Group B Strep (GBS)
WHAT IS GROUP B STREPTOCOCCUS INFECTION?
Since the early 1970's, the bacteria Group B Streptococcus (GBS) has been identified as the number one cause of life threatening infections in newborn babies.
This bacteria is normally found in the vagina and/or lower intestine of 15% to 40% of all healthy, adult women. Those women who test positive for GBS are said to be colonized.
Group B Streptococcus should not be confused with Group A Streptococcus which causes strep throat.
The vast majority of GBS infections are acquired during childbirth when the baby comes into direct contact with the bacteria carried by the mother.
An estimated 12,000 infants in the United States will become infected with GBS each year. This bacteria will result in the death of an estimated 2,000 infants yearly, while leaving many others mentally and/or physically handicapped.
GBS usually causes infant illness within the first seven days of life, but late onset infections may occur up to three months of age. Performance of a cesarean section will not eliminate the risk of infection.
GBS infections are more common than other illnesses for which pregnant women are screened, such as rubella, Down's Syndrome and spina bifida. Yet, GBS remains generally unknown to the public.
Fortunately, there is testing and a preventative treatment available that can help prevent many of these infections.
ENCLOSED ARE SOME INFORMATIVE FACTS ABOUT:
GBS AND PREGNANCY
"Do All Women Carry GBS?"
If 1000 women, regardless of race or socioeconomic status, had a vaginal culture taken, 150-350 would test positive for GBS. Because GBS usually does not cause problems for the adult female, most women carry it and do not know it. Yet, GBS can cause serious illness in babies born to women who carry the bacteria.
GBS is also responsible for causing infections in nearly 50,000 pregnant women each year including fever after birth, uterine inflammation, and infections following cesarean sections.
HIGH RISK SITUATIONS:
"Can GBS Infections Be Prevented?"
Yes. There is a fast and effective treatment for many situations. Medical research indicates that giving antibiotics through the vein to the mother during labor can greatly reduce the frequency of GBS infection in the baby immediately after birth or during the first week of life.
Treating the mother with oral antibiotics during the pregnancy may decrease the amount of GBS for a short time, but it will not eliminate the bacteria completely and will leave the baby unprotected at birth. Also, waiting to treat the baby with antibiotics after birth is often too late to prevent illness.
Women who are found to carry the bacteria can then be treated as potential GBS risk patients. But, just like any other bacteria in the human body, GBS can be present in small amounts on one day which would result in a negative culture. Therefore, one negative culture result does not guarantee that you will be negative on the day you deliver. (Current studies indicate that a lower vaginal AND rectal culture done late in pregnancy is more than 93% accurate in detecting who will not carry the bacteria at delivery.)
Infants born to these heavily colonized women are at greatest risk of infection. Women who carry less amounts of the bacteria may not be identified by the test; however, medical research indicates that their babies are at lower risk of becoming infected. Although GBS can strike anyone, infants at greatest risk of infection are those that fall into the HIGH RISK SITUATIONS mentioned previously. It is in these situations that it could be particularly beneficial to perform the rapid test during labor to determine of the mother is carrying GBS.
THE CHOICE IS YOURS
No one really knows ahead of time if she will find herself in a high risk situation during pregnancy or labor. Now that you are aware of GBS disease, please take the time to discuss GBS testing and preventative treatment with your doctor.
The Centers for Disease Control state that it is cost effective to routinely screen pregnant women for GBS. They further state that is all women are screened at 35-37 weeks gestation and all GBS+ moms are treated with IV antibiotics in labor, more than 3/4 of all cases of GBS in the first week of life could be prevented.
Group B Strep Association is a nonprofit organization formed by parents whose babies were victims of GBS infections. Having experienced the pain and devastation of this illness, these parents sought the help of prominent researchers and physicians from all over the country. These doctors responded with great support and have joined together to act as the Medical Advisory Board for the organization. Together we hope to create public awareness of GBS disease, to bring about guidelines for testing and treatment of GBS, and to generate continuing support for vaccine research. Our greatest underlying purpose is to serve the public by being a resource for both information and support.
The Group B Strep Association was formed:
B strep: are antibiotics necessary?
Most women who have been pregnant in the last few years are familiar with the term group B strep (for group B streptococcus), or GBS. The American College of Obstetricians and Gynecologists (ACOG) and the US Centers for Disease Control and Prevention (CDC) recommend that all pregnant women be screened between weeks 35 and 37 of their pregnancies to determine if they are carriers of GBS. This screening involves taking a swab of the pregnant woman's vaginal and rectal areas. Studies show that approximately 30 percent of pregnant women ate found to be colonized with GBS in one of both areas. (1-5)
The CDC and ACOG advise all pregnant women who are found to be carriers of GBS to be treated with intravenous antibiotics during labor. Doctors and midwives have such great concern because GBS can be passed from the mother to the infant during delivery and can cause sepsis (a blood infection), pneumonia, and meningitis (an infection of the fluid and lining of the brain) in newborn infants. Therefore, most pregnant women who test positive for GBS choose to follow CDC and ACOG recommendations and attempt to avoid transmitting GBS to their newborns through treatment with IV antibiotics throughout their labors. Given all this, why would any woman choose not to accept JV antibiotics? But no woman can make a truly informed decision about this issue without taking a critical look at any recommendation that a third of all women and their infants be given antibiotics during labor.
GBS is a bacterium that normally lives in the intestinal tracts of many healthy people. A vaginal-rectal area colonized by GBS should not be termed "infected" any more than an intestinal tract colonized by GBS would be. GBS is a problem only when it is present in the genital area of a pregnant woman during labor and delivery. When this happens, there is a small risk that the bacteria will be passed on to the newborn infant and that she or he will become sick as a result. Approximately 0.5 percent of women found to have GBS bacteria in their genital areas at 35 to 37 weeks into their pregnancies and who are not treated with antibiotics will go on to deliver a baby who becomes ill from GBS.
We should not take lightly the use of antibiotics for 200 women and their babies to prevent only a single blood infection--however serious that infection might be--especially in this age of increasing resistance to antibiotics. Concerns have arisen in several areas regarding the use of antibiotics for so many laboring women. One dilemma is that colonization of the vaginal area by GBS is, at best, a poor method of predicting whether a newborn will develop a GBS infection. As mentioned, even without any intervention during labor, fewer than 1 percent of infants born to carriers of GBS develop infections. (6,7)
Some studies have shown a decrease in GBS infection in newborns whose mothers accepted TV antibiotics during labor, but no decrease in the incidence of death. (8,9) Still other research has found that preventive use of antibiotics is not always effective. (10) In fact, one study found no decrease in GBS infection of deaths among newborns whose mothers were given IV antibiotics during labor. (11)
Perhaps the greatest area of concern to medical researchers, as it should be to us all, is the alarming increase in antibiotic-resistant strains of bacteria. Antibiotic-resistant bacteria can cause infections in newborns that are very difficult to treat. Many large research studies have found not only resistant strains of GBS but also antibiotic-resistant strains of E. coli and other bacteria caused by the use of antibiotics in laboring women. (12-21) Some strains of GBS have been found to be resistant to treatment by all currently used forms of antibiotics. (22)
While many studies have found that giving antibiotics during labor, to women who test positive for GBS decreases the rate of GBS infection among newborns, research is beginning to show that this benefit is being outweighed by increases in other forms of infection. One study, which looked at the rates of blood infection among newborns over a six-year period, found that the use of antibiotics during labor reduced the instance of GBS infection in newborns but increased the incidence of other forms of blood infection. (23) The overall effect was that the incidence of newborn blood infection remained unchanged.
The increase in other forms of blood infection among newborns is likely due to bacteria made drug-resistant by the overuse of antibiotics. Evidence shows that increased use of antibiotics frequently leads to increasing bacterial resistance. When a woman is given antibiotics during labor to treat GBS, the antibiotics cross the placenta and enter the amniotic fluid. While the antibiotics may have the desired effect of killing the GBS bacteria, some GBS bacteria can survive and become difficult, if it not impossible, to kill with traditionally used antibiotics. Similarly, other bacteria that may be present in the mother of infant, such as E. coli, can become resistant to antibiotic treatment. These bacteria may not have presented a large risk of infection to the newborn until they were exposed to antibiotics and made into "superbugs."
A study of 43 newborns with blood infections caused by GBS and other bacteria found that when the mothers of the ill newborns had been given antibiotics during labor, 88 to 91 percent of the infants' infections were resistant to antibiotics. It is unlikely to be a coincidence that the drugs to which the bacteria showed resistance were the same antibiotics that had been administered during labor. (24) For the newborns who had developed blood infections without exposure to antibiotics during labor and delivery, only 18 to 20 percent of their infections were resistant to antibiotics.
E. coli, in particular, is becoming an increasing cause of bacterial infection in newborns as the use of antibiotics in labor has increased. One study, which looked at causes of newborn blood infections between 1991 and 1996, found that the incidence of infections caused by GBS decreased during this time, but that the incidence of infection caused by other bacteria, especially E. coli, increased. (25) During those years, antibiotic use during labor increased from less than 10 percent to almost 17 percent of the women included in this study. The researchers concluded that increased use of antibiotics during labor was the likely cause of increased newborn blood infections with bacteria other than GBS.
E. coli infection is particularly difficult to treat in premature babies. Unfortunately, the proportion of E. coli bacteria that are resistant to antibiotic treatment has increased astronomically in premature infants in the past few years. In a review of 70 cases of E. coli infection in newborns over a two-year period, researchers found that 29 percent of the E. coli bacteria present in premature babies were resistant to ampicillin in 1998; two years later, 84 percent of the E. coli bacteria present in premature babies were resistant to the same antibiotic. (26)
Preterm labor (labor before 37 weeks) is a well-accepted risk factor for transmission of GBS to the infant during labor and delivery. Due to the larger risk of transmitting GBS to a premature baby during delivery, most women who go into early labor will opt to receive IV antibiotics during labor. However, infants born prematurely are at a greater risk from superbugs caused by the very antibiotics that are supposed to be reducing their risk of infection. Severe complications for the babies, even deaths, have occurred when women whose waters broke before 37 weeks were given antibiotics to prevent transmission of GBS to their newborns. St. Joseph's Hospital in Denver, Colorado, tracked four cases in which women whose waters broke before 37 weeks were given ampicillin or amoxicillin. Following the administration of antibiotics, infection of the amniotic fluid occurred in all four cases. Two of the infants died as a result of blood infections from resistant bacteria; a third was stillborn, presumably from the same cause. (27)
Given the frightening results of these studies, what is a woman to do if she tests positive for GBS during her pregnancy? A closer look at the real risks of transmission, a frank talk with her provider of prenatal care, and a consideration of alternatives for eradicating GBS are all good places to start.
How great is the risk of my baby becoming sick from GBS?
There ate three significant factors that place a woman at increased risk of delivering ah infant who becomes ill from GBS: fever during labor, her water breaking 18 hours of more before delivery (prolonged rupture of membranes, or PROM), and/or labor or broken water before 37 weeks gestation. (28) Other factors that can contribute to a newborn's risk of contracting GBS infection include age, ethnicity, and medical criteria, such as the following: being born to a mother who is less than 20 years old, (29, 30) being African American, (31, 32) the mother having large amounts of GBS bacteria in her vaginal tract, (33-37) and being born to a mother who has given birth to a prior sibling with GBS disease. (38-40)
In the absence of the first three risk factors (fever during labor, PROM, or labor before 37 weeks), the risk of a newborn developing GBS infection is very small: The CDC estimates that, without the use of antibiotics during labor, only one out of every 200 GBS-positive women without these risk factors (0.5 percent) will deliver an infant with GBS disease. Some studies have found even lower rates of transmission. If antibiotics are given to the mother during labor, the CDC estimates that one in 4,000 GBS-positive women with no other risk factors will deliver an infant with GBS infection.
Conservative studies find that the use of antibiotics during labor fails to prevent up to 30 percent of GBS infections and 10 percent of deaths from GBS disease or infections. (41, 42) Although, by CDC estimations, there is a reduced risk of GBS transmission with the use of antibiotics, one must take into account the risks posed by the use of the antibiotics themselves.
For a woman who has a negative culture for GBS at 35 to 37 weeks, there is a one in 2,000 risk of her newborn developing a GBS infection, and antibiotics are not recommended by the CDC. The CDC does recommend treating with antibiotics all women with risk factors (fever, PROM, premature labor) if they have not been tested to determine whether they are carriers of GBS.
What are the symptoms of GBS infection in a baby?
There are two forms of GBS infection: early and late onset. In early-onset GBS disease, the infant will become ill within seven days of birth. Of those infants who do develop a severe early-onset GBS infection, approximately 6 percent will die from complications of the infection. (43) Full-term babies are less likely to die; 2 to 8 percent of them suffer fatal complications. (44) Premature infants have mortality rates of 25 to 30 percent. (45) Late-onset GBS infection is more complex and has not been convincingly tied to the GBS status of the mother. Late-onset GBS infection occurs between seven days and three months of age.
In newborns, symptoms of early-onset GBS infection can include any of the following: fever or abnormally low body temperature, jaundice (yellowing of the skin and whites of the eyes), poor feeding, vomiting, seizures, difficulty in breathing, swelling of the abdomen, and bloody stools. Of course, any of the above symptoms can also be a sign of a sick newborn who does not have a bacterial infection. Newborns with any of these symptoms should be immediately evaluated by a medical professional.
How great is the risk from antibiotics?
The recommended antibiotic for treating GBS during labor is penicillin. Fewer bacteria currently show a resistance to penicillin than to other antibiotics used to treat GBS. The options are fewer for women known to be allergic to penicillin. Up to 29 percent of GBS strains have been shown to be resistant to non-penicillin antibiotics. (46) For women not known to be allergic to penicillin, there is a one in ten risk of a mild allergic reaction to penicillin, such as a rash. Even for those women who have no prior experience of a penicillin allergy, there is a one in 10,000 chance of developing anaphylaxis, a life-threatening allergic reaction.
We can compare these statistics to CDC estimates that 0.5 percent of babies born to GBS-positive mothers with no treatment will develop a GBS infection, and that 6 percent of those who develop a GBS infection will die. Six percent of 0.5 percent means that three out of every 10,000 babies born to GBS-positive mothers given no antibiotics during labor will die from GBS infection. If the mother develops anaphylaxis during labor (one in 10,000 will), and it is untreated, it is likely that the infant, too, will die. So, by CDC estimates, we save the lives of two in 10,000 babies--0.02 percent--by administering antibiotics during labor to one-third of all laboring women. We should also keep in mind that this figure does not take into account the infants who will the as a result of bacteria made antibiotic-resistant by the use of antibiotics during labor--Infants who would not otherwise have become ill. When you take that into account, there may not be any lives saved by using antibiotics during labor.
It should be noted, however, that antibiotics such as penicillin do kill GBS as well as other bacteria that might cause a newborn to become ill. The benefits of using penicillin during labor must be weighed against your individual risk factors for passing GBS on to your baby. It was only a few years ago that the same could have been said about other antibiotics. Ampicillin and amoxicillin have been rendered virtually useless for treating GBS by their prior overuse in laboring women in an effort to prevent GBS infection in newborns. How long will it be before penicillin, too, becomes useless in the battle to prevent GBS infections?
More minor risks of the use of antibiotics include an increase in thrush and other yeast infections among newborns. Along with the risks of thrush and allergic reactions, women must take into consideration the risk of creating antibiotic resistant bacteria in themselves and their newborns. It is possible that exposure to antibiotics during birth could delay establishment of healthy bacteria in an infant's intestinal tract and allow penicillin resistant bacteria, many of which are harmful, to become established.
Each woman must weigh for herself the likelihood of GBS infection in her newborn, taking into account her individual risk factors as well as the risk of other forms of infection caused by antibiotic-resistant bacteria. This is a good discussion to have with your healthcare provider so that you can be an informed partner in your own health care.
Are there alternatives to antibiotics?
Many women are interested in alternatives to antibiotics that may help get rid of GBS prior to labor. Unfortunately, no scientific studies of alternative treatments have been published. Several researchers have suggested that studies are needed Io determine whether alternative approaches to eradicating GBS in pregnant women would be effective. Alternate approaches that have been suggested include vaginal washing and immunotherapy. (47) At this point, however, these alternatives remain to be studied, and I am aware of no healthcare providers who use either method.
Some practitioners of natural medicine have suggested supplements for the mother in an effort to eradicate GBS prior to delivery. One suggestion is that when a woman tests positive for GBS, she should take a course of garlic, vitamin C, echinacea, and/or bee propolis, and then be retested to determine if she is still carrying GBS. Any supplements that a pregnant woman considers taking should first be discussed with a homeopathic or naturopathic physician or other knowledgeable practitioner of natural medicine.
Because colonization by GBS is intermittent or transient for 60 percent of carriers, testing positive for GBS once does not indicate that a woman will always be colonized. (48) However, most studies indicate that a positive culture at 35 to 37 weeks gestation is a fairly accurate predictor of GBS colonization at delivery. Without an active effort to eradicate the GBS colonization, it is likely that a woman will still be colonized at delivery.
Ultimately, it is the pregnant woman herself who will have to decide what is right for her and her baby. Deciding to follow the recommendations of ACOG and the CDC is not necessarily the wrong choice, as long as a woman is adequately informed of the risks that come with antibiotic use. But none of us should blindly follow recommendations to interfere with the natural birth process without taking a good look at the risks, as well as the benefits, of doing so.
Ideally, you will begin treatment at about 32 weeks, on confirmation of the presence of GBS in a vaginal culture, a urine sample, or a rectal sample. (Some doctors will do both a vaginal and a rectal swab.) Treatment will include orally taking herbs that strengthen your immune system and vaginally applying herbs that will restore your healthy vaginal flora, enable your body to reduce bacterial over-growth, and directly fight the bacteria. As you enter the last few weeks of pregnancy, from 37 weeks onward (since your baby is unlikely to be premature), most midwives will be willing to assist you at home if this is your plan. in the hospital, your baby will also be considered close to full term and will not be treated as premature in most circumstances, At 37 weeks, you can therefore begin to use certain herbs, both orally and vaginally, that are sometimes considered labor stimulants but are nonetheless effective for reducing bacterial infections.
At 32 weeks, begin to take a supplement of 500 mg of vitamin C and one cup of burdock root and echinacea root infusion. To prepare the infusion, steep one-half ounce of each of these herbs in four cups of boiling water for two hours. Strain and take the above dose, storing the rest in the refrigerator for the next day.
Eat a lot of fresh garlic every day.
Take one-half teaspoon each of echinacea and astragalus tinctures twice daily. You can also get dried astragalus in the herb department of your health food store, and cook two strips into a pot of rice or soup two to three times per week Remove the strips when done cooking and eat the rice or soup. Astragalus is an immune system tonic, well known in the Chinese pharmacopoeia but also found in America
* Chop a clove of fresh garlic and mix with a teaspoon of honey. Swallow this mixture without chewing it. Repeat several times a day, preferably with a meal.
* Make a garlic elixir by blending one-half cup of honey, one quarter cup of apple cider vinegar, and half a bulb of fresh garlic in your blender until liquified. Take one-half teaspoon up to twice a day. Adjust the taste as necessary with more or less honey or vinegar.
* Chop fresh garlic onto a salad or mix with olive oil to use as a dressing or a dip for French bread.
* Take garlic perles according to the dosage on he brand you purchase.
Excerpted from The Natural Pregnancy Book, by Aviva Jill Romm, copyright [c]2003. Reprinted by permission of Celestial Arts. Available at bookstores everywhere
(1.) B. E Anthony et al., "Epidemiology
of Group B Streptosoccus: Longitudinal Observations
during Pregnancy," Journal of Infectious
Disease 137 (1978): 524-530.
Christa Novelli has a master's degree in public health. She lives in Colorado with her husband and two daughters, Angelina (5) and Tessa (3). Christa tested positive for group B strep with her second pregnancy and opted not to take IV antibiotics. Tessa did not develop a GBS infection.
COPYRIGHT 2003 Mothering Magazine
in association with The Gale Group and LookSmart.
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