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10 A C T A M E D I C A M A R T I N I A N A 2 0 0 5 5/3 results from transmission either in utero by ascending spread or, mostly, during passage through the birth canal. The rate of vertical transmission in neonates born to women colonized with GBS at time of delivery ranges from 30 to 70 % (7, 6). Although most newborns of colonized mothers become colonized on skin or mucous membranes, they remain asymptomatic; among them, 1 to 4 % rapidly develop a clinical infection. Because of the persistent high incidence and severity of GBS disease, several preventive strategies have been evaluated. The reference recommendations were published by the CDC in 1996 (12), reevaluated and updated in 2002 (1). Maternal intrapartum antibiotic prophylaxis (IAP) is currently considered the most effective strategy to prevent neonatal GBS disease and it is the method of choice. Thus the recommended strategy for the prevention of perinatal GBS disease is based on a universal prenatal screening-approach with the integration of risk-based options when necessary. However, maternal intrapartum chemoprophylaxis will not prevent all cases of early-onset GBS disease (9). In case that intrapartum antibiotics are not given despite an indication (e.g., delivery occurred precipitously before antibiotics could be administered to a GBS-positive woman), insufficient data are available on which to recommend a single management strategy for the newborn (1). Giving an injection of penicillin immediately after birth to newborn babies routinely has been proposed as another way of preventing infection (11). Some centers provide intramuscular penicillin to asymptomatic infants within 1 hour of birth, based on results of observational studies showing declines in early-onset GBS disease (1). The complete absence of EOGBSD was reported as an unexpected benefit of a policy of routine administration of intramuscular penicillin to prevent gonococcal ophthalmia (13). However, it is important to become aware of the fact, that routine use of antimicrobial prophylaxis for newborns whose mothers received IAP is not recommended (1, 9). Most of the infants affected are full-term infants, even if the attack rate is higher in premature and low weight neonates (7). Term infants account for approximately 70 % of cases of earlyonset GBS septicemia in neonates (9). Our objective is to determine whether the administration of intramuscular penicillin at birth to a defined group of full-term newborns of colonized mothers is an effective and safe method to prevent morbidity and mortality from EOGBSD. The aim of the pilot study is to design an optimal strategy for administering postnatal antibiotic prophylaxis (PAP). METHODS There are no national guidelines for the EOGBSD prevention currently available in many European countries (7). Nevertheless, obstetric program in our hospital already includes a GBS prevention policy based on a universal prenatal screening-based strategy with the integration of risk-based options when necessary. In order to prevent further neonatal GBS disease, we pay attention to obstetric risk factors and information about administering IAP, and we identify a group of colonized mothers’ newborns at higher risk to administer PAP. We have chosen GBS positive culture at 35 to 37 weeks of gestation, and, at the same time, either the total number of newborns’ leucocytes at birth more than 25, or less than 8 x 10 9 per liter, or the presence of more obstetric risk factors, as the indication criteria for PAP. For the postnatal prophylaxis we use intramuscular penicillin in a daily dose of 80, 000 units per kilogram of newborn’s weight, applied in two doses per day. After the third dose of penicillin, the blood count is checked, and if it does not return to normal levels, penicillin is continued. If there is a positive blood culture result, the prophylaxis has to be changed into therapy. If sepsis is suspected, based on clinical and laboratory evaluations, empiric antibiotic therapy, using ampicillin and gentamicin, should be started. We have created a protocol for management of a full-term infant born to a GBS colonized mother. We analyze weight at birth, Apgar score, maternal risk factors such as intrapartum fever (38 o C or higher), prolonged rupture of membranes (18 hours or more), previous infant with invasive GBS infection, and urinary tract infection during current pregnancy, then administrating of
A C T A M E D I C A M A R T I N I A N A 2 0 0 5 5/3 11 IAP and its duration, blood cell count at birth and after the third dose of postnatal penicillin, clinical signs, amniotic water culture and newborn’s outer ear canal culture results. The study is prospective. The pilot study was started in September 2004, and in July 2005 the study sample consisted of 100 newborns. The study group accounts for 11.3 % of all fullterm infants born within that time period. The mean birth weight of the study group was 3. 394 grams (± SD = 490 grams). The mean gestational age was 40.2 gestational weeks (± SD = 1.1 weeks). Postnatal adaptation of the newborns was adequate, only in one infant with Apgar score 5/7/8 it was more difficult. RESULTS There were 11.3 % of all full-term newborns born to GBS colonized mothers. Firstly, we assess the risk for GBS sepsis according to the Swiss Society of Neonatology. Full-term infants of GBS colonized mothers, without any additional risk factors and without IAP, are considered at risk for GBS sepsis 6 / 1, 000. If there are any additional risk factors, the risk grows 12.5 times. If duration of IAP is longer than 4 hours, it reduces the risk 33 times (the risk is 0.18 / 1 000) (14). It is not known how much postnatal antimicrobial prophylaxis reduces the risk for the disease. In our study group there were 73 newborns at risk for sepsis 6 / 1 000. Twenty two neonates were at risk 0.18 / 1 000, because of administration of IAP. There were 4 neonates at risk 2.25 / 1 000, because of additional risk factors and IAP at the same time. Only one newborn was at risk 75 / 1 000, because of prolonged rupture of membranes and unsatisfactory duration of IAP. In this infant, to whom PAP was not administered because of adequate blood count, there were no signs of infection found and there were negative culture results. (Fig.1) Fig. 1 Distribution of risk for GBS sepsis in the study group Out of 100 infants, PAP was administered in 9 cases. In 8 cases the indication criteria included leucocytosis, in 1 case it included additional risk factors such as prolonged rupture of membranes and intrapartum fever in mother (Fig.2). In 8 newborns, the total number of leucocytes went back to normal after three doses of penicillin. In 1 newborn the PNP had to be prolonged. Out of the 9 newborns with PNP, in 5 of their mothers was not administered any IAP. According to our criteria, PAP was administered to 4 infants, although their mothers received ampicillin prophylaxis and the infants were at risk 0.18 / 1000 (Fig.3). We keep in mind that IAP does not prevent all EOGBSD cases.
Page 1 and 2: ISSN 1335-8421 Acta Med Mart 2005,
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