D

  • is showing abnormal behaviour (for example, inconsolable crying or listlessness), or
  • is unusually floppy, or
  • has developed difficulties with feeding or with tolerating feeds, or
  • has an abnormal temperature unexplained by environmental factors (lower than 36°C or higher than 38°C), or
  • has rapid breathing, or
  • has a change in skin colour. [New 2016]

How should term babies whose mothers have received adequate IAP be managed?

Term babies who are clinically well at birth and whose mothers have received IAP for prevention of EOGBS disease more than 4 hours before delivery do not require special observation. [New 2016]

Grade of recommendation: ✓

The babies of women who have received broad-spectrum antibiotics during labour for indications other than GBS prophylaxis may require investigation and treatment as per the NICE clinical guideline on early-onset neonatal infection. [New 2016]

Grade of recommendation: ✓

How should well babies at risk of EOGBS disease whose mothers have not received adequate IAP be monitored?

Well babies should be evaluated at birth for clinical indicators of neonatal infection and have their vital signs checked at 0, 1 and 2 hours, and then 2 hourly until 12 hours. [New 2016]

Grade of recommendation: ✓

Should postnatal antibiotic prophylaxis be given to low-risk term babies?

Postnatal antibiotic prophylaxis is not recommended for asymptomatic term infants without known antenatal risk factors.

Grade of recommendation: C

How should a baby with clinical signs of EOGBS disease be managed?

Babies with clinical signs of EOGBS disease should be treated with penicillin and gentamicin within an hour of the decision to treat. [New 2016]

Grade of recommendation: ✓

How should the baby of a mother who has had a previous baby with GBS disease be managed?

Babies should be evaluated at birth for clinical indicators of neonatal infection and have their vital signs checked at 0, 1 and 2 hours, and then 2 hourly until 12 hours. [New 2016]

Grade of recommendation: ✓

What advice should be given to women regarding breastfeeding?

Breastfeeding should be encouraged irrespective of GBS status. [New 2016]

Grade of recommendation: ✓

Pathway of care

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