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GBS in Saudi Arabia

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					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
• 1930s, 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
   10% - 30% of women
    higher in African Americans and
    nonsmokers
   clinical signs not predictive
   dynamic condition
• Risk factor for early-onset disease: GBS
  colonization at delivery
   prenatal 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%                                  50%
 Non-colonized                          Colonized
   newborn                              newborn


                 98%                         2%

 Asymptomatic                     Early-onset sepsis,
                                  pneumonia, meningitis
                     GBS Disease in Infants Before
                          Prevention Efforts
                   90
                   80
Percent of cases




                   70
                   60
                   50
                   40
                   30
                   20
                   10
                    0
                        < 1 1-3   1   2   3   4    5   6     7   8   9   10 11
                        wk wk
                                              Age (months)

                   A Schuchat. Clin Micro Rev 1998;11:497-513.
         Early-Onset 
Neonatal GBS
         Disease Before Prevention Efforts
                   90
                   80
                   70
Percent of cases




                   60
                   50
                   40
                   30
                   20
                   10
                    0
                        0      1        2       3        4   5   6
                                            Age (days)

               A Schuchat. Clin Micro Rev 1998;11:497-513.
Milestone of the guidelines
                               Rate of Early- and Late-onset GBS
                                   Disease in the 1990s, U.S.
                                     Group B Strep
                                     Association   1st ACOG & AAP
                                     formed         statements
  Cases per 1000 live births



                               2.5                             CDC draft
                                                         guidelines published
                                2                                        Consensus
                                                                         guidelines
                               1.5

                                1

                               0.5

                                0
                                1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000
                                                              Year

                                                      Early-onset    Late-onset
Schrag, New Engl J Med 2000 342: 15-20
 Rates of Early-Onset GBS Disease by
 Prenatal Colonization & Risk Factors
                                 45     40.8
                                 40
    Cases per 1000 live births




                                 35
                                                 Col: prenatal vag/rect culture
                                 30              RF: risk factors (gest. <37 wks,
                                 25              ROM >12 hr, fever > 37.5 C)
                                 20
                                 15
                                 10
                                                     5.1
                                  5                              0.9         0.3
                                  0
                                      Col+,RF+     Col+,RF-    Col-,RF+    Col-,RF-


Boyer & Gotoff, Antibiot Chemother 1985.
Change in incidence of early-onset GBS
disease in hospitals w/ and w/out new
policies
                                             1996   1997
Cases per 1000 births




                         1
                        0.8
                        0.6
                        0.4
                        0.2
                         0
                              Hospitals w/ new      Hospitals w/out
                                  policy               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 > 12hrs, 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):21-
  4
  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 3rd 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.
Northwestern territories:
3 hospitals, no screening, one
 trying!!
Western territories:
8 hospitals, one screening, one ++.
Southwestern territories:
2 hospitals, one have a policy.
Middle:
One +/-, one +, two ++
 Why there is disparity and
        diversity?
Lack of adequate time!!
Lack of administrative support.
Limited resources.
Unbooked mothers.
Different opinions.
What is the incidence of
GBS ENOS
AlMuneef et al,
29601 live birth, 1990-1994
23 had GBS spsis
0.8/ 1000 >>>> 0.64/1000
Others
Many neonatologists feel it is a rare.
During survey:
A- no confirmed case per 7000
B- no confirmed case per > 5000
C- one case per 6000 (unbooked)
D- no case last few yr, 1300/ yr
E- one case in 34 wk, 5000
Why it is rare?
 Underdetection.
 Intrapartum antimicrobial exposure.
 Different serotypes.
 Different scale of colonization.
 False believe?
Future plan!!
Depends on:
Incidence of GBS EONS.
Patients characteristics.
? Colonization rate.
Available resources.
 Accurate incidence of EONS due to
 GBS is unknown in Saudi Arabia.
 Mohle-Boetani et al, JAMA,1993:
 Risk-based approach is not cost
 effective unless incidence is > 0.6/1000
 Screening not cost effective unless it is
 1.2/1000
 Strickland et al, 1990,
 Colonization rate has to be > 10%
 Allardice et al, 1982,
 16 women NNT to prevent on EONS

 Garland et al, 1991,
 2059 colonized women NNT to
 prevent one case of EONS.
Conclusions
 Screening approach is probably is
 better than risk based approach
 based on cohort study, level II
 evidence (fair).
 Probably is not cost effective if the
 neonatal infection is rare or
 uncommon.
 The incidence of EONS due to GBS is
 probably rare or low in Saudi Arabia.
 Hospital with adequate resources may
 follow the guidelines for booked pt.

 Hospital with limited resources may follow
 the risk based approach.

 Self collection is an option for busy clinics.

 Rapid testing can be useful for unbooked
 mothers
 Vaccines

				
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