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OfficialreprintfromUpToDate
www.uptodate.com2015UpToDate

NeonatalgroupBstreptococcaldisease:Prevention
Author
CarolJBaker,MD

SectionEditors
SusanMRamin,MD
DanielJSexton,MD

DeputyEditor
VanessaABarss,MD,FACOG

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Jul2015.|Thistopiclastupdated:Mar11,2015.
INTRODUCTIONGroupBstreptococcus(GBSorStreptococcusagalactiae)isanencapsulatedgrampositive
coccusthatcolonizesthegastrointestinalandgenitaltractsof15to40percentofpregnantwomen[1].Although
GBScolonizationusuallyremainsasymptomaticinthesewomen,maternalcolonizationisthecriticaldeterminant
ofinfectioninneonatesandyounginfants(lessthan90daysofage),inwhomGBSisthemostcommoncauseof
bacterialinfection[2,3].Vertical(mothertochild)transmissionprimarilyoccurswhenGBSascendsfromthe
vaginatotheamnioticfluidafteronsetoflabororruptureofmembranes,butcanoccurwithintactmembranes
[4,5].
Inthemid1980s,randomizedandcontrolledclinicaltrialsdemonstratedthatintrapartumadministrationof
intravenouspenicillinorampicillintoGBScarriersprotectedtheirnewbornsfromdevelopingearlyonsetdisease
(ie,GBSinfectionat0to6daysofage)[68].Baseduponthisevidence,theCentersforDiseaseControland
Prevention(CDC)publishedguidelinesforpreventionofneonatalGBSdiseasein2002[4]and2010[3].Thekey
interventionoftheseguidelinesisintrapartumparenteralantibioticprophylaxisofwomenwhoseinfantsareathigh
riskofdevelopingearlyonsetGBSinfectionbecauseamaternalGBSculturewaspositiveintheweeksbefore
deliveryorbecauseofmaternalcharacteristicsthatincreasetheriskofearlyonsetGBSdiseaseintheiroffspring.
The2010CDCguidelinesforpreventionofearlyonsetGBSdiseasewillbereviewedhere.Theseguidelineshave
beenendorsedbytheAmericanCollegeofObstetriciansandGynecologists[9]andtheAmericanAcademyof
Pediatrics[10].Themicrobiology,epidemiology,clinicalmanifestations,andtreatmentofperinatalandadultGBS
infections,andthestatusofGBSvaccinesarediscussedseparately:

(See"GroupBstreptococcalinfectioninpregnantwomen".)
(See"ManagementoftheinfantwhosemotherhasreceivedgroupBstreptococcalchemoprophylaxis".)
(See"GroupBstreptococcalinfectioninneonatesandyounginfants".)
(See"GroupBstreptococcus:Virulencefactorsandpathogenicmechanisms".)

IDENTIFICATIONOFCOLONIZEDGRAVIDASIdentificationofwomencolonizedwithGBSplaysthemajor
roleinthepreventionofearlyonsetneonataldiseasesinceGBSinfectionresultsfromverticaltransmission.
Colonizedwomencanbeidentifieddirectlybycultureorindirectlybythepresenceofspecificmaternal
characteristics.
CultureversusriskfactorbasedscreeningThefirstCDCguidelinespublishedin1996foruseofintrapartum
chemoprophylaxistopreventearlyonsetGBSinfantdiseaseallowedeitherculturebasedorriskbasedstrategies.
TheculturebasedapproachinvolvedperformingroutineantepartumGBSculturesonallpregnantwomen,witha
fewexceptionsforwomenatveryhighriskofhavinganinfectedinfantallcolonizedwomenreceivedintrapartum
antibioticprophylaxis.Theriskfactorbasedapproachadministeredintrapartumantibioticprophylaxistowomen
withintrapartumriskfactorsforinfantinfection(see'Riskfactorbasedapproach'below).Althoughrandomized
trialsdirectlycomparingthesetwostrategieshadnotbeenperformedatthetimetheseguidelineswerewritten,the
bulkofevidencesupportedculturebasedscreeningfollowedbyintrapartumchemoprophylaxisofwomenwith
positiveresultssincethemajorityofcasesofearlyonsetdiseaseoccurininfantsofwomenwhohaveno
identifiableriskfactorsorinwhomriskfactorsarenotidentifiedintimetoprovideeffectivechemoprophylaxis.
Thevalueofroutinecultures,ratherthanassessmentofriskfactors,wasbestdemonstratedinaretrospective
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cohortstudyofdeliveriesintheUnitedStatesfrom1998to1999[11].Performinglowervaginalandrectal
screeningculturesat35to37weeksofgestationandadministeringantibioticprophylaxistoGBScarrierswas
associatedwithfewercasesofearlyonsetGBSdiseaseinneonatesthanprophylaxisbaseduponthepresenceof
oneormorematernalriskfactors(adjustedRR0.46,95%CI0.360.60).Infact,almostoneinfiveculturepositive
womendidnothavematernalriskfactorsforearlyonsetneonatalinfectionandwouldnothavereceived
intrapartumantibioticprophylaxis.Basedprimarilyonthisstudy,butalsoonresultsfromothercontrolledstudies,
majororganizationsintheUnitedStates,includingtheCDC,AmericanCollegeofObstetriciansand
Gynecologists,andAmericanAcademyofPediatrics,haverecommendedscreeningculturesoverriskbased
screeningforGBS[3,12].
CulturebasedapproachTheCDCrecommendsGBSrectovaginalscreeningculturesforallpregnant
womenat35to37weeksofgestation,withthefollowingtwoexceptions:(1)womenwithGBSbacteriuria(104
coloniesinpurecultureormixedwithasecondmicroorganism[3])duringthecurrentpregnancyand(2)women
whopreviouslygavebirthtoaninfantwithinvasiveGBSdisease(see'Exceptions'below).Culturesareperformed
neartermbecausemanywomenhavetransientorintermittentdisease,thusGBScolonizationstatusinearly
pregnancymaynotbepredictiveofstatuslateinpregnancy[5,13,14].Culturesareperformedat35to37weeksof
gestationbecausetheresultswillbeavailablebeforemostwomengointolaborandarereasonablypredictiveof
GBSstatusforaboutfiveweeks.ThenegativepredictivevalueofGBSculturesperformed5weeksbefore
deliveryis95to98percent,butdeclinesafterfiveweeks[14].
Exceptions
GBSbacteriuriaincurrentpregnancyWomenwithGBSbacteriuria(anycolonycount)anytimeinthe
currentpregnancyshouldroutinelyreceiveprophylacticintrapartumantibiotics,evenifbacteriuriaistreated
andarepeaturinecultureisnegativetherefore,theycanbeexcludedfromculturebasedscreening.The
rationaleforthisrecommendationisthatGBSbacteriuriaisamarkerofheavyvaginalandrectalcolonization
(thesourceofGBSbacteriuriainthesewomen),oraltreatmentofbacteriuriaduringpregnancydoesnot
achievelongtermeradicationofanogenitalcolonization,andtheneonatesofwomenwithGBSbacteriuria
areathigherriskforearlyonsetGBSdisease[13,1517].
ThereisexpertconsensusthatsymptomaticorasymptomaticwomenwithGBSbacteriuria105cfu/mL
duringpregnancyshouldbetreatedaccordingtocurrentstandardsfortreatingbacteriuriaduringpregnancy.
TheutilityoftreatingGBSbacteriuriaatcolonycounts<105cfu/mLisuncertainsomefavortreatmentto
preventurinarytractandothersequelae[18],whileothersdonottreatpatientswithlowlevelsofbacteriuria
[19].(See"GroupBstreptococcalinfectioninpregnantwomen"and"Urinarytractinfectionsand
asymptomaticbacteriuriainpregnancy".)
DeliveryofaninfantwithearlyonsetGBSdiseaseinapreviouspregnancyThereisalsogood
evidencethatpreviousdeliveryofaninfantwithearlyonsetGBSdiseaseisassociatedwithahigherriskof
earlyonsetdiseaseinsubsequentdeliveries[11,2022].Forthisreason,womenwiththishistoryshould
routinelyreceiveprophylacticintrapartumantibiotics,andthereforecanbeexcludedfromculturebased
screening.
WomenwithahistoryofapositiveGBScultureinoneormorepreviouspregnanciesbutnoinfantwithearly
onsetGBSdiseaseshouldbeculturedineverypregnancy.AlthoughahistoryofGBScolonizationinaprior
pregnancyisariskfactorforcolonizationinsubsequentpregnancies[2325],50to60percentofthese
womenarenotcolonizedinthesubsequentpregnancy[25,26].
PerformanceofGBSculturesSwabsforcultureshouldbeobtained,ideallybeforedigitalexaminationoruse
oflubricants,fromboththelowervagina(vaginalintroitus)andrectum(insertswabthroughtheanalsphincter)to
achievemaximumsensitivity[2729].Eithertwoswabs(oneforeachsite)orasingleswabcanbeusedone
swabismorecostsaving.Theswabsmaybeobtainedbyeitherthehealthcareproviderorbythepatientherself
afterappropriateinstructionasstudieshaveshownequivalentsensitivity[3032].Aspeculumshouldnotbeused
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toobtainthevaginalswabspecimen.Sitesotherthanthevaginaandrectum(ie,cervical,perianal,perirectalor
perineal)shouldnotbesampledastheyarelesssensitivefordetectionofGBS,andaddtothecost.
Bothswabs,orasingleswabofeachsite,shouldbeplacedpromptlyintononnutrienttransportmedia(eg,Amies
orStuart'swithoutcharcoal)andtransportedatroomtemperature(intemperateclimates)orrefrigerated[33].The
swaborswabsarethentransferredtoaselectiveenrichmentbrothatalaboratoryexperiencedintheisolationof
GBS,incubatedovernightat37C,andsubculturedontobloodagarplates(algorithm1).Useofselective
enrichmentmediasubstantiallyimprovesdetectionofGBSbyenhancingGBSgrowthandpreventingovergrowth
ofotherorganismsthatmaymaskgrowthofGBS[3].TheCDCguidelinesincludedetailedstepsforisolationand
properidentificationoftheorganism[3].Culturesrequire24to48hourstoshowpositiveresults.Ittakes48hours
todefinitivelyexcludeGBS.
SusceptibilitytestingisnotnecessaryinmostcasesbecauseGBSisolateswithconfirmedresistancetopenicillin
orampicillinhavenotbeenobserved[34].InpatientswithpositiveGBScultureswhohaveaseriousallergyto
penicillin(historyofanaphylaxis,angioedema,respiratorydistress,orurticaria),testingforsensitivityto
erythromycinandclindamycinshouldbeperformedifoneoftheseantibioticsisusedforintrapartumantibiotic
prophylaxis[3].(See'Patientswithpenicillinallergy'below.)
IncidentalfindingsSomelaboratoriesreportnonGBSstreptococcalorganismsidentifiedduringGBS
screeningcultures.Intheonlyavailablestudy,groupAStreptococcus(GAS)waspresentin0.03percentof
rectovaginalculturesfrompregnantwomen[35].ReportingGAScolonizationidentifiedduringGBSscreening
shouldbediscouragedbecausethematernalfetalneonatalattackrateofGASinthissettingisunknown
(describedincasereports[36]),opinionsaboutmanagementofthesepregnanciesvarywidelyamonginfectious
diseaseexperts,andfewguidelinesareavailable[37].
RapiddiagnostictestsNucleicacidamplificationtest(NAAT)methodologyamplifiesDNAorRNA
sequencesusingvarioustechniques,suchaspolymerasechainreaction(PCR).NAATsforGBSare
commerciallyavailableandprovideresultsinlessthantwohoursfromthetimethespecimenisreceivedbythe
laboratory.Thesetestshavenotbeenuniversallyadoptedbecauseoffactorssuchascost,inabilitytorun
susceptibilitytesting,andlowersensitivitythanstandardcultureusingselectiveenrichedbrothmedia.Compared
tostandardculturewithselectivebrothmedia,thesensitivityofNAATsperformedonnonenrichedsamples
rangesfrom62.5to98.5percent,and92.5to100percentwhenperformedonenrichedsamples(butuseof
enrichedsamplestakesmoretime,reducingthemajoradvantageofNAAT)[3].
WeagreewiththeCDCthatthebenefitsandlimitationsofcurrentlyavailableNAATsdonotsupporttheiruseto
replaceantenatalcultureorriskbasedassessmentofintrapartumwomenwithunknownGBSstatus.Themajor
benefitofNAAToverstandardcultureistherapidityofobtainingresultsthisismuchlessrelevantinthe
antepartumperiod.Intrapartum,thesensitivityofNAATperformeddirectlyonvaginal/rectalswabswithoutan
enrichmentstepwaslessthanthatofcultureinsomestudiestherefore,thepresenceofintrapartumriskfactors
forGBScolonizationratherthanNAATresultsshouldguideadministrationofintrapartumantibioticprophylaxis.
Whereavailable,NAATisanoptionforwomenattermwithunknownantepartumGBScolonizationstatusandno
intrapartumriskfactorsforGBScolonizationatthetimeoftesting(riskfactors:gestationalage<37weeks,GBS
bacteriuriaincurrentpregnancy,previousinfantwithGBSdisease,temperature100.4F[38.0C],orruptureof
amnioticmembranes18hours)[3].WomenattermwithunknownantepartumGBScolonizationstatus,no
intrapartumriskfactorsforGBScolonization,andpositiveNAATresultsshouldreceiveintrapartumantibiotic
prophylaxis.WomenwhotestnegativeonadmissionNAATbutsubsequentlydevelopfeverorprolongedruptureof
membranesshouldreceiveintrapartumprophylaxis.(See'Indicationsforantibioticprophylaxis'below.)
Otherrapiddiagnostictestshavebeendeveloped,includingopticalimmunoassaysandenzymeimmunoassays,
butnoneissufficientlysensitivewhenusedonadirectspecimentodetectGBScolonizationreliablyinthe
intrapartumsetting[3,38].
RiskfactorbasedapproachThepresenceofcertaincharacteristicsisanindirectmeansofidentifyingwomen
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whoseinfantsareatincreasedriskofdevelopingearlyonsetdisease[4].Theseriskfactorscanbeusedinstead
ofculturestoidentifywomenwhoshouldreceiveantibioticprophylaxisinlabortoreducetheriskofhavingan
affectedinfant[3944]:

Intrapartumfever100.4F[38C]
Deliverybefore370/7thsweeksofgestation
Ruptureofmembranes18hours
PreviousdeliveryofaninfantaffectedbyGBSdisease
GBSbacteriuria(104cfu/mL)inthecurrentpregnancy

Mathematicalmodelingsuggeststhattheseriskfactorsclassify25to30percentofintrapartumwomenasatrisk
ofGBScolonization,aprevalencesimilartothatpredictedbyaculturebasedapproach[45,46].However,astudy
thatcomparedtheriskbasedapproachtoaculturebasedapproachforidentifyingwomenforintrapartumantibiotic
prophylaxisfoundthatnearly50percentofwomenwhodeliveredinfantswithearlyonsetGBSdiseasehadnone
oftheselistedriskfactors[11].
ThepresenceofprolongedruptureofmembranesdoesnotoverrideanegativeGBSculturewithinthepreviousfive
weeksGBSprophylaxisisnotindictedinthissetting.Antibioticswouldbeindicatedifthepatientdevelops
clinicalsignsofinfection,suchasintrapartumfever.
INTRAPARTUMANTIBIOTICPROPHYLAXISAntibioticsaregivenintrapartumratherthanatthetimeofa
positiveculturebecauseantibioticadministrationremotefromdeliverydoesnoteradicateGBScolonizationatthe
timeofdelivery,whichiswhentheinfantisatriskofverticaltransmission[4749].Theintravenousrouteis
requiredtoachieverapidhighconcentrationsbothinmaternalserumforplacentaltransfertothefetalsystemic
circulationandintheamnioticfluid,whichisinhaledandswallowedbythefetus.
WomenwithGBScolonizationcanenterlaborspontaneouslyorbeinducedcesareandeliveryshouldbereserved
forstandardobstetricalindications.
IndicationsforantibioticprophylaxisIntrapartumantibioticprophylaxisisgiveninthefollowingsettings,
whichcanbeidentifiedbylaboratorytesting,obstetricalhistory,orphysicalexaminationandarepredictiveofan
increasedriskofearlyonsetGBSinfection[3]:(See'Identificationofcolonizedgravidas'above.)
PositivescreeningcultureforGBSfromeithervaginaorrectum[5]
PositivehistoryofbirthofaninfantwithearlyonsetGBSdisease[2022]
GBSbacteriuriaduringthecurrentpregnancy[15,16]
Unknownantepartumculturestatus(culturenotperformedorresultnotavailable)and:
Intrapartumfever(100.4F,38C)or
Pretermlabor(<37weeksofgestation)or
Prolongedruptureofmembranes(18hours)[45]or
IntrapartumNAATpositiveforGBS(see'Rapiddiagnostictests'above)
AntibioticprophylaxisforGBSisnotindicatedIntrapartumantibioticprophylaxisisnotrecommendedfor
womenwith[3]:
ApositiveGBSrectovaginalcultureorGBSbacteriuriainapreviouspregnancyandnoneoftheindications
forprophylaxislistedabove.Culturesremotefromdeliveryarenotpredictiveofculturestatusatdelivery
[11,14].
WomenwithapositiveGBSculturewhoundergoplannedcesareandelivery(atanygestationalage)without
labororruptureofmembranes,astheriskofGBStransmissionismuchlowerinthissetting[3,50].
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However,patientsplanningcesareandeliveryshouldundergoroutinevaginalandrectalscreeningforGBSat
35to37weeksbecauseonsetoflabororruptureofmembranesmayoccurbeforetheplannedcesarean
deliveryandeitheroftheseeventsincreasestheriskofGBStransmissionandthereforewouldbean
indicationforantibioticprophylaxis.
PregnantwomenwithnegativeGBSculturesat35to37weeksofgestation,eveniftheyhaveoneormore
ofthefollowingintrapartumriskfactors:intrapartumfever(100.4F,38C),pretermlabor(<37weeksof
gestation),orprolongedruptureofmembranes(18hours)[4].However,theuseofbroadspectrum
intrapartumantibioticsforthetreatment(notprophylaxis)isindicatedforfebrilewomeninlaboriftheyhave
clinicalevidenceofchorioamnionitis.
AntibioticregimenPenicillinG5millionunitsintravenouslyinitialdose,then2.5to3millionunits
intravenouslyeveryfourhoursuntildeliveryisrecommendedforintrapartumantibioticprophylaxistherangeof2.5
to3millionunitsallowsforthevariousformulationsofpenicillinthatareavailableinpharmacies[3].GBSisolates
withconfirmedresistancetopenicillinorampicillinhavenotbeenobserved[34].Ampicillin2gintravenouslyinitial
dose,then1gintravenouslyeveryfourhoursuntildeliverycanbeused,butpenicillinispreferredbaseduponits
narrowerspectrumofactivity,whichtheoreticallyreducestheopportunityfordevelopmentofampicillinresistant
organisms(see'Developmentofantibioticresistance'below).
GBSissusceptibletopenicillinG,ampicillin,extendedspectrumpenicillins,cephalosporins,andvancomycin,but
penicillinGisthemostactiveagentinvitro.Approximately30percentofGBSisolatesareresistantto
erythromycinand20percentareresistanttoclindamycin,andtheseratesappeartobeincreasing[5155].
Erythromycinisnolongerrecommendedforprophylaxis,whileclindamycinusedependsonresultsofmultiple
susceptibilitytests(see'Patientswithpenicillinallergy'below).Almostallisolatesareresistanttotrimethoprim
sulfamethoxazole[56].
Oraltreatmentisnotrecommended,althoughrandomizedtrialscomparingoralversusparenteraltherapyhavenot
beenperformed.Inlaboringwomen,absorptionfromthegastrointestinaltractisnotreliablebecauseofdelayed
transittimeandvomiting.Theintravenousrouteisrequiredtoachieverapidhighconcentrationsbothinmaternal
serumforplacentaltransfertothefetalsystemiccirculationandintheamnioticfluid,whichisinhaledand
swallowedbythefetus.Also,thehighdoseofantibioticsrequiredtorapidlyreducethenumberoforganismsinthe
genitalsecretionsandamnioticfluid(ifcolonized)topreventneonatalinfectioncannotbetoleratedorally.Innon
laboringwomen,prospectivestudiesfoundthatoraltherapydidnotsubstantiallyreducerectovaginalcolonization
[49,57].
PatientswithpenicillinallergyIfthepatient'shistorysuggestsa"lowrisk"foranaphylaxis(eg,isolated
maculopapularrashwithouturticariaorpruritus),thencefazolin2ginitialdose,then1geveryeighthoursuntil
deliveryisrecommendedforintrapartumantibioticprophylaxis(algorithm2)[3].(See"Penicillinallergy:Immediate
reactions".)Thisrecommendationisbasedontheabilityofcefazolintoreachbactericidalconcentrationsinthe
amnioticfluidthreehoursafteranintravenousdose.
Ifthepatient'shistorysuggestsa"highrisk"foranaphylaxis(eg,anaphylaxis,angioedema,respiratorydistress,
urticaria,particularlyifthesesymptomsoccurredwithin30minutesofdrugadministration),thenantibiotic
susceptibilitytestingofGBSisolatesmustbeperformedtoverifysusceptibilitytoclindamycin.Iflaboratory
facilitiesareadequate,clindamycinanderythromycinsusceptibilitytestingisrecommendedonprenatalGBS
isolatesfrompenicillinallergicwomenathighriskforanaphylaxis.Resistancetoerythromycinisoftenassociated
withclindamycinresistance.Ifanisolateisresistanttoerythromycin,itmayhaveinducibleresistanceto
clindamycin,evenifitappearssusceptibletoclindamycinbystandardinvitrotestingmethods.IfaGBSisolateis
susceptibletoclindamycin,resistanttoerythromycin,andDzonetestingforinducibleresistanceisnegative(no
inducibleresistance),thenclindamycin900mgintravenouslyeveryeighthoursuntildeliverycanbeusedforGBS
intrapartumprophylaxis[3].
IftheGBSisolateisresistanttoclindamycinorsusceptibilityresultsarenotavailable,2010CDCguidelines
recommenduseofvancomycin1gevery12hoursinpatientswithnormalrenalfunctionuntildeliveryoftheinfant
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[3].Infectiousdiseaseguidelinesadvocateweightbaseddosingofvancomycin(15to20mg/kg)becauseofthe
highprevalenceofoverweightandobeseAmericanwomen.Weagreewithweightbasedvancomycindosing(20
mg/kgmaximumdose2g).Thisapproachissupportedbyastudyofvancomycinlevelsinneonatalcordblood
thatnotedtherapeuticneonatallevelswereusuallyachievedinneonatesexposedtoamaternalvancomycin
regimenof20mg/kgevery8hours(maximumindividualdose2g)butinfrequentlyachievedinneonatesexposed
tostandardmaternaldosingof1gevery12hours(therapeuticlevels:>80percentversus9percent)[58].
However,vancomycinhasnotbeenevaluatedforeffectivenessinpreventingearlyonsetGBSandits
pharmacokineticprofileisnotfavorabletoachievingbactericidalconcentrationsintheamnioticfluid.Inaddition,
vancomycinresistantGBSisolateshavebeenreported[59].(See"Vancomycindosingandserumconcentration
monitoringinadults".)
Analternativeapproachistoperformpenicillinskintestinginawomanwithahistoryofpenicillinallergyto
determineherallergystatus[60].Patientswithnegativeskintestscouldthenreceiveintrapartumantibiotic
prophylaxiswithpenicillin.However,patientswithnegativeskintestsshouldavoidtakingapenicillinbaseddrug
untilitisadministeredforintrapartumantibioticprophylaxis,duetoasmallpotentialriskofresensitizationfroma
subsequentcourse.(See"Penicillinallergy:Immediatereactions".)
In2008,76percentofGBSpositivewomenwhowereallergictopenicillininonelargehospitalreceivedan
appropriateantibioticcomparedwith16percentin2004to2006[61].Theimprovementinantibioticselectionwas
theresultofeducatingprovidersthroughlectures,publicizingtheCDCguidelinesonpostersthroughoutthe
hospital,andaddingafieldforPCNallergytothelaboratoryorderingsystemssothat,iffilledoutproperly,the
laboratorycouldbereflexivelypromptedtoperformGBSsensitivitytesting.
TiminganddurationofprophylaxisIntrapartumantibioticprophylaxiswithpenicillin,ampicillin,orcefazolinis
mosteffectiveifadministeredatleastfourhoursbeforedelivery[56,6264].Althoughfetalserumpenicillinlevels
withtheseagentsarehighwithin30minutesofamaternalintravenousinfusion[65,66]andmaternalvaginalGBS
colonycountsbegintofallpromptlyafterbeginningintravenousantibiotics,thenadirinGBScolonycountsinthe
amnioticandvaginalfluidisnotreacheduntilapproximatelythreehoursafterthefirstantibioticdose[67].
Sincethetimeofdeliverycannotbepredicted,prophylaxisisbegunathospitaladmissionforlabororruptureof
membranesandcontinuedeveryfourhoursuntiltheinfantisdelivered.Fewstudiesexaminingtheoptimum
durationofintrapartumantibioticprophylaxishavebeenreported,butcasesofearlyonsetneonataldiseaseare
rareifappropriatedosesofpenicillinorampicillinaregiven,iffourormorehourshavepassedbetweenthefirst
doseanddelivery,andifnomaternalinfection(eg,chorioamnionitisorbacteremia)ispresent.Inanobservational
studyof33GBScarrierswithpretermprematureruptureofmembranesreceivingpenicillinprophylaxis,daily
genitaltractculturesforGBSwerenegativein29/33patients(88percent)byday1,in32/33patientsbyday2,
andinall33patientsbyday3[68].
Medicallynecessaryproceduresshouldnotbedelayedinordertoprovidefourhoursbetweenantibiotic
administrationandtheprocedure.
Recolonizationcanoccuraftercessationoftherapy.
APPROACHTOTHREATENEDPRETERMDELIVERY
PretermlaborWomenwithaknownpositiveGBSculturewithinthepreviousfiveweeksshouldbegivenGBS
prophylaxisifadmittedinpretermlabor.
Thecolonizationstatusofwomenadmittedwithpretermlabororpretermruptureofmembranesgenerallyisnot
knownsincescreeningisperformedat35to37weeksofgestationtomaximizeagreementbetweenantepartum
cultureresultsandmaternalGBSstatusatdelivery.Ifcolonizationstatusisunknown,GBSculturesareobtained
attimeofpresentationandthenantibioticprophylaxisisadministeredifthebirthispotentiallyviable.Ifthepatient
isintruepretermlabor,GBSprophylaxisiscontinueduntilshedelivers.Ifafteraperiodofobservationthepatient
isnotfelttobeintruelabor,GBSprophylaxisshouldbediscontinued(algorithm3)[3].
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Managementofsubsequentepisodesofpretermlabordependsonfinalcultureresultsat48hours.Iftheculture
resultisnegative,noGBSprophylaxisisneededifpretermlaborrecurswithinthenextfiveweeks.Cultureresults
arenotpredictiveofGBSstatusformorethanfiveweeks[14],soifpretermlaboroccursmorethanfiveweeks
afterthenegativeculture,theapproachisthesameasthatforawomanwithunknowncolonizationstatus.
Ifthepatientisundeliveredat35to37weeksofgestation,avaginalrectalcultureshouldberepeatedtopredict
GBSstatusandguidemanagementatterm.
PretermprematureruptureofmembranesWomenwithchorioamnionitistypicallyreceivebroadspectrum
antibiotictherapy.ThistherapyshouldincludeanagentknowntobeactiveagainstGBStoreplaceGBS
prophylaxis.
Womenwithpretermprematureruptureofmembranesundergoingexpectantmanagementandgivenantibioticsfor
latencyshouldreceivearegimenthatincludesprophylaxisforGBS,afterGBScultureshavebeenobtained
(algorithm4).GBSprophylaxisisdiscontinuediftheculturesarenegativeforGBS.Themanagementofthese
patientsisdiscussedseparately.(See"Pretermpremature(prelabor)ruptureofmembranes",sectionon
'ChemoprophylaxisforGBS'.)
OUTCOMEMaternalintrapartumGBSchemoprophylaxishasresultedinasignificantreductioninearlyonset
GBSdisease(>80percentofcases)andneonataldeath[4,6971].LateonsetGBSdiseasehasremainedstable
ordecreased[72,73].
EarlyonsetGBSA2014Cochranereviewofrandomizedtrialsofintrapartumantibiotictreatmentofwomen
colonizedwithGBSfoundthatintrapartumantibioticprophylaxisresultedinasignificantreductioninearlyonset
neonatalGBSinfection(OR0.17,95%CI0.040.74),andanonstatisticalreductioninneonatalmortality(allcause
mortalityRR0.19,95%CI0.013.92mortalityfromearlyonsetGBSRR0.31,95%CI0.017.50)[71].
IntheUnitedStates,widespreaduseofGBSscreeningandintrapartumantibioticprophylaxishasresultedina
substantialdecreaseinearlyonsetGBSinfections(ie,diagnosisofneonatalGBSinfectionwithinsixdaysafter
birth).ThiswasillustratedinareportfromtheCDCshowingthat,in1993,beforeactiveeffortsatprevention,the
incidenceofearlyonsetGBSinfectionwas1.5per1000livebirths[4].Afterpublicationoftheinitial
recommendationsinthe1990s(riskfactorbasedapproach),theincidenceofearlyonsetdiseasefellto0.52per
1000livebirths(in2000).Revisionoftheserecommendationsin2002(universalscreening)wasassociatedwitha
furtherdropinincidenceto0.31casesper1000livebirths(in2003),ariseto0.40casesper1000livebirthsin
2006,andthenafallto0.24casesper1000livebirthsin2010[3,69,73].Thiswasmostlyduetoasignificant
increaseinearlyonsetdiseasefrom2003to2006amongtermblackinfants(from0.33to0.70casesper1000live
births).
LateonsetGBSIntheUnitedStates,theincidenceoflateonsetGBSinfection(7to89daysafterbirth)
hasremainedstableatanaverage0.35cases/1000livebirths[73].TheincidenceoflateonsetGBSinfectionin
EuropeappearstobesimilartoorslightlylowerthanthatintheUnitedStates,butislesswelldefinedbecause
mostEuropeanstudieshavenotperformedpopulationbasedactivesurveillanceofcultureconfirmedinvasive
infection[72].
MissedcasesSomewomencolonizedatdeliveryarenotidentified,despitescreening.About4percentof
womenwhotestnegativeat35to37weekshaveafalsenegativeresult,andabout60percentofearlyonsetGBS
occursinthesewomen[14,7476].
Inaretrospectivereviewof25neonateswithearlyonsetGBS,maternalGBSculturesat35to37weeksof
gestationwerepresumablyfalselynegativein16(64percent)themothersin19ofthese25pregnancieshad
oneormoreriskfactorsforearlyonsetGBSinfection(deliveryat<37weeks,intrapartumfever>100.4F,
clinicalchorioamnionitis,orGBScolonization)[74].
Anotherretrospectivereviewincluded254casesofearlyonsetGBSamong7691livebirthsfromamulti
stateGBSsurveillancesystem[75].About75percentofGBScases(189/254)occurredinterminfants,but
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onlyaboutonefifthofthesecases(37/189)occurredinwomenwhosescreenresultswerepositive116
cases(61.4percent)occurredinwomenwhosescreenresultswerenegative,34cases(13.4percent)were
attributedtomissedscreening,andtwocasesoccurredinwomenwhosescreenresultswerenotknown.
Themethodsusedforprocessingscreeningculturesinthesestudieswerenotdescribed,andmayhaveaffected
theresults.Thesefindingssuggestthatmoresensitivemethodsofdetectionwouldbeuseful.
IntheUnitedStates,somemissedcasesareduetononadherencetotheCDCsprenatalscreeningand
intrapartumprophylaxisguidelines[77,78].
DevelopmentofantibioticresistanceThereisatheoreticalpossibilitythatextensiveuseofintrapartum
prophylaxiscouldresultinincreasedantibioticresistanceamongGBSisolatesand/oranincreasedincidenceof
infectionsduetootherpathogens.Thusfar,noconsistenttrendshavebeenidentified[7988].Apopulationbased
GBSsurveillanceprogramin10statestested4882GBSisolatesandfoundthat100percentweresensitiveto
penicillin,ampicillin,andvancomycin,but32percentwereresistanttoerythromycinand15percentwereresistant
toclindamycin[89].Susceptibilitytofirstgenerationcephalosporinswasnotassessedhowever,asimilar
populationbasedsurveillancestudyreportedallGBSisolatesweresensitivetocefazolin[90].
Exposuretobroadspectrumintrapartumantibioticprophylaxishasbeenassociatedwithanincreasedriskoflate
onsetseriousbacterialinfectionsandinfectionwithresistantorganisms[84,91,92].Thesefindingssupportthe
recommendationtousepenicillinasthepreferredagentforGBSprophylaxis,ratherthanbroaderspectrum
antibiotics,suchasampicillin.
GBSPROPHYLAXISFOROBSTETRICALPROCEDURES
AntepartumproceduresTherearenohighqualitydataabouttheusefulnessofantibioticprophylaxisof
antepartumobstetricalproceduresinwomencolonizedwithGBSorinthoseinwhomGBSstatusisunknown[4].
Suchproceduresincludevaginalexamination,mechanicalandpharmacologiccervicalripening,andmembrane
stripping/sweeping.Intheabsenceofsuchdata,wesuggestnotadministeringprophylacticantibiotics.
Lowqualityindirectsupportforavoidingchemoprophylaxiswasprovidedbyametaanalysisof19trialsof
membranestrippingforinductionoflaborinwomenofundeterminedGBSstatus[93].Theprevalenceofneonatal
infectionamongneonatesexposedandunexposedtothisprocedurewassimilar.
IntrapartumproceduresThereisnoevidencethatintrapartumvaginalexaminationsandotherclinically
indicatedinvasiveprocedures(eg,placementofafetalscalpelectrode,amniotomy)increasetheriskofearly
onsetGBSinfectionininfantsofwomenwhoareknowntobecolonized,althoughdataontransmissionriskin
thesesettingsarelimited[94].Ideally,amniotomyandotherinvasiveproceduresareperformedatleastfourhours
afterintrapartumantibioticprophylaxishasbeeninitiatedhowever,theseproceduresshouldnotbedelayedto
achieveanoptimalantibioticconcentrationwhenthereismedically/obstetricallyurgentneedforthem.
CesareandeliveryAsdiscussedabove,GBScolonizationisnotanindicationforcesareandelivery
cesareandeliveryshouldbeperformedforstandardmedical/obstetricalindications.WomenwithapositiveGBS
culturewhoundergoplannedcesareandeliverywithoutlabororruptureofmembranesdonotrequireGBS
prophylaxis,astheriskofGBStransmissiontothefetus/neonateismuchlowerinthissetting[3,50].However,
onsetoflabororruptureofmembranesmayoccurbeforetheplannedcesareandeliveryandeitheroftheseevents
increasestheriskofGBStransmissioninthesecases,GBSprophylaxisisindicatedandshouldbeinitiatedas
soonaspossible.Anurgentcesareandeliveryshouldnotbedelayedtoachieve4hoursofintrapartumantibiotic
prophylaxisbeforetheprocedure.
NEWBORNS
PreventivestrategiesafterbirthTheefficacyofpreventionstrategiestargetingnewborns,ratherthanmaternal
colonization,iscontroversial.Largeobservationalstudieshavesuggestedthatadministrationofintramuscular
penicillintothenewbornimmediatelyafterdeliverymayreduceearlyonsetGBSdisease[95,96].However,a
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nonblindedrandomizedtrialinvolving1187infantsfailedtoidentifyabenefitinoutcomeofGBSdiseaseor
neonatalmortality[97].
Thediscrepancybetweentheresultsoftheobservationalstudiesandtherandomizedtrialmaybeexplainedby
methodologicissues[98].Therandomizedtrialmaynothaveincludedsufficientnumbersofpatientstodetecta
differenceinoutcomebetweentreatedandcontrolinfants.Inaddition,theparticipantsintherandomizedtrialwere
pretermlowbirthweightinfantswhoweretransferredtoaneonatalintensivecareunit.Twentyof24infected
babiesbecamesymptomaticwithinthefirsthouroflife,suggestingthatinfectionmayhavebeenpresentatthe
timeofdelivery.Finally,thereweredifferencesingeneralmanagementthatmayhavecontributedtothe
discrepantfindings.Unlesshighqualityevidencebecomesavailable,thestandardforpreventionofearlyonset
GBSdiseaseismaternalratherthannewbornchemoprophylaxis.
ManagementofnewbornsManagementofnewbornsisdiscussedseparately.
(See"ManagementoftheinfantwhosemotherhasreceivedgroupBstreptococcalchemoprophylaxis".)
(See"GroupBstreptococcalinfectioninneonatesandyounginfants".)
GUIDELINESFROMNATIONALORGANIZATIONS
RoyalCollegeofObstetriciansandGynecologists.ThePreventionofEarlyonsetneonatalGroupB
StreptococcalDisease.GreentopguidelineNo.36July2012.
SocietyofObstetriciansandGynaecologistsofCanada.ThePreventionofEarlyOnsetNeonatalGroupB
StreptococcalDisease.October2013.
RoyalAustralianandNewZealandCollegeofObstetriciansandGynaecologists.ScreeningandTreatment
forGroupBStreptococcusinPregnancy.November2012.
CentersforDiseaseControlandPrevention.2010GuidelinesforthePreventionofPerinatalGroupB
StreptococcalDisease(endorsedbytheAmericanAcademyofFamilyPhysicians,AmericanAcademyof
Pediatrics,AmericanCollegeofObstetriciansandGynecologists,AmericanCollegeofNurseMidwives).
INFORMATIONFORPATIENTSUpToDateofferstwotypesofpatienteducationmaterials,TheBasicsand
BeyondtheBasics.TheBasicspatienteducationpiecesarewritteninplainlanguage,atthe5thto6thgrade
readinglevel,andtheyanswerthefourorfivekeyquestionsapatientmighthaveaboutagivencondition.These
articlesarebestforpatientswhowantageneraloverviewandwhoprefershort,easytoreadmaterials.Beyond
theBasicspatienteducationpiecesarelonger,moresophisticated,andmoredetailed.Thesearticlesarewritten
atthe10thto12thgradereadinglevelandarebestforpatientswhowantindepthinformationandarecomfortable
withsomemedicaljargon.
Herearethepatienteducationarticlesthatarerelevanttothistopic.Weencourageyoutoprintoremailthese
topicstoyourpatients.(Youcanalsolocatepatienteducationarticlesonavarietyofsubjectsbysearchingon
patientinfoandthekeyword(s)ofinterest.)
Basicstopics(see"Patientinformation:GroupBstreptococcaldisease(TheBasics)")
BeyondtheBasicstopics(see"Patientinformation:GroupBstreptococcusandpregnancy(Beyondthe
Basics)")
SUMMARYANDRECOMMENDATIONS
MaternalGroupBstreptococcal(GBS)colonizationoccursin10to40percentofwomenandisthecritical
determinantofearlyonsetGBSinfectioninneonateslessthan7daysofage.(See'Introduction'above.)
Werecommenduniversalscreeningofpregnantwomentoidentifythoseatriskforhavinganewbornwith
earlyonsetGBSdisease(Grade1A).ColonizedwomencantransmitGBStooffspring,resultinginearly
onsetdiseaseinneonates,andsomeofthesecaseswillbemissedifaselectiveriskfactorbasedapproach
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istaken.(See'Identificationofcolonizedgravidas'aboveand'Outcome'above.)
WerecommendobtainingGBSculturesat35to37weeksofgestation,ratherthanariskfactorbased
approach.WomenwithGBSbacteriuriaanytimeinpregnancy(Grade2B)oraninfantwithearlyonsetGBS
infectioninapreviouspregnancy(Grade2C)shouldroutinelyreceiveprophylacticintrapartumantibiotics
therefore,theycanbeexcludedfromculturebasedscreening.(See'Culturebasedapproach'aboveand
'Exceptions'above.)
SwabsforGBScultureshouldbeobtainedfromboththelowervagina(notcervix)andrectum(nottheanal
orifice)toachievemaximumsensitivitytheseshouldbeplacedintransportmedia,senttothelaboratoryand
inoculatedintoselectivemediaforincubationandfurtherprocessing.(See'PerformanceofGBScultures'
above.)
InwomenwithpositiveGBSculturesfromeitherthevaginaorrectum,werecommendintrapartumantibiotic
prophylaxisattheonsetoflabor,withadministrationuntildelivery(Grade1A).(See'Intrapartumantibiotic
prophylaxis'above.)
InwomenwithpositiveGBSvaginalrectalculturesundergoingaplannedcesareandeliveryintheabsenceof
labororruptureofmembranes,werecommendnotadministeringintrapartumantibioticprophylaxis,giventhe
lowriskofearlyonsetdisease(Grade1B).(See'Intrapartumantibioticprophylaxis'aboveand'Outcome'
above.)
Womenwithintrapartumfever(100.4F,38C)whoseculturestatusisunknown(culturenotperformedor
resultnotavailable)shouldreceiveintrapartumantibiotictreatment(notprophylaxis)thatincludesanagent
activeagainstGBS.(See'Intrapartumantibioticprophylaxis'aboveand'Outcome'above.)
Thecolonizationstatusofwomenwhopresentwiththreatenedpretermdeliverygenerallyisnotknown.In
thesewomen,wesuggestobtainingaGBSrectovaginalcultureandgivingantibioticprophylaxis(Grade2B).
Continuationoftherapyisthenguidedbycultureresultsanduterineactivity.Antibiotictherapyiscontinued
untildeliveryoruntilthethreatofimminentpretermdeliveryhaspassed.(See'Approachtothreatened
pretermdelivery'above.)
Forwomeninlaborwithunknownculturestatus,werecommendintrapartumantibioticprophylaxisifthe
gestationalageislessthan37weeksorthedurationofmembraneruptureis18hours(Grade1B).Maternal
temperature100.4F(38.0C)issuggestiveofinfectionandshouldbetreatedwithantibioticsthatprovide
activityagainstGBS.(See'Intrapartumantibioticprophylaxis'above.)
Intrapartumantibioticprophylaxisismosteffectiveifpenicillin,ampicillin,orcefazolinareadministeredat
leastfourhoursbeforedelivery.(See'Timinganddurationofprophylaxis'above.)
Inwomenwithoutpenicillinallergy,penicillinGisthepreferreddrugforprophylaxis,givenitslowcost,low
incidenceofsideeffects,anduniformGBSsusceptibility.TheCentersforDiseaseControlrecommenda
doseof5millionunitsintravenouslyinitially,then2.5to3millionunitsintravenouslyeveryfourhoursuntil
delivery.Ampicillin2gintravenouslyinitialdosethen1geveryfourhoursuntildeliveryisanacceptable
alternative.(See'Antibioticregimen'above.)
Inpatientswithanonseriouspenicillinallergy,cefazolinisrecommendedinplaceofpenicillinG.(See
'Patientswithpenicillinallergy'above.)
Inpatientswithpenicillinallergyatriskforanaphylaxis,clindamycinisrecommendedifsusceptibilitytesting
hasbeenperformedandsensitivitytoclindamycinisdocumented.IftheGBSisolateisresistantto
clindamycinorsusceptibilityresultsarenotavailable,wesuggestvancomycin20mg/kgevery12hours,
maximum2gramsperdoseratherthanvancomycin1gramevery12hours(Grade2C).Neitherclindamycin
norvancomycinhasbeenevaluatedforeffectivenessinpreventingearlyonsetGBSinfantdisease.(See
'Patientswithpenicillinallergy'above.)
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AntepartumantibiotictreatmentofGBScolonizationremotefromdeliverydoesnotreducetheincidenceof
GBScolonizationatthetimeofdelivery,andshouldbeavoided.(See'Intrapartumantibioticprophylaxis'
above.)
WomenwithunknownculturestatusattermandnoriskfactorsforearlyonsetGBSdiseasewhotest
positiveforGBSwithintrapartumNAATshouldreceiveintrapartumantibioticprophylaxis.(See'Rapid
diagnostictests'above.)
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
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months:systematicreviewandmetaanalysis.Lancet2012379:547.
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streptococcus.NEnglJMed2009360:2626.
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earlyonsetgroupBStreptococcaldisease.PediatrInfectDisJ201130:759.
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78. VeraniJR,SpinaNL,LynfieldR,etal.EarlyonsetgroupBstreptococcaldiseaseintheUnitedStates:
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sepsis.ObstetGynecol2005105:581.
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84. GlasgowTS,YoungPC,WallinJ,etal.Associationofintrapartumantibioticexposureandlateonset
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85. RentzAC,SamoreMH,StoddardGJ,etal.Riskfactorsassociatedwithampicillinresistantinfectionin
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86. SinhaA,YokoeD,PlattR.Intrapartumantibioticsandneonatalinvasiveinfectionscausedbyorganisms
otherthangroupBstreptococcus.JPediatr2003142:492.
87. SchragSJ,HadlerJL,ArnoldKE,etal.Riskfactorsforinvasive,earlyonsetEscherichiacoliinfectionsin
theeraofwidespreadintrapartumantibioticuse.Pediatrics2006118:570.
88. PuopoloKM,EichenwaldEC.Nochangeintheincidenceofampicillinresistant,neonatal,earlyonset
sepsisover18years.Pediatrics2010125:e1031.
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89. PharesCR,LynfieldR,FarleyMM,etal.EpidemiologyofinvasivegroupBstreptococcaldiseaseinthe
UnitedStates,19992005.JAMA2008299:2056.
90. CastorML,WhitneyCG,ComoSabettiK,etal.AntibioticresistancepatternsininvasivegroupB
streptococcalisolates.InfectDisObstetGynecol20082008:727505.
91. BizzarroMJ,DembryLM,BaltimoreRS,GallagherPG.ChangingpatternsinneonatalEscherichiacoli
sepsisandampicillinresistanceintheeraofintrapartumantibioticprophylaxis.Pediatrics2008121:689.
92. EckerKL,DonohuePK,KimKS,etal.TheimpactofgroupBstreptococcusprophylaxisonlateonset
neonatalinfections.JPerinatol201333:206.
93. BoulvainM,StanC,IrionO.Membranesweepingforinductionoflabour.CochraneDatabaseSystRev
2005:CD000451.
94. GibbsRS,SchragS,SchuchatA.PerinatalinfectionsduetogroupBstreptococci.ObstetGynecol2004
104:1062.
95. SiegelJD,McCrackenGHJr,ThrelkeldN,etal.SingledosepenicillinprophylaxisofneonatalgroupB
streptococcaldisease.Lancet19821:1426.
96. PatelDM,RhodesPG,LeBlancMH,etal.Roleofpostnatalpenicillinprophylaxisinpreventionofneonatal
groupBstreptococcusinfection.ActaPaediatr199988:874.
97. PyatiSP,PildesRS,JacobsNM,etal.Penicillinininfantsweighingtwokilogramsorlesswithearlyonset
GroupBstreptococcaldisease.NEnglJMed1983308:1383.
98. WoodgateP,FlenadyV,SteerP.IntramuscularpenicillinforthepreventionofearlyonsetgroupB
streptococcalinfectioninnewborninfants.CochraneDatabaseSystRev2004:CD003667.
Topic438Version45.0

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GRAPHICS
Algorithmforrecommendedlaboratorytestingforprenatal
screeningforgroupBstreptococcal(GBS)colonization

*Directplatingwithappropriatemediamaybedoneinadditiontoenrichedculture.Directplating
shouldnotbeusedasthesolemeanstoidentifyGBS.
Reproducedfrom:VeraniJR,McGeeL,SchragSJ.DivisionofBacterialDiseases,NationalCenterfor
ImmunizationandRespiratoryDiseases,CentersforDiseaseControlandPrevention(CDC).Prevention
ofperinatalgroupBstreptococcaldiseaserevisedguidelinesfromCDC,2010.MMWRRecommRep
201059:1.
Graphic57194Version2.0

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CDCalgorithmforGBSprophylaxisinpenicillinallergy*

IV:intravenously.
*Broaderspectrumagents,includinganagentactiveagainstGBS,mightbenecessaryfortreatment
ofchorioamnionitis.
Dosesrangingfrom2.5to3.0millionunitsareacceptableforthedosesadministeredevery4
hoursfollowingtheinitialdose.Thechoiceofdosewithinthatrangeshouldbeguidedbywhich
formulationsofpenicillinGarereadilyavailabletoreducetheneedforpharmaciestospecially
preparedoses.
Penicillinallergicpatientswithahistoryofanaphylaxis,angioedema,respiratorydistress,or
urticariafollowingadministrationofpenicillinoracephalosporinareconsideredtobeathighriskfor
anaphylaxisandshouldnotreceivepenicillin,ampicillin,orcefazolinforGBSintrapartumprophylaxis.
Forpenicillinallergicpatientswhodonothaveahistoryofthosereactions,cefazolinisthepreferred
agentbecausepharmacologicdatasuggestitachieveseffectiveintraamnioticconcentrations.
Vancomycinandclindamycinshouldbereservedforpenicillinallergicwomenathighriskfor
anaphylaxis.
Iflaboratoryfacilitiesareadequate,clindamycinanderythromycinsusceptibilitytestingshouldbe
performedonprenatalGBSisolatesfrompenicillinallergicwomenathighriskforanaphylaxis.Ifno
susceptibilitytestingisperformed,ortheresultsarenotavailableatthetimeoflabor,vancomycinis
thepreferredagentforGBSintrapartumprophylaxisforpenicillinallergicwomenathighriskfor
anaphylaxis.
Resistancetoerythromycinisoftenbutnotalwaysassociatedwithclindamycinresistance.Ifan
isolateisresistanttoerythromycin,itmighthaveinducibleresistancetoclindamycin,evenifit
appearssusceptibletoclindamycin.IfaGBSisolateissusceptibletoclindamycin,resistantto
erythromycin,andtestingforinducibleclindamycinresistancehasbeenperformedandisnegative
(noinducibleresistance),thenclindamycincanbeusedforGBSintrapartumprophylaxisinsteadof
vancomycin.
Reproducedfrom:VeraniJR,McGeeL,SchragSJ.DivisionofBacterialDiseases,NationalCenterfor
ImmunizationandRespiratoryDiseases,CentersforDiseaseControlandPrevention(CDC).
PreventionofperinatalgroupBstreptococcaldiseaserevisedguidelinesfromCDC,2010.MMWR
RecommRep201059:1.

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Graphic70001Version3.0

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CDCalgorithmforscreeningforGBSinpreterm
laborbefore37weeks

CDC:CentersforDiseaseControlandPreventionGBS:GroupBstreptococcus.
*IfpatienthasundergonevaginalrectalGBSculturewithinthepreceding5
weeks,theresultsofthatcultureshouldguidemanagement.GBScolonized
womenshouldreceiveintrapartumantibioticprophylaxis.Noantibioticsare
indicatedforGBSprophylaxisifavaginalrectalscreenwithin5weekswas
negative.
Patientshouldberegularlyassessedforprogressiontotruelaborifthe
patientisconsiderednottobeintruelabor,discontinueGBSprophylaxis.
IfGBScultureresultsbecomeavailablepriortodeliveryandarenegative,
thendiscontinueGBSprophylaxis.
UnlesssubsequentGBSculturepriortodeliveryispositive.
AnegativeGBSscreenisconsideredvalidfor5weeks.Ifapatientwitha
historyofPTLisreadmittedwithsignsandsymptomsofpretermlaborandhad
anegativeGBSscreen>5weeksprior,sheshouldberescreenedandmanaged
accordingtothisalgorithmatthattime.
Reproducedfrom:CentersforDiseaseControlandPrevention.Preventionof
PerinatalGroupBStreptococcalDisease.RevisedGuidelinesfromCDC,2010.
MMWR201059:No.RR10.
Graphic72587Version7.0

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CDCalgorithmforscreeningforGBSinPROM
before37weeksofgestation

CDC:CentersforDiseaseControlandPreventionGBS:GroupB
streptococcusPROM:prematureruptureofmembranes.
*IfpatienthasundergonevaginalrectalGBSculturewithinthepreceding5
weeks,theresultsofthatcultureshouldguidemanagement.GBScolonized
womenshouldreceiveintrapartumantibioticprophylaxis.Noantibioticsare
indicatedforGBSprophylaxisifavaginalrectalscreenwithin5weekswas
negative.
AntibioticsgivenforlatencyinthesettingofpPROMthatincludeampicillin2
gintravenously(IV)once,followedby1gIVevery6hoursforatleast48
hoursareadequateforGBSprophylaxis.Ifotherregimensareused,GBS
prophylaxisshouldbeinitiatedinaddition.
GBSprophylaxisshouldbediscontinuedat48hoursforwomenwithpPROM
whoarenotinlabor.IfresultsfromaGBSscreenperformedonadmission
becomeavailableduringthe48hourperiodandarenegative,GBSprophylaxis
shouldbediscontinuedatthattime.
UnlesssubsequentGBSculturepriortodeliveryispositive.
AnegativeGBSscreenisconsideredvalidfor5weeks.Ifapatientwith
pPROMisenteringlaborandhadanegativeGBSscreen>5weeksprior,she
shouldberescreenedandmanagedaccordingtothisalgorithmatthattime.
Reproducedfrom:CentersforDiseaseControlandPrevention.Preventionof
PerinatalGroupBStreptococcalDisease.RevisedGuidelinesfromCDC,2010.
MMWR201059:No.RR10.
Graphic60841Version6.0
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Disclosures
Disclosures:CarolJBaker,MDConsultant/AdvisoryBoards:Pfizer(vaccinesnoproduct)NovartisVaccines(vaccinesnoproduct).
SusanMRamin,MDNothingtodisclose.DanielJSexton,MDGrant/Research/ClinicalTrailSupport:Cubist[C.difficileinfection
(Fidaxomycin)].Consultant/AdvisoryBoards:Johnson&Johnson[Pelvicmeshrelatedinfection]Sterilis[Medicalwastedisposal
systems]MagnoliaMedicalTechnologies[Intravenousdevices].OtherFinancialInterest:NationalFootballLeague[Infectioncontrol
program].EquityOwnership/StockOptions:MagnoliaMedicalTechnologies[Intravenousdevices].VanessaABarss,MD,FACOG
Nothingtodisclose.
Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseareaddressedbyvettingthrougha
multilevelreviewprocess,andthroughrequirementsforreferencestobeprovidedtosupportthecontent.Appropriatelyreferenced
contentisrequiredofallauthorsandmustconformtoUpToDatestandardsofevidence.
Conflictofinterestpolicy

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