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Intrapartum antibiotic lowered early-onset neonatal GBS sepsis rate
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Nearly a fivefold decrease in the overall incidence of early-onset neonatal group B streptococcus sepsis occurred after a hospital in south India implemented an intrapartum antibiotic policy, according to study findings in The Pediatric Infectious Disease Journal.
Santhanam Sridhar, DNB, of Christian Medical College in Vellore, India, and colleagues studied medical records of infants who tested positive for group B streptococcus (GBS) and their mothers. Records of infants born between 1998 and 2010 were included in the study.
Before 2004, intrapartum antibiotics were administered only to patients with chorioamnionitis or urinary tract infection besides GBS during pregnancy. However, study results published in 2003 showed a prevalence of GBS risk factors among pregnant patients of the south Indian hospital. As a result, since 2004, patients receive intrapartum ampicillin if they experience ruptured membranes for more than 18 hours, a fever of 38°C or higher, threatened preterm labor, premature rupture of membranes, chorioamnionitis, UTI with GBS during pregnancy, or have three or more vaginal examinations.
There were 107,692 live births during the study period; 84 infants tested positive for GBS and 73 infants had early-onset sepsis. The overall incidence of GBS sepsis was 0.76 per 1,000 live births. The incidence rate for early-onset sepsis was 0.68 per 1,000 live births. Escherichia coli was the most common cause of sepsis. Researchers noted a nearly fivefold decrease in the incidence of early-onset GBS sepsis among preterm infants since the implementation of the intrapartum antibiotic policy.
“In our institution, there has been a substantial increase of GBS [early-onset sepsis] compared with 1988-1997. Even after the adoption of [intrapartum antibiotic policy] in the hospital, the rates of GBS in 2004-10 are still higher than the 1990s. This almost certainly points to GBS emerging as a major pathogen causing [early-onset sepsis] in our population. Further studies among newborns in other parts of India and the Indian subcontinent may help elucidate if this increasing trend is seen in other regions as well. Use of [intrapartum antibiotic policy] has long been proven to decrease the incidence of GBS [early-onset sepsis] among newborns. A similar decline was seen in our (study),” the researchers concluded.
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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Carol J. Baker, MD
Invasive GBS early-onset disease (EOD) in neonates was first reported four decades ago in several US tertiary care hospitals. We still do not know why this organism became and remains the most frequent cause of EOD. But what is clear is that GBS as an “emerging” pathogen in other parts of the world is really an emergence of proper surveillance. Even an estimate of incidence requires hospital birth, routine collection of blood and cerebrospinal fluid cultures from ill-appearing neonates and hospital laboratories that can properly process and identify GBS. The final surveillance component, exemplified by the CDC’s ABCs network, is population-based surveillance, which is uncommon except in the United States and a few European countries. Now, with some surveillance components, EOD is being “discovered” in Central and South American countries, Africa and now India.
The article by Sridhar and associates from a single tertiary care hospital in Vellore, India, has the limitations of retrospective design, little information as to the indications for evaluating neonates for EOD or for laboratory processing of specimens during the study period, 1998-2010. This limits the generalization of their findings to all of India, but it does show two things: GBS causes substantial neonatal morbidity and mortality (as in high income countries) and intrapartum antibiotic prophylaxis can prevent some EOD (0.68 to 0.55/1000 live births), an impact limited by lack of antenatal culture screening. However, accumulating data call for GBS vaccine development, the only practical intervention for resource-limited countries.
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