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Prevention of Early Onset Group-B Streptococcus Disease in the Neonate Page 1 of 9 See the Intranet for the latest version. Version Number: 1

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Title: Prevention of Early Onset Group-B Streptococcus Disease in the Neonate Version: 1 MFT

Reference Number: SMH OBS 8

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Supersedes: Legacy guidelines: Prevention of Early Onset Neonatal Group B Strep guideline V1 for Wythenshawe, Group B Haemolytic Streptococcus in Pregnancy and Childbirth guideline for St Mary’s V3

Significant Changes: Antibiotics for women with penicillin allergy, testing women with previous GBS at 35-37 weeks

M in o r A me n d m e n t Date:

Notified To: Date:

Summary of amendments :

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Originated / Modified By: Dr S Loveridge, Dr Akila Anbazhagan Designation: ST7 Trainee, Consultant Obstetrician

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on Ratified by: Obstetric Clinical Effectiveness Group, Medicines Management Committee Adults, Medicines Management Committee Paediatrics

Date of Ratification: September 2018

A p p licati o n

Target Audience: All staff

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n Issue Date: 05/02/19

Circulated by: Clinical Governance Team

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iew Review Date: September 2021 Responsibility of: Authors Date placed on the Intranet: 05/02/19

Please enter your EqIA Registration Number here: 132/18

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Section Contents Page

1 Introduction 3

2 Purpose 3

3 Roles and Responsibilities 3

4 Information for women 3

5 Risks of Neonatal GBS 3

6 Antenatal Screening 4

7 Women who request GBS swabs 4

8 GBS carriage identified in the antenatal period on LVS/anorectal swab

4 9 Women with GBS bacteriuria (positive mid-stream

sample urine (MSU) result)

5 10 Women with a GBS positive swab and preterm pre-labour

rupture of membranes

5

11 Preterm labour 5

12 Women with GBS and pre-labour spontaneous rupture of membranes (SROM) >37+0

6 13 Women with GBS having an elective caesarean section

(LSCS)

6 14 Women with a previous baby with GBS disease 6 15 Intrapartum Antibiotic Prophylaxis in Labour

15.1 Women requiring broad-spectrum intrapartum antibiotic prophylaxis (includes reasonable GBS cover)

7

16.1 Neonatal Care 7

16.2 Term babies whose mothers have received adequate IAP 7 16.3 Monitoring of well babies at risk of EOGBS disease

whose mothers have not received adequate IAP 8 16.4 Management of a baby with signs of EOGBS 8 16.5 Management of the baby of a mother who has had a

previous baby with GBS disease

8

16.6 Breastfeeding 8

16.7 GBS identified after delivery or on placental swabs 8

17 Equality Impact Assessment 9

18 Consultation, Approval and Ratification Process 9

19 Dissemination and Implementation 9

20 Monitoring Compliance of Procedural Documents 9

21 References and Bibliography 9

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1. Introduction

Group B Streptococcus (Streptococcus agalactiae) is recognised as the most frequent cause of severe early-onset (<7 days of age) infection in newborn infants. However, there remains controversy regarding prevention. The incidence of early-onset Group B Streptococcus (EOGBS) disease in the UK and Ireland in 2015 was 0.57/1000 births, a significant increase from 2000 (0.48/1000). The UK National Screening Committee examined strategies for the prevention of EOGBS disease in 2016–17 and in March 2017 recommended that routine screening using near-patient testing or bacteriological culture should not be introduced into UK practice.

2. Purpose

The purpose of this guideline is to aid the management of women with current and previous Group B Streptococcus carriage. It reflects the recently updated Green-top Guideline No. 36 from the RCOG (September 2017).

3. Roles and Responsibilities

All healthcare practitioners in maternity should be familiar with the contents of the guideline, including when to offer testing to pregnant women and when intrapartum antibiotic prophylaxis (IAP) should be offered.

4. Information for Women

All pregnant women should be provided with an appropriate information leaflet about Group B Strep (RCOG 2017), or directed to a web version at booking available from

https://www.rcog.org.uk/globalassets/documents/patients/patient-information-leaflets/pregnancy/pi-gbs-pregnancy-newborn.pdf or www.gbss.org.uk.

5. Risks of Neonatal GBS

The following table of the risks of early onset neonatal GBS sepsis may be used to inform a detailed discussion with women (RCOG, 2012).

Risk Factor Risk of early onset

neonatal GBS sepsis disease if IAP* not given

Risk of early onset neonatal GBS sepsis disease if full IAP* given Incidental GBS carrier 1 in 434 1 in 2170

Intrapartum fever >38oC 1 in 189 1 in 943 Prolonged ROM >18hrs 1 in 556 1 in 2777 Prematurity <37wk 1 in 435 1 in 2173 Prematurity <35wk 1 in 357 1 in 1786

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6. Antenatal Screening

Routine antenatal screening is not recommended. (RCOG, 2012)

Women who have had GBS identified in a previous pregnancy should be informed that the likelihood of maternal GBS carriage in this pregnancy is 50%.

Identification of previous history of GBS should actively be sought at booking from maternal history, documentation and stickers from previous hospital records and GBS positive swabs including placental swabs identified from lab systems. For women with GBS in a previous pregnancy, discuss the options of IAP, or bacteriological testing between 35 and 37 weeks gestation (or 3-5 weeks before anticipated date of delivery, eg 32-34 weeks for twins), then offer IAP if still GBS positive (RCOG 2017).

Bacteriological testing for carrier status should be a swab taken from the lower vagina (LVS) and the anorectum (RCOG 2017). A single swab (vagina then anorectum) or two different swabs can be used.

7. Women requesting swabs for GBS isolation

Women should be advised that routine antenatal screening is not recommended, nor is screening upon maternal request in the absence of a clinical indication (RCOG, 2017)

A high vaginal swab (HVS) using our hospital swab medium will grow GBS in only about 50% of carriers.

A rectal swab and lower vaginal swab (LVS) using enriched culture medium swabs are available commercially via the Group B Strep Support website

(www.gbss.org.uk), although no sensitivity figure is quoted.

If women request these swabs which they then send off for private processing, this should be supported, but they should be informed of the lack of a published

sensitivity figure.

8. GBS carriage identified in the antenatal period on LVS/anorectal swab The maternal records should be labelled with a yellow GBS sticker after obtaining consent from the woman. Stickers should be placed on page 17 and 40 and on the front of the hand held notes. A sticker should also be placed on the first page of the hospital antenatal notes for the current pregnancy.

Women should be informed that no antenatal antibiotic treatment is required if

asymptomatic (RCOG 2012). Since 20-40% of antenatal women are carrying GBS at any time isolation is usually incidental – treatment does not alter the chances of being a carrier at the time of delivery.

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If the woman attends with symptoms of infection (e.g. offensive discharge) and only GBS is isolated then a course of appropriate antibiotics will be needed - please contact microbiology for advice.

Intravenous (IV) intrapartum antibiotic prophylaxis (IAP) is indicated for all women who are GBS+ve in the antenatal period.

If a woman declines IAP the discussion should be documented in the maternal records and the neonatal team informed. Women 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.

9. Women with a GBS bacteriuria (positive mid-stream sample urine (MSU) result)

A woman with GBS bacteriuria needs antenatal treatment (as per sensitivities) even if asymptomatic, as progression to ascending urinary tract infection may precipitate premature labour or pyelonephritis.

Intrapartum IV IAP is indicated and should be offered.

10. Women with GBS and preterm pre-labour rupture of membranes

No specific GBS antibiotic treatment is required until the woman is in established labour. Most GBS is sensitive to the erythromycin used for preterm pre-labour rupture of membranes prophylaxis.

See Pre labour Rupture of Membranes (PROM) before 37 weeks gestation guidelines for management of this group of women.

For women <34 weeks gestation, the perinatal risks associated with preterm delivery are likely to outweigh the risk of infection.

For women >34/40 it may be beneficial to expedite delivery. Consider augmentation of labour after discussion with Consultant Obstetrician and Neonatal Unit.

Women should be offered IV IAP when in labour.

11. Preterm labour

IAP is indicated for all women in confirmed preterm labour (RCOG 2017) regardless of GBS carriage.

IAP is not indicated for women not in labour having a preterm caesarean section with intact membranes.

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12. Women with GBS and pre-labour spontaneous rupture of membranes (SROM) >37+0:

Offer immediate IV antibiotics and augmentation of labour as soon as workload permits. See Induction of Labour Guideline and Pre labour Spontaneous Rupture of Membranes (SROM) at Term (>37 weeks).

13. Women with GBS having an elective caesarean section (LSCS)

Antibiotics are not required prior to elective LSCS for women with intact membranes, but they do require the usual surgical prophylaxis as per the Obstetric Anti-Infective Prescribing Guideline.

14. Women with a previous baby with early or late onset GBS disease

Offer intrapartum antibiotic prophylaxis to women with a previous baby infected with GBS (even if swabs are negative for GBS in this pregnancy).

15. Intrapartum Antibiotic Prophylaxis in Labour The following antibiotic regime is advised (RCOG 2017):

 Benzylpenicillin 3g IV as soon as possible after the onset of labour and 1.5g 4 hourly until delivery

 To optimise the efficiency of IAP, the first dose should be given at least 4 hours prior to delivery

 In penicillin allergy:

 Unlikely allergy (e.g. vomiting) – benzylpenicillin

 Mild allergy (no anaphylaxis/angioedema/respiratory distress or urticaria) cefuroxime 1.5g stat then 750mg 8 hourly until delivery

 Severe allergy – vancomycin 12 hrly

 The first dose of vancomycin is based on booking weight:

Booking Weight (kg)

First dose Volume of sodium

chloride 0.9% or glucose 5% Duration of infusion <40 750mg 250mL 1.5 hr 40-59 1000mg 250mL 2 hr 60-90 1500mg 500mL 3 hr >90 2000mg 500mL 4 hr

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 Subsequent doses also require creatinine level for calculation of the correct dose. Please take blood for U&E if another dose is likely to be required after12 hours.

 See Obstetric Anti-Infective Prescribing Guidelines and Vancomycin Dosing Calculator below.

 Click on the link below then click on Belfast calculator in the bottom left corner.

 Enter sex, age, height, weight and serum creatinine then click calculate. This will tell you the correct dose and over how long it should be

administered.

http://microguide.horizonsp.co.uk/viewer/bhsct/adult

15.1 Women requiring broad-spectrum intrapartum antibiotic prophylaxis

(includes reasonable GBS cover):

 Women with a temperature in labour 38oC or greater on one occasion - send blood cultures, MSU and vaginal +/- throat swabs (depending on symptoms) before commencement.

 Women with clinically suspected chorioamnionitis e.g. offensive liquor, tender uterus etc

 See Management of Sepsis in Obstetrics and Obstetric Anti-Infective Prescribing Guideline.

16. Neonatal Care

16.1 As 90% of infants who are diagnosed with early-onset infection will display signs by 12 hours of age, parents and carers should be given an information leaflet advising them to seek urgent medical advice if they are concerned that the baby has developed any of the following:

 abnormal behaviour (for example, inconsolable crying or listlessness)  unusually floppy

 difficulties with feeding or with tolerating feeds

 abnormal temperature unexplained by environmental factors (lower than 36°C or higher than 38°C)

 rapid breathing  change in skin colour

 Parents with concerns can contact their community midwife, GP, health visitor, or call the postnatal ward helpline.

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16.2 Term babies whose mothers have received adequate IAP

 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.

 The babies of women who have received broad-spectrum antibiotics during labour for indications other than GBS prophylaxis may require investigation and treatment.

16.3 Monitoring of well babies at risk of EOGBS disease whose mothers have not received adequate IAP

 Well babies should be evaluated at birth for clinical indicators of neonatal infection and have observations checked at 0, 1 and 2 hours, and then 2 hourly until 12 hours.

16.4 Management of a baby with signs of EOGBS

 Babies with clinical signs of EOGBS disease should be treated with benzylpenicillin and gentamicin within an hour of the decision to treat. 16.5 Management of the baby of a mother who has had a previous baby with

GBS disease

 Babies should be evaluated at birth for clinical indicators of neonatal infection and have their observations checked at 0, 1 and 2 hours, and then 2 hourly until 12 hours.

16.6 Breastfeeding

 Breastfeeding should be encouraged irrespective of GBS status. 16.7 GBS identified on HVS post-delivery or on placental swabs

 If GBS is identified during the postnatal period the woman should be given clear information regarding GBS isolation and signs of GBS infection in the neonate.

 A sticker should still be placed on the front of the hand held notes so as to alert the health professionals during subsequent pregnancies.

 The community midwives should be informed if the woman is at home, the ward midwives if the baby is on the postnatal ward, or the neonatal staff if baby is on the Neonatal Unit.

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17 Equality Impact Assessment

The Trust is committed to promoting Equality, Diversity and Human Rights in all areas of its activities. This guideline has been equality impact assessed using the Trust’s equality impact assessment (EqIA) framework. No significant issues were identified in relation to equality, diversity, gender, colour, race or religion are identified.

18 Consultation, Approval and Ratification Process

Consultation group – consultant obstetricians, microbiologists, pharmacists, neonatologists, governance teams on both sites.

Approved by the Antimicrobial Subgroup Committee, Medicines Management Committees (adults and paediatrics)

Ratified by: Obstetric Clinical Effectiveness Group 19 Dissemination and Implementation

Dissemination electronically via the Trust intranet.

20 Monitoring Compliance of Prevention of Early Onset Group-B Streptococcus disease in the neonate

The Clinical Director is responsible for monitoring compliance with the Prevention of Early Onset Group-B Streptococcus disease in the neonate at Division and Corporate Level.

This will be completed on a yearly basis and reported to the Clinical Governance committee.

21 References and Bibliography

Hughes RG, Brocklehurst P, Steer PJ, Heath P, Stenson BM on behalf of the Royal

College of Obstetricians and Gynaecologists. Prevention of early-onset neonatal

group B streptococcal disease. Green-top Guideline No.36. BJOG 2017; 124:e280– e305.

Royal College of Obstetricians and Gynaecologists (2012) Prevention of early onset neonatal group b streptococcal disease London: RCOG.

22 Associated Trust Documents

Obstetric Anti-Infective Prescribing Guideline Management of Sepsis in Obstetrics guideline. Pre labour Rupture of Membranes at Term guideline.

Pre labour Rupture of Membranes before 37+0 weeks guideline. Induction of Labour guideline.