The first report from The Royal College of Obstetricians & Gynaecologists 2013-14 audit on (early-onset) group B Strep prevention policies in UK maternity units was published on 5th March. It was eye opening to say the least and shed a spotlight on how health professionals in the trenches are really dealing with the most common cause of infection in newborns and meningitis in babies fewer than three months.
To recap, the UK’s current approach to group B Strep prevention is well behind most developed countries. Countries like Australia, Argentina, Belgium, Canada, Chile, Czech Republic, Dubai, France, Germany, Hong Kong, Italy, Japan, Kenya, Lithuania, New Zealand, Oman, Poland, Spain, Slovenia, Switzerland and the USA offer routine antenatal screening for group B Strep carriage and antibiotics in labour to those positive Mums. Countries that do screen have seen the rate of group B Strep infections fall by 71-86%1. Instead of routine screening, the UK uses a ‘risk-based’ strategy. The rate of early-onset group B Strep infection in England, Wales & Northern Ireland has not changed since the RCOG’s introduction of this risk factor approach in 2003: 0.37/1000 live births in 2003 and 0.38/1000 in 20132.
The rate has not changed because, to put it plainly, the risk factors are failing. They are poor at predicting whether a pregnant woman is carrying group B Strep, which happens to be the key risk factor for Mum passing it on to her newborn baby. Up to 40% of babies who do develop group B Strep infection are born to mothers without any of these clinical risk factors!
Obstetricians and midwives are recognising that the RCOG’s guidelines are failing. They see this in their practice and, as we learned from the audit, they are taking their own action….like offering testing. More than half (55.9%) of UK maternity units are offering testing to some or all pregnant women for group B Strep carriage. Parents are becoming more aware because 76% of these units are testing at the mother’s request. These women have been directly affected by group B Strep in a previous pregnancy, know someone who has, or have come across the information either online or in print… and they are speaking up.
We gave ourselves a pat on the back when we read that the most common source of written information given to women about GBS came from Group B Strep Support… used by 37.5% of obstetric units!
While on the surface this increase in testing seems like progress, the dark side of the issue is that the majority of these testing units are using the ‘wrong’ test or worse, unsure what test they’re offering. 61.5% are using the NON-enriched culture media method, so the conventional NHS swab test rather than the Enriched Culture Medium method described in Public Health England’s UK SMI B583… considered the ‘gold standard’ for GBS carriage detection. The NHS non-enriched culture test uses the Standard Direct Plating technique and can miss up to 50% of all group B Strep carriers at the time the swab was taken. Because the test is unselective, other bacteria present in the sample may outgrow or camouflage the GBS. To see more on the differences between these two tests, click here. False negatives mean, according to the guidelines, that a woman wouldn’t then be offered the intrapartum antibiotic prophylaxis she very well may need. The lack of availability and proper knowledge about this recommended ECM test versus the NHS test isn’t helping.
Clinicians are also taking their own action in terms of antibiotic administration. While most hospitals are offering IAP (intrapartum antibiotic prophylaxis) in accordance with the approved risk factors recommended by RCOG, the audit highlights 13 situations in which women are being offered IAP against the RCOG guidelines. There is such a heated debate about unnecessary antibiotic use, yet this is already happening! When women are given antibiotics in labour on the basis of risk factors, instead of doing an ECM test, 71% will not be carriers of group B Strep. Almost three quarters of women will be given antibiotics to prevent EOGBS infection unnecessarily.4
Many maternity units have put their own strategies in place eager to reduce the number of group B Strep infections on their watch, but the right tools and information are not being made available to them. Instead of calling for stricter adherence to the guidelines (which was the moral of the RCOG audit story) is it not more appropriate for the guidelines to catch up with the practice that is in already in play for these progressive units?
To read the RCOG audit in full, click here: gbss.org.uk/wp-content/uplo...
1 Albouy-Llaty M, Nadeau C, Descombes E, Pierre F, Migeot V. Improving perinatal Group B streptococcus screening with process indicators. J Eval Clin Pract 2011
2 PHE data series online, summarised at gbss.org.uk/what-is-gbs/abo...
3 Public Health England’s UK Standards for Microbiology Investigations B 58 Processing Swabs for GBS Carriage
4 Daniels JP, Gray J, Gray R, Hills RK, Khan KS, Pattison HM; Intrapartum tests for group B streptococcus: accuracy and acceptability of screening: GBS Collaborative Group. BJOG. Jan 2011;118 (2):257-65. Epub 2010 Oct 13. Full article at onlinelibrary.wiley.com/doi...