• About Us
    • Contact Us
    • Login
    • ObGFirst
  • COVID-19
  • Alerts
  • OB
  • 2T US Atlas
  • The Genome
  • GYN
    • GYN
    • Sexual Health
  • Primary Care
  • Your Practice
  • GrandRounds
  • My Bookshelf
  • Now@ObG
  • Media
About Us Contact Us Login ObGFirst
  • COVID-19
  • Alerts
  • OB
  • 2T US Atlas
  • The Genome
  • GYN
    • GYN
    • Sexual Health
  • Primary Care
  • Your Practice
  • GrandRounds
  • My Bookshelf
  • Now@ObG
  • Media
OB
CMECNE

Updated Guidance on GBS Screening and Prophylaxis

image_pdfFavoriteLoadingFavorite

Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Recall antibiotic choices for patients who are not allergic to penicillin
2. List antibiotics that may be used in the setting of penicillin allergy

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.

The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from Dec 31 2017 through Jan 25 2023, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Designated for 0.1 contact hours of pharmacotherapy credit for Advance Practice Registered Nurses.

Read Disclaimer & Fine Print

SUMMARY:

Group B streptococcal (GBS) disease remains a leading cause of early-onset neonatal sepsis in the US. The ACOG committee opinion has been endorsed by the AAP, ACNM, AWHONN and SMFM. Furthermore, CDC states that the ACOG committee opinion supersedes the 2010 CDC recommendations.

Updates to note:

  • Universal screening with a window of 36w0d – 37w6d
  • Alert lab to penicillin allergy so that clindamycin susceptibility testing can be performed on GBS culture positive specimen
  • Vancomycin dosing is now weight based
  • Unknown culture status and in labor at ≥37w0d
    • Administer intrapartum prophylaxis if GBS colonized in previous pregnancy
  • Penicillin still remains agent of choice for intrapartum prophylaxis and penicillin allergy testing

…if available, is safe during pregnancy and can be beneficial for all women who report a penicillin allergy, particularly those that are suggestive of being IGE mediated, or of unknown severity, or both.

CLINICAL ACTIONS:

GBS SCREENING

Pregnant women should undergo vaginal-rectal screening for GBS colonization at 36w0d – 37w6d (screening valid up to at least 41w0d) 

Intrapartum antibiotic prophylaxis is recommended for women

  • Who delivered a previous infant with GBS disease
  • With GBS bacteriuria in the current pregnancy
  • With a GBS-positive screening result in the current pregnancy
  • With unknown GBS status and
    • Birth <37w0d
    • Have an intrapartum temperature of ≥100.4°F (38.0°C)
    • Have rupture of membranes for ≥18 hours
  • Intrapartum NAAT result
    • Positive for GBS
    • Negative for GBS but above risk factors develop (e.g., intrapartum fever)
  • ‘Consider’ in women with positive GBS colonization in previous pregnancy and present at ≥37w0d in labor with unknown culture status in current pregnancy

Note: (1) Penicillin remains the preferred agent with ampicillin an acceptable alternative; (2) Clinicians do not need to test women who had a previous baby who developed GBS disease – These women should receive antibiotics (see above)

INTRAPARTUM ANTIBIOTIC PROPHYLAXIS

Q: Is the patient allergic to penicillin?  

NO – not allergic to penicillin

  • Penicillin G, 5 million units IV initial dose, then 2.5–3.0 million units every 4 hrs until delivery  or
  • Ampicillin, 2 g IV initial dose, then 1 g IV every 4 hrs until delivery

YES! – is allergic to penicillin 

Low risk for anaphylaxis: History of any of the following after receiving penicillin or a cephalosporin

  • Nonurticarial maculopapular (morbilliform) rash without systemic symptoms | Family history but no personal history | Patient reports personal history but can not recall symptoms | Pruritis but no rash | Nonspecific symptoms (e.g., nausea, diarrhea, vaginal candidiasis) that are unlikely to be allergic
    • Cefazolin, 2g IV initial dose, then 1 g IV every 8 hrs until delivery

High risk for anaphylaxis: History of any of the following after receiving penicillin or a cephalosporin

  • Suggested of IgE-mediated event: Anaphylaxis | Angioedema | Respiratory distress | Urticaria (hives) |Pruritic rash | laryngeal edema | Hypotension | Immediate flushing
  • Recurrent reactions | Reactions to multiple beta-lactam antibiotics | Positive penicillin allergy test
  • Severe non IgE-mediated reaction (T-cell mediated): Severe rare delayed-onset cutaneous or systemic reactions (e.g., Steven-Johnson syndrome)
    • DO NOT give penicillin, ampicillin or cefazolin
    • Clindamycin susceptible: Clindamycin 900 mg IV every 8 hrs until delivery
    • Isolate not clindamycin susceptible: Vancomycin 20 mg/kg every 8 hours

Note: Vancomycin: Max single dose is 2 g | Minimum infusion time of 1 hour (500 mg/30 minutes) for a dose >1 g


Risk Unknown – options include

    • Penicillin allergy testing
    • Use cephalosporin
    • Use clindamycin if isolate susceptible
    • Vancomycin if isolate not clindamycin susceptible

PRETERM LABOR

Possible preterm labor

  • Obtain GBS culture
    • If GBS screening performed within previous 5 weeks, that culture result should be used for management
  • Start intrapartum prophylaxis and continue through labor

Preterm labor no longer imminent

  • May stop prophylaxis and manage based on most recent GBS culture report
  • GBS culture positive
    • Do not repeat GBS screen
    • Restart prophylaxis when labor recurs
  • GBS culture negative
    • Labor recurs <5 weeks from screen: Prophylaxis not necessary
    • Labor recurs ≥5 weeks from screen: Repeat GBS screen if labor ≥36w0d – 37w6d
  • GBS status unknown
    • Administer prophylaxis if labor recurs
    • If GBS screen not done previously, obtain GBS culture before starting prophylaxis

Note: ACOG notes that there are different standards internationally: For example, RCOG recommends GBS culture 3 to 5 weeks prior to anticipated delivery date for high risk pregnancy, otherwise at 35-37 weeks gestation for uncomplicated pregnancies (see ‘Learn More – Primary Sources’ below for RCOG standards)

PPROM

Obtain GBS culture and Start latency antibiotics (that cover GBS)

  • In labor
    • Continue antibiotics
  • Not in labor
    • Continue IV latency antibiotics x 48 hours, followed by 5 day oral course
      • Low risk penicillin allergy: 5 day oral with first-generation cephalosporin
      • High risk penicillin allergy: Clindamycin or azithromycin
    • GBS negative: No prophylaxis and repeat GBS culture beyond 5 week window
    • GBS positive or result unavailable: Prophylaxis when labor starts

Note: Induction recommended for PPROM ≥34w0d, although some women may wish to delay in order to enter spontaneous labor | If patient is GBS positive, expectant management should be discouraged

KEY POINTS:

  • ≥4 hours of antibiotics is optimal, but no medically urgent intervention should be delayed to provide 4 hours of coverage
    • Interventions that should not be delayed when clinically indicated include: AROM | Oxytocin | Cesarean
  • Amniotomy (with appropriate GBS prophylaxis)
    • Perform as indicated
  • Membrane sweeping
    • Based on limited evidence, no association with risk
    • Some may choose to avoid this procedure in GBS positive women
  • Foley catheter
    • Small theoretical risk
    • “…no recommendation can be made either for or against timing of antibiotic prophylaxis”
  • Water immersion
    • No evidence of increased risk if appropriate GBS prophylaxis administered
    • Above assumes guidelines met that water immersion be offered to women with uncomplicated pregnancies
  • Vaginal exam (with appropriate GBS prophylaxis)
    • Perform exams as indicated
  • Intrauterine monitoring (with appropriate GBS prophylaxis)
    • Not contraindicated | Apply as indicated
  • Planned cesarean delivery, GBS culture positive and admitted in active labor
    • Single dose or combination that provides both GBS and surgical prophylaxis
    • Consider cefazolin
  • Cesarean delivery with intact membranes before labor onset
    • Intrapartum prophylaxis is not required, regardless of GBS status or gestational age
  • GBS Bacteriuria
    • No need for additional vaginal-rectal culture in 3rd trimester as intrapartum prophylaxis is indicated regardless of concentration
    • Treat bacteriuria at concentration of ≥105 CFU/mL regardless of symptoms
    • Mark sample being sent to the lab as ‘pregnant’ and especially for patients with penicillin allergy, lab should provide clindamycin susceptibility results to guide intrapartum GBS prophylaxis
    • Note: Do not use clindamycin to treat bacteriuria as it is poorly concentrated in urine (i.e., used for soft tissue/systemic infection rather than UTI)
  • Penicillin allergy testing
    • Referral to allergy or immunology specialist
    • Testing has been done in pregnancy for IgE-mediated events (some experts classify as ‘moderate risk of anaphylaxis’)
    • Delayed T-cell mediated events (e.g., a history of Steven Johnson syndrome or toxic epidermal necrolysis) is considered by some experts to be a “contraindication to standard penicillin allergy testing”

Learn More – Primary Sources:

ACOG Committee Opinion 797: Prevention of Group B Streptococcal Early-Onset Disease in Newborns

RCOG Green Top Guideline 36: Prevention of Early‐onset Neonatal Group B Streptococcal Disease

Take a post-test and get CME credits

TAKE THE POST TEST

Want to be notified when new guidelines are released? Get ObGFirst!

Learn More »

image_pdfFavoriteLoadingFavorite

< Previous
All OB Posts
Next >

Related ObG Topics:

Chorioamnionitis: ACOG Committee Opinion on Diagnosis and Management
ACOG Guidance Update: Diagnosis and Management of PROM (Prelabor Rupture of Membranes)
Practical info on evidence based medicine for your women's healthcare practice
Stevens-Johnson Syndrome – recognizing the triggers and preventing mortality

Sections

  • COVID-19
  • Alerts
  • OB
  • GYN
    • GYN
    • Sexual Health
  • 2T US Atlas
  • The Genome
  • Primary Care
  • Your Practice
  • Grand Rounds
  • My Bookshelf
  • Now@ObG
  • Media

Are you an
ObG Insider?

Get specially curated clinical summaries delivered to your inbox every week for free

  • Site Map/
  • © ObG Project/
  • Terms and Conditions/
  • Privacy/
  • Contact Us/
© ObG Project
SSL Certificate


  • Already an ObGFirst Member?
    Welcome back

    Log In

    Want to sign up?
    Get guideline notifications
    CME Included

    Sign Up

Get Guideline Alerts Direct to Your Phone
Try ObGFirst Free!

Sign In

Lost your password?

Sign Up for ObGFirst and Stay Ahead

  • - Professional guideline notifications
  • - Daily summary of a clinically relevant
    research paper
  • - Includes 1 hour of CME every month

ObGFirst Free Trial

Already a Member of ObGFirst®?

Please log in to ObGFirst to access the 2T US Atlas

Password Trouble?

Not an ObGFirst® Member Yet?

  • - Access 2T US Atlas
  • - Guideline notifications
  • - Daily research paper summaries
  • - And lots more!
ObGFirst Free Trial

Media - Internet

Computer System Requirements

OBG Project CME requires a modern web browser (Internet Explorer 10+, Mozilla Firefox, Apple Safari, Google Chrome, Microsoft Edge). Certain educational activities may require additional software to view multimedia, presentation, or printable versions of their content. These activities will be marked as such and will provide links to the required software. That software may be: Adobe Flash, Apple QuickTime, Adobe Acrobat, Microsoft PowerPoint, Windows Media Player, or Real Networks Real One Player.

Disclosure of Unlabeled Use

This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.

The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

Jointly provided by

NOT ENOUGH CME HOURS

It appears you don't have enough CME Hours to take this Post-Test. Feel free to buy additional CME hours or upgrade your current CME subscription plan

Subscribe

JOIN OBGFIRST AND GET CME/CE CREDITS

One of the benefits of an ObGFirst subscription is the ability to earn CME/CE credits from the ObG entries you read. Tap the button to learn more about ObGFirst

Learn More
Leaving ObG Website

You are now leaving the ObG website and on your way to PRIORITY at UCSF, an independent website. Therefore, we are not responsible for the content or availability of this site