Effects of Group B Streptococcus in Pregnant Women on their Newborns

The healthcare topic I chose for this task if the effects of Group B streptococcus in pregnant women on their newborns that has not been treated or has been under treated. Even though there are guidelines for antibiotic prophylaxis for GBS, this infection is still the leading cause morbidity and mortality for neonates (Women’s Health Care Physicians, 2011). Since the 1990s, there has been an 80% reduction in neonatal sepsis due to GBS thanks to the use of new protocols (Women’s Health Care Physicians, 2011). Since GBS is still a major concern we need to make sure mothers are educated better. There needs to be more education when mothers go to see their OBGYN doctors.

In my opinion, I think the current way that GBS is being handled is moderately effective. The ACOG, has developed algorithms for the prophylaxis and treatment of Group B Strep (Women’s Health Care Physicians, 2011).  The first algorithm is for a patient who has the diagnosis of preterm labor. The patient would then get a culture swab for the infection and start prophylaxis treatment. If the patient is not getting into true labor the prophylaxis treatment would then be stopped. Once the GBS culture swab results are in, if the patient has the infection or if the results aren’t ready and they are still in preterm labor then they will continue with the prophylactic treatment until true labor kicks in. If the results are negative for the infection then no treatment is needed, however the doctor will want another swab to be done at 35-37 weeks of gestation (Women’s Health Care Physicians, 2011).  The second algorithm is for a patient who has a rupture of membranes prematurely. A culture swab is taken, and the patient will begin antibiotic treatment for the infection. If the patient is not in true labor, you continue the treatment for 48 hours or per standard of care if they are receiving the treatment for latency. However, if the patient is in labor you will continue to administer the treatment until delivery. Culture swab results will follow the same protocol as they did for the first algorithm (Women’s Health Care Physicians, 2011).

The ACOG has an algorithm for recommended regimens for prophylactic GBS prevention. If the patient does not have a penicillin allergy, they will take Penicillin G or ampicillin but if they do have an allergy to penicillin then a sensitivity to clindamycin and erythromycin needs to be obtained. If the GBS is sensitive, then you need to 900 mg of clindamycin intravenously every 8 hours until the patient delivers. If the GBS is not sensitive, you will administer 1gm of Vancomycin every 12 hours until delivery. If the patient is not allergic to penicillin, you can give an initial dose of 2gm and then every 4 hours you give 1gm intravenously until delivery (Women’s Health Care Physicians, 2011).

The ACOG’s recommendations for GBS prophylaxis intrapartum are based on previous infants with the GBS disease, women who had GBS bacteriuria at any point during their current pregnancy, have a positive culture swab result during current pregnancy, had an unknown GBS status at labor while also having any other troubles such as delivery before 37 weeks, membrane rupture that was before or at 18 hours and more criteria (Women’s Health Care Physicians, 2011).

In my opinion, I think that every OBGYN office should be more diligent with detecting and treating GBS infections. Culture swabs are a must and if a patient has not gone into labor and delivered by 39 weeks, another culture should be repeated. This, however, is not the standard practice for OBGYNs. I also believe that expecting mothers need to be educated more on the infection, signs and symptoms to look out for, when to visit their OBGYN and also the importance of getting the screening done even if they do not see any outrights signs and symptoms. I do not work in the maternity sector of nursing, but I have friends from Caribbean and African American cultural backgrounds and of lower socioeconomic backgrounds who were pregnant, and they had no idea what GBS was or that they could get screened for it. They tended to go to health clinics not in the best parts of town and were not properly educated. However, I also have friends who are from Caucasian, Hispanic and Asian cultures who were either not told about the screening or were told maybe a brief sentence or two about the screening but were told not to worry about it. The friends who were told about the screening decided to get screened because they wanted to make sure that they would have a healthy pregnancy and delivery. I believe it is something that OBGYNs should offer to expecting mother’s, regardless of race or cultural background, and let them decide if they want to be screened for the infection or not. GBS is not an infection that discriminates, anyone can become infected.

PICO TABLE

The question formulated from the PICO table is: Does the use of prophylactic antibiotics before delivery along with being properly educated about the infection reduce the risk of morbidity and mortality of neonates affected by GBS? I used the WGU library to search for the most current research articles I could find on the standards of treatment and screening for Group B Strep along with how the infection affects neonates and pregnant women. I came across a lot of research and non-research articles that I could take my pick from. I selected 2 research and 2 non research articles that best represented this topic and thus I could collect the most evidence from to formulate this paper. I used research articles, cross sectional prospect study, a quality improvement project and also a protective descriptive study.

The first research article I came across and choose is from the Journal of The College of Physicians and Surgeons, 2016 and it is titled, “Frequency of Group B Streptococci in Pregnant Women in a Tertiary Care Hospital”. The article shows a cross sectional study that was done to see the risk factors of pregnant women with GBS is their last trimester (Munir, Waheed, Khanum, Iqbal, Eusaph, and Hanif, 2016). Culture swabs were taken from 200 pregnant women in their last trimester, ages 20 and older, who did not have any history of ruptured membranes, chronic illness, no vaginal bleeding or intake of recent antibiotics. To analyze qualitative and quantitative date, version 20 of SPSS was used (Munir, et al., 2016).  Using the Chi-square test, categorical variables associated with diagnosing GBS were tested and the study showed that 14 percent of pregnant women in their last trimester actually had the GBS infection colonized in their body (Munir, et al., 2016).  The study also showed a correlation between previous miscarriage, parity and vaginal discharge with the chances of having the GBS infection colonized in pregnant women (Munir, et al., 2016). 

The second research article I used was from Roloff and is titled, “Prevalence of oropharyngeal group B streptococcus colonization, in mother, family, and health care providers. The article wants to show that neonatal GBS exposure potential can come from the serotype and prevalence of oropharyngeal GBS in mothers, health care providers and also a mother’s friends and family of patients who had recently delivered GBS (Roloff, Stepanyan, and Valenzuela, 2018). The study was a single center observational study that focused on the patient, the health care providers who were in close contact to the neonates and also the patient’s friends and family. 373 samples were taken and there was a 26 percent of oropharyngeal GBS colonization in mothers, 22 percent amongst friends and family and 21.6 percent in the health care providers in contact with the neonates (Roloff, et al., 2018). III, V and 1b were the most frequent serotypes (Roloff, et al., 2018). More research needs to be done to truly determine if exposure could cause late or early onset of GBS in a neonate (Roloff, et al., 2018).

The first non-research article I used was from the Medical Laboratory Observer, 2017 and was titled, “Detection methods for prevention of early onset neonatal group b strep infections. The article discussed different methods used detect GBS and how each method was effective (Kawa, 2017).  Isolating GBS via vaginal culture is a traditional method that the article says is not reliable and it does not detect many women who carry the GBS infection (Kawa, 2017). The article discusses how taking a culture takes 24-72 hours which can cause a delay in prophylactic treatment or treating the affected infant. A more up to date method of testing is called Nucleic acid amplification or NAAT for short (Kawa, 2017). This method of testing is based on PCR or polymerase chain reaction or loop mediated amplification and is more simplified that regular DNA hybridization (Kawa, 2017). NAAT turnaround runs from 18-24 hours and have sensitivities from 95 to 99% making it a more superior method to regular vaginal swabs (Kawa, 2017).

The second non-research I used is from BMC Pregnancy and Childbirth 2015 and it titled, “Prevention of bacterial infections in the newborn by pre-delivery administration of azithromycin: Study protocol of a randomized efficacy trial”. This clinical trial was a controlled and randomized double-blind placebo kind of trial (Roca, Oluwalana, Camara, Bojang, Burr, Davis, D’Alessandro, 2015). The study wanted to see how one dose of azithromycin given during labor could impact the outcome of the infant.  The trial also wanted to how interventions on GBS colonization during the first month of life would impact the infant and the mother (Roca, Oluwalana, Camara, Bojang, Burr, Davis, D’Alessandro, 2015). The trial was done in Western Gambia and included pregnant women in labor from the ages of 18-45. 830 women in labor had 2 grams of single dose azithromycin or a placebo administered orally, and a checkup was completed after birth before being discharge as well as 8-10 days after delivery (Roca, Oluwalana, Camara, Bojang, Burr, Davis, D’Alessandro, 2015). The study discovered that streptococcus pneudmoniae, GBS and staph were found in samples of breast milk and also in vaginal swabs from the mothers. The conclusion was that if proper prophylaxis was started after a positive GBS infection was detected, it lowered the chance of the neonate contracting bacterial infections (Roca, Oluwalana, Camara, Bojang, Burr, Davis, D’Alessandro, 2015).

The practice change that is recommended would be to collect culture between 35-37 weeks with a repeat culture being done at 40 weeks if the pregnant woman has not given birth and to have electronic notices for lab results when they come in (Khan, 2015) (Munir, 2016). Using NAAT cultures, as they are more sensitive, can result in a better turn-around time for treatment if a patient is positive (Kawa, 2017). Better follow up after birth post infection is another change that is recommended. That way other infections that may arise and threaten the infant, mother, family or friends who come in contact with the infection can be treated accordingly (Roca, et al., 2015) (Roloff, et al., 2018). By creating a team with key stakeholders such as neonatologists, labor and delivery nurse managers, clinical nurse managers and perinatologists who can come together to form a team to better address the policies that need to be put in place to properly treat and screen for the GBS infection. A potential barrier that you may come across is doctors being slow or resistant to making the necessary changes to the way that they treat and screen their patients. The physicians might feel that their years of training and medical expertise is being questioned and that can cause some doctors to be uncooperative or more stubborn to change. Another barrier is the lack of transparency and communication between the patient and the doctor regarding collecting GBS cultures for screening and also the lack of documentation of these screenings. I think one strategy for these barriers is timely documentation and another strategy is better access to health records. For example, doctors should finish their documentation ideally by the end of their practice day so that the nurses who will care for the patient is up to date with the condition of that patient. Also, medical records should be easily accessible or the transition of medical records from one practice to another should be easier so that if a patient moves to another physician’s practice or changes hospitals, the information can be made available quickly. Better documentation would include checklists that makes the patients most pertinent information easy to identify such as age, weeks of gestation, relevant medical history and if a screening has been done and include the date, the results and what interventions were implemented based on the results. I think making these small but necessary changes can and will decrease the rate of GBS infection in neonates or help in the treatment of the infection to prevent fatality.

References

• Kawa, D. (2017). Detection methods for prevention of early-onset neonatal group B strep infections. MLO: Medical Laboratory Observer, 49(5), 20–21. Retrieved from
• https://wgu.idm.oclc.org/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=heh&AN=122701726&site=eds-live&scope=site
• Khan, M. A., Faiz, A., & Ashshi, A. M. (2015). Maternal colonization of group B streptococcus: prevalence, associated factors and antimicrobial resistance. Annals Of Saudi Medicine, 35(6), 423–427. https://doi-org.wgu.idm.oclc.org/10.5144/0256-4947.2015.423
• MacLaughlin, K., Garrison, G., Matthews, M., O’Brien, M., Westby, E., & Targonski, P. (2015). Increased Adherence to Prenatal Group B Streptococcal Screening Guidelines Through a Paired
• Electronic Reminder and Education Intervention. Maternal & Child Health Journal, 18(1), 16. Retrieved from https://wgu.idm.oclc.org/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=edb&AN=93448680&site=eds-live&scope=site
• Munir, S. I., Waheed, K., Khanum, A., Iqbal, R., Eusaph, A. Z., & Hanif, A. (2016). Frequency of Group B Streptococci in Pregnant Women in a Tertiary Care Hospital. Journal Of The College Of Physicians And Surgeons—Pakistan: JCPSP, 26(1), 27–30. https://doi-org.wgu.idm.oclc.org/01.2016/JCPSP.2730
• Roca, A., Oluwalana, C., Camara, B., Bojang, A., Burr, S., Davis, T. M. E., … D’Alessandro, U. (2015). Prevention of bacterial infections in the newborn by pre-delivery administration of
• azithromycin: Study protocol of a randomized efficacy trial. BMC Pregnancy & Childbirth, 15, 1–13. https://doi-org.wgu.idm.oclc.org/10.1186/s12884-015-0737-3 
• Roloff, K., Stepanyan, G., & Valenzuela, G. (2018). Prevalence of oropharyngeal group B Streptococcus colonization in mothers, family, and health care providers. Plos One, 13(9), e0204617. https://doi-org.wgu.idm.oclc.org/10.1371/journal.pone.0204617
• Shaohua Wang, Li Li, Benqing Wu, & Weiyuan Wu. (2018). Serotype, Genotype, and Clinical Manifestations of Group B Streptococcus (GBS) Isolated from Neonates in China. Iranian Journal of Pediatrics, 28(1), 1–6. https://doi-org.wgu.idm.oclc.org/10.5812/ijp.14580
• Women’s Health Care Physicians. (2011). Retrieved from https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Prevention-of-Early-Onset-Group-B-Streptococcal-Disease-in-Newborns?IsMobileSet=false
• Xi Wang, Yingna Song, Liangkun Ma, Juntao Liu, Yingchun Xu, & Jie Yi. (2016). Group B streptococcus detection in China: comparison of different screening methods and different sampling sites. Journal of Microbiology & Infectious Diseases, 6(4), 179–183. https://doi-org.wgu.idm.oclc.org/10.5799/ahinjs.02.2016.04.0240