GBS in Saudi Arabia Nawaf AlDajani 2008 Discolsure

GBS in Saudi Arabia Nawaf Al-Dajani, 2008

Discolsure

• • History Introduction Milestone of the guidelines GBS carriage during pregnancy in KSA Current practice Future plans Conclusions

History • 1930 s, GBS ass’ mastitis in Cows. • 1935, Lancefield isolated GBS from adult female patients. • 1970’s GBS emerged as major pathogen in neonates

Postnatal Sepsis: Change in Etiology in North America GBS proph revised GBS proph 1900 1950 2000 GAS GBS E. coli

Introduction

GBS Maternal Colonization • GBS Carriers Z 10% - 30% of women higher in African Americans and nonsmokers Zclinical signs not predictive Zdynamic condition • Risk factor for early-onset disease: GBS colonization at delivery Zprenatal cultures late in pregnancy can predict delivery status

Additional Risk Factors for Early-Onset GBS Disease • Obstetric: prolonged rupture of membranes, preterm delivery, intrapartum fever • GBS bacteriuria • Previous infant with GBS disease • Demographic (African American race, young age) • Immunologic (low antibody to GBS capsular polysaccharide)

Mother to Infant Transmission GBS colonized mother 50% Non-colonized newborn Colonized newborn 98% Asymptomatic 2% Early-onset sepsis, pneumonia, meningitis

GBS Disease in Infants Before Prevention Efforts A Schuchat. Clin Micro Rev 1998; 11: 497 -513.

Early-Onset 
Neonatal GBS Disease Before Prevention Efforts A Schuchat. Clin Micro Rev 1998; 11: 497 -513.

Milestone of the guidelines

Rate of Early- and Late-onset GBS Disease in the 1990 s, U. S. Group B Strep 1 st ACOG & AAP Association statements formed CDC draft guidelines published Consensus guidelines Schrag, New Engl J Med 2000 342: 15 -20

Rates of Early-Onset GBS Disease by Prenatal Colonization & Risk Factors Col: prenatal vag/rect culture RF: risk factors (gest. <37 wks, ROM >12 hr, fever > 37. 5 C) Boyer & Gotoff, Antibiot Chemother 1985.

Change in incidence of early-onset GBS disease in hospitals w/ and w/out new policies Factor, Obstet Gynecol 2000; 95: 377 -82

GBS partners meeting to re-evaluate the 1996 guidelines, November 1 -2, 2001 • Recommendation: Universal prenatal screening at 35 -37 wks’ gestation • Risk based strategy reserved for women with unknown GBS culture status at the time of labor MMWR, VOLUME 51 (RR-11), 2002 Schrag et al, NEJM 2002, 347: 233 -9

Screening !! • Boyer et al, 1986 • RCT of selective IPC, < 37 wk, PPROM > 12 hrs, 83 (85) received Abx vs 77(79) • NC vs EOD. • NC 8/85 vs 40/79 p < 0. 001 • EOD 0/85 vs 4/79 p 0. 052

Screening !! • Matorras et el, 1991 • RCT, 121 pt. 57 received ampicillin, 64 placebo. EOD 0/60 vs 3/65, p= 0. 137. • In Summary: • Relative risk reduction 0. 21, CI 0. 04 -1. 17 • No statistically significant.

• • Gilson et al, 2003, J Perinatol, Case control study 420 vs 470 0/420 vs 4/470, p 0. 04

GBS carriage rate in KSA

• Uduman et al, 1985, J Gynaecol Obstet. 1985 Feb ; 23 (1): 214 260 pt in labour, 24 had +ve GBS, 9. 2% 3 neonate screened +ve, 12. 5% • Aguis et al, 1987 3% colonised @ term • Al-Suleiman et al, 1991. 1939 pt. screened in 3 rd trimester. 17. 2% were colonized with GBS • El-Kersh et al, 2002, Saudi medical journal. 217 pt. screened 27. 6 % colonised

Current Practice

• Majority of regional hospital are not following the recommendation for screening. • Few hospital have a policy for screening. • Obstetricians vary among them self. • Hospitals following screening approach doing various other approaches.

Z Northwestern territories: Z 3 hospitals, no screening, one trying!! Z Western territories: Z 8 hospitals, one screening, one ++. Z Southwestern territories: Z 2 hospitals, one have a policy. Z Middle: Z One +/-, one +, two ++

Why there is disparity and diversity? ZLack of adequate time!! ZLack of administrative support. ZLimited resources. ZUnbooked mothers. ZDifferent opinions.

What is the incidence of GBS ENOS ZAl. Muneef et al, Z 29601 live birth, 1990 -1994 Z 23 had GBS spsis Z 0. 8/ 1000 >>>> 0. 64/1000

Others Z Many neonatologists feel it is a rare. Z During survey: Z A- no confirmed case per 7000 Z B- no confirmed case per > 5000 Z C- one case per 6000 (unbooked) Z D- no case last few yr, 1300/ yr Z E- one case in 34 wk, 5000

Why it is rare? Z Underdetection. Z Intrapartum antimicrobial exposure. Z Different serotypes. Z Different scale of colonization. Z False believe?

Future plan!! ZDepends on: ZIncidence of GBS EONS. ZPatients characteristics. Z? Colonization rate. ZAvailable resources.

Z Accurate incidence of EONS due to GBS is unknown in Saudi Arabia. Z Mohle-Boetani et al, JAMA, 1993: Z Risk-based approach is not cost effective unless incidence is > 0. 6/1000 Z Screening not cost effective unless it is 1. 2/1000 Z Strickland et al, 1990, Z Colonization rate has to be > 10%

Z Allardice et al, 1982, 16 women NNT to prevent on EONS Z Garland et al, 1991, 2059 colonized women NNT to prevent one case of EONS.

Conclusions Z Screening approach is probably is better than risk based approach based on cohort study, level II evidence (fair). Z Probably is not cost effective if the neonatal infection is rare or uncommon. Z The incidence of EONS due to GBS is probably rare or low in Saudi Arabia.

Z Hospital with adequate resources may follow the guidelines for booked pt. Z Hospital with limited resources may follow the risk based approach. Z Self collection is an option for busy clinics. Z Rapid testing can be useful for unbooked mothers Z Vaccines