Strepto 2020
Strepto 2020
Strepto 2020
Background Early-onset group B streptococcal (EOGBS) disease studies, RR 0.43, 95% CI 0.32–0.56) or with no policy (four
(including sepsis, meningitis, and pneumonia) causes significant studies, RR 0.31, 95% CI 0.11–0.84). Meta-analysis could not
morbidity and mortality in newborn infants worldwide. Antibiotic demonstrate a significant effect of risk-based protocols versus no
prophylaxis can prevent vertical streptococcal transmission, yet no policy (seven studies, RR 0.86, 95% CI 0.61–1.20). In studies
uniform criteria exist to identify eligible women for prophylaxis. reporting on the use of antibiotics, screening was not associated
Some guidelines recommend universal GBS screening to pregnant with higher antibiotic administration rates (31 versus 29%).
women in their third trimester (screening-based protocol),
Conclusions Screening-based protocols were associated with lower
whereas others employ risk-based protocols.
incidences of EOGBS disease compared with risk-based protocols,
Objectives To compare the effectiveness of screening-based versus while not clearly overexposing women to antibiotics. This
risk-based protocols in preventing EOGBS disease. information is of relevance for future policymaking.
Search strategy Key words for the database searches included Keywords Antibiotic prophylaxis, early-onset neonatal sepsis,
GBS, Streptococcus agalactiae, pregnancy, screening, culture-based, group B streptococcus, meta-analysis, newborn infant, risk-based,
risk-based. screening, sepsis, streptococcal infections, Streptococcus agalactiae,
Selection criteria Studies were included if they investigated systematic review, vertical transmission.
EOGBS disease incidence in newborn infants and compared Tweetable abstract Meta-analysis: general screening is associated
screening or risk-based protocols with each other or with controls. with lower rates of early-onset group B strep. neonatal sepsis
Data collection and analysis Risk ratios (RR) and 95% confidence compared with risk-based protocols.
intervals (CI) were determined using Mantel-Haenszel analyses Linked article This article is commented on by MA Turrentine,
with random effects. p. 692 in this issue. To view this mini commentary visit
Main results Seventeen eligible studies were included. In this https://doi.org/10.1111/1471-0528.16097. This article is also
meta-analysis, screening was associated with a reduced risk for commented on by KF Walker et al., p. 693 in this issue. To view this
EOGBS disease compared either with risk-based protocols (ten mini commentary visit https://doi.org/10.1111/1471-0528.16116.
Please cite this paper as: Hasperhoven GF, Al-Nasiry S, Bekker V, Villamor E, Kramer BWW. Universal screening versus risk-based protocols for antibiotic
prophylaxis during childbirth to prevent early-onset group B streptococcal disease: a systematic review and meta-analysis. BJOG 2020;127:680–691.
680 2020 The Authors. BJOG: An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd on behalf of
Royal College of Obstetricians and Gynaecologists.
This is an open access article under the terms of the Creative Commons Attribution License, which permits use,
distribution and reproduction in any medium, provided the original work is properly cited.
Screening versus risk-based protocols to prevent EOGBS, a meta-analysis
by invading through the intact membranes.4 Intravenous policies: universal culture-based maternal GBS screening
antibiotics for at least 4 hours during labour was introduced and risk-based protocols. Studies with concurrent as well as
around 19805 as intrapartum antibiotic prophylaxis (IAP), with historical controls were considered.
and has successfully reduced vertical transmission.6
Women eligible for IAP are generally identified through Types of participants
two strategies: universal culture-based screening for GBS The participants were all pregnant women. Outcomes were
colonisation, or presence of clinical risk factors for GBS measured in all live newborn infants. No exclusion criteria
transmission.7–9 The Centers for Disease Control (CDC) were employed.
recommend universal screening for maternal colonisation
between 36 and 38 weeks of pregnancy.9 In contrast, guide- Types of interventions
lines in the UK, the Netherlands, and New Zealand recom- Screening-based protocols versus risk-based protocols used
mend risk-based protocols.7,10,11 These clinical indicators by clinicians to determine for each individual pregnant
include prolonged rupture of membranes, bacteriuria, an woman whether intrapartum prophylaxis is indicated. ‘No
earlier child with EOGBS, and maternal fever. The inci- policy’ was defined as a situation in which no consistent
dence of EOGBS disease has increased in both the Nether- protocol was used but IAP could have been administered
lands and the UK in recent years.12,13 on an individual basis. Therefore, all groups included the
Missed opportunities for EOGBS prevention exist in administration of IAP, defined as intravenous antibiotic
both protocols and lead to preventable infant morbidity, treatment intended to commence at least 4 hours before
while overtreatment, undesirable in the light of rising birth. All antibiotic agents (penicillin, clindamycin, etc.)
antibiotic resistance and potential effects on the micro- used in this way and for this purpose were accepted as
biome, occurs, too.14–17 Although technical developments IAP.
such as vaccines or polymerase chain reaction quick tests
are promising for EOGBS prevention, they have not been Types of outcome measures
widely implemented.18–20 The outcome measure was the incidence of EOGBS disease
Improving efficacy of IAP through either of the targeting in newborn infants as determined by positive bacterial cul-
protocols will help reduce the incidence of EOGBS disease, ture from blood or cerebrospinal fluid.24
and may reduce overtreatment. No international consensus
on the best protocol currently exists and a future strategy Information sources
is under debate.21 As no randomised studies on the topic Records were obtained through literature searches in MED-
have been carried out, policy-making remains a challenge. LINE (using PubMed), CINAHL, and Embase databases.
Additional publications were obtained manually by search-
Objectives ing reference lists and relevant reviews.
The objective of this systematic review and meta-analysis was
to determine the relative success of screening-based and risk- Search strategy
based protocols in preventing EOGBS disease in newborn An overview of the search terms and the syntax used in
infants. It is, to the best of our knowledge, the only meta- MEDLINE is presented in Tables S1 and S2. Articles in
analysis comparing available data on these two policies. English and Dutch with publication dates until 2019 were
included in the final search. Last queries were run in
March 2019.
Methods
Protocol and registration Study selection
The PRISMA statement for reporting systematic reviews was The study selection process was performed by a primary
used to conduct and report this systematic review.22 The investigator (G.H.) and critically reviewed by a second
protocol was made public in advance in the International (B.K.). Records obtained from the various databases were
Prospective Register of Systematic Reviews (PROSPERO entered in ENDNOTE X8 (Clarivate Analytics, Boston,
CRD42019127633).23 This study had no patient involvement MA, USA; 2018)25 to deduplicate automatically the dataset.
as the review is based completely on data from the literature. Remaining studies were identified by titles and abstracts
and were excluded if they did not fit the eligibility criteria.
Eligibility criteria Remaining records were assessed by full-text analysis, and a
final selection of relevant publications was constructed.
Types of studies Potential disagreements between reviewers were solved
Randomised or non-randomised studies, performed in any through discussion and re-evaluation. Reviewers were not
country, on the effect of either of the two GBS prevention blinded.
2020 The Authors. BJOG: An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd on behalf of 681
Royal College of Obstetricians and Gynaecologists
Hasperhoven et al.
682 2020 The Authors. BJOG: An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd on behalf of
Royal College of Obstetricians and Gynaecologists
Table 1. Study characteristics of analysis 1 (studies comparing screening-based protocols with risk-based protocols, using either historical or concurrent controls) and primary outcomes:
incidences of EOGBS disease under different policies
Authors study design Controls Country Setting/data EOGBS disease Screening-based: Risk-based: Antibiotic agent EOGBS disease incidence per 1000 live births
source definition criteria for IAP criteria for IAP [95% confidence interval]
Angstetra et al. Retrospective historical Australia One tertiary Blood culture ++ 34–37 weeks. NI benzylpenicillin IV n/a 0.84 [0.57– 0
(2007) cohort study obstetric unit and necessity for Culture = pos or 1.2 g- 600 mg/h 1.2]
admission to N(I) risk factor: previous OR clindamycin
CU with GBS, GBS IV 600 mg/8 h
ABs + ventilation bacteriuria, OR cephalothin
<7 days. preterm labour IV 2 g - 1 g/h
2020 The Authors. BJOG: An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd on behalf of
infants excluded) ml units/4 h
Gopal Rao et al. Retrospective historical London, UK One general Positive blood or Screening offered to previous GBS Benzylpenicillin n/a 1.1 [0.8–1.6] 0.33 [0.11–1.0]
(2017)* observational hospital CSF culture all women in the child; GBS 3 g IV – 1.5 g/h
study <7 days population. bacteriuria; OR clindamycin
According to CDC temp. > 38 C; 900 mg IV/8 h
(35–37 weeks). chorioamnionitis
Not screened ->
risk group
Screening versus risk-based protocols to prevent EOGBS, a meta-analysis
683
684
Table 1. (Continued)
Authors study design Controls Country Setting/data EOGBS disease Screening-based: Risk-based: Antibiotic agent EOGBS disease incidence per 1000 live births
source definition criteria for IAP criteria for IAP [95% confidence interval]
Hasperhoven et al.
Ma et al. (2018) Retrospective historical Hong Kong The eight Positive blood or 35–37 weeks GA, A previous NI n/a 1 (not 0.24 (not
cohort study hospitals of CSF culture later or at delivery with available) available)
Hong Kong <7 days admission. 2 EOGBS; GBS
separate swabs: bacteriuria; ROM
vagina and rectum. 18 h or more;
Non-screened -> GA <37 weeks;
risk-based. (women Intrapartum
with previous GBS fever
child excluded)
Main & Slagle Retrospective historical US (California) A primary practice + tertiary Positive blood or 35–37 weeks preterm <37, ROM> 18 h, Ampicilin
(2000) cohort & prosp. obstetric referral centre CSF culture vaginal and temp. >38 2 g + 1 g/4 h
Observational <7 days rectal culture C, GBS IV OR
study (+IAP for bacteriuria, clindamycin
preterm) previous GBS 900 mg/8 h
1.1 [0.58–2.3] 1.1 [0.68–1.9] 0.071
[0.010–
5.0)
Schrag et al. Retrospective concurrent USA Multiple hospitals Pos. blood Retrospective preterm <37, NI n/a 0.68 [0.59– 0.33 [0.27–
(2002) cohort study of the Emerging culture, CSF or selection: found rupture> 18 h, 0.77] 0.40]
Infections other ‘normally any GBS status in temp. >38C,
Program sterile fluid’. record, taken at GBS bacteriuria,
Network Days unclear. least 2 days before previous GBS
birth -> screening
group
Vergani et al. Retrospective Historical Italy One tertiary care Positive blood or <’97 Vaginal culture Preterm <37; Rom Ampiccilin 0.93 [0.47– 0.78 [0.39– 0.44 [0.20–
(2002) cohort study centre (university CSF culture between 26– >12 h; temp. 2 g + 1 g/4 h IV 1.9] 1.6] 0.97]
hospital) <7 days 28 week GA. >’97 >37.5C, GBS OR Erythromycin
between 35– bacteriuria; 500 mg/6 h
37 week GA previous child
GBS
Yu
€ cesoy et al. Prospective, quasi- concurrent Turkey One antenatal Positive blood Between 35– PPROM, Ampiccilin n/a 3.3 [1.0–10] 5.0 [0.71–35]
(2004) experimental clinic (in- and culture <72 h 37 weeks (note: prolonged ROM, 2 g + 1 g/4 h IV
out-patient) risk factor + neg. temp. >38C,
culture -> no IAP) preterm (but
individualised,
tocolytics etc.)
CSF, cerebrospinal fluid; EOGBS, Early-onset Group B streptococcal infection; IAP, intrapartum antibiotic prophylaxis; IV, intravenously; NI, no information; ROM, rupture of membranes.
*Pre-screening and post-screening periods are taken together (cross-over design).
2020 The Authors. BJOG: An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd on behalf of
Royal College of Obstetricians and Gynaecologists
Table 2. Study characteristics analysis 2 (introduction of any policy versus no policy) and primary outcomes: incidences of EOGBS disease under different policies
Author study design Controls country Setting/data source EOGBS disease Screening-based Risk-based criteria for Antibiotic EOGBS disease incidence (per 1000 live
definition criteria for IAP I IAP agent births)
Bekker et al Surveillance study Historical NL Netherlands Reference Positive blood or CSF n/a Previous GBS child or Penicillin/ 0.11 [0.10– 0.18 [0.16– n/a
(2014) (retrospective) Laboratory for culture <7 days bacteriuria -> IAP. amoxicillin 0.13] 0.20]
Bacterial Meningitis Confirmed GBS or
(all hospitals) threat preterm ->
consider IAP.
2020 The Authors. BJOG: An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd on behalf of
Network
CSF, cerebrospinal fluid; EOGBS, Early-onset Group B streptococcal disease; IAP, intrapartum antibiotic prophylaxis; IV, intravenously; NI, no information; ROM, rupture of membranes.
Screening versus risk-based protocols to prevent EOGBS, a meta-analysis
685
Hasperhoven et al.
Figure 1. Forest plot of risk ratio (with 95% confidence intervals) of EOGBS disease (defined as positive GBS culture from a normally sterile site
<7 days of age) in universal screening policy groups versus risk-based policy groups. CI, confidence interval; M-H, Mantel-Haenszel.
686 2020 The Authors. BJOG: An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd on behalf of
Royal College of Obstetricians and Gynaecologists
Screening versus risk-based protocols to prevent EOGBS, a meta-analysis
Figure 2. Forest plot of risk ratio (with 95% confidence intervals) of EOGBS disease (defined as positive GBS culture from a normally sterile site
<7 days of age) in universal screening policy groups versus no policy groups. CI, confidence interval; M-H, Mantel-Haenszel.
Figure 3. Forest plot of risk ratio (with 95% confidence intervals) of EOGBS disease (defined as positive GBS culture from a normally sterile site
<7 days of age) in risk-based policy groups versus no policy groups. CI, confidence interval; M-H, Mantel-Haenszel.
risk-based group of 0.94/1000 infants) for screening versus could not demonstrate a significant effect of risk-based
risk-based protocols was 1874 (Table S6). The percentage protocols versus no policy (seven studies, RR 0.86, 95% CI
of births during which IAP was administered was reported 0.61–1.20; heterogeneity: I2 = 89%) (Figure 3). The funnel
in four studies. Weighted means were 31 and 29% in the plot for analysis 1 (universal screening versus risk-based
screening and risk-based groups, respectively (Table S7). protocols) showed slight asymmetry (Figure S3), suggesting
None of the studies reported GBS resistance to penicillin a low risk of publication bias. Egger’s regression test did
or ampicillin, whereas resistance to erythromycin and clin- not show statistically significant asymmetry of the funnel
damycin was reported by three studies (Table S7).12,35,38 plot (2-tailed P = 0.180). Publication bias was not investi-
Lastly, mothers of infants with EOGBS sepsis did not pre- gated for the other two analyses due to the low number of
sent any risk factors in times of risk-based protocols in studies.
41.3% of cases (weighted mean, Table S8). False negatives
(EOBGS children born to women with negative screening
Discussion
results) were present in 24.2% of cases during periods of
screening protocols (weighted mean, Table S8). Main findings
This systematic review summarised the available observa-
Synthesis of results tional data on the two most common EOGBS prevention
Meta-analysis showed that universal screening was associ- policies. Overall, our meta-analysis shows lower incidences
ated with a reduced risk of EOGBS disease when compared of EOGBS disease under screening-based policies than under
either with risk-based protocols (10 studies, RR 0.43, 95% risk-based policies. Additionally, the retrospective data show
CI 0.32–0.56; heterogeneity: I2 = 13%) (Figure 1) or with no significant EOGBS reductions resulting from the initial
no policy (four studies, RR 0.31 95% CI 0.11–0.84; hetero- introduction of risk-based policies, whereas studies on the
geneity: I2 = 91%) (Figure 2). In contrast, meta-analysis introduction of universal screening do. Notably, two studies
2020 The Authors. BJOG: An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd on behalf of 687
Royal College of Obstetricians and Gynaecologists
Hasperhoven et al.
688 2020 The Authors. BJOG: An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd on behalf of
Royal College of Obstetricians and Gynaecologists
Screening versus risk-based protocols to prevent EOGBS, a meta-analysis
unhindered in all studies in this review, even though some contributed to the statistical analyses and interpretation of
GBS strains with increasing minimum inhibitory concen- the results, and reviewed and revised the manuscript.
trations (MICs) for beta-lactam antibiotics have been
observed elsewhere.51 Funding
A point of concern in both strategies is how to approach The authors did not receive funding or other support for
GBS prevention in preterm deliveries. It was beyond the scope this publication.
of this article to compare subgroups of term and preterm
infants, mostly because the available studies generally did not
Supporting Information
provide data necessary to make a subdivision. As the recom-
mended timing for screening was between 35 and 37, and Additional supporting information may be found online in
now lies between 36 to 38 weeks of gestational age (GA), the Supporting Information section at the end of the
infants born at 35 weeks GA or less are not covered.9,52 Nota- article.
bly, these infants are at much higher risk of EOGBS disease as Figure S1. PRISMA6 flow diagram: a visual representa-
well as GBS-related mortality.53 For this reason, the CDC has tion of the systematic research process.
suggested that most preterm deliveries be accompanied by Figure S2. Visual representation of risk of bias assess-
IAP. However, more research towards best IAP management ment done using the risk of bias tool ‘ROBINS-I’ by
for women delivering preterm is needed, as long-term expo- Cochrane. + low risk of bias; +– moderate risk; – serious
sure to antibiotics poses a risk for preterm infants.54 Ideally, risk, – – critical risk, ? no information
immunisation of mothers should be introduced to prevent Figure S3. Funnel plot for meta-analysis of studies com-
EOGBS invasive infections, but although research in this field paring universal screening versus risk-based protocols.
has been going on for years, no effective GBS vaccine has been Egger’s regression test did not show statistically significant
made available so far.18 Until that time, it is recommended asymmetry of the funnel plot (2-tailed P = 0.180).
that the GBS prevention protocols are periodically re-evalu- Table S1. Search protocol, MeSH = Medical Subject
ated, and research aimed at accurate and fast detection meth- Headings
ods for all pregnant women is continued. Table S2. Search strategy used to identify records in
MEDLINE (final search March 2019). Similar queries were
run in CINAHL and Embase
Conclusion
Table S3. Articles excluded from analysis in the last step
In this systematic review and meta-analysis screening pro- of the reviewing process
tocols were associated with lower rates of EOGBS disease Table S4. Risk of bias assessment according to ROBINS-
compared with risk-based protocols. While there is insuffi- I, in studies comparing screening-based protocols and risk-
cient evidence to assume that risk-based policies reduce the based protocols (analysis 1). RoB, risk of bias; PB, perfor-
use of prophylactic intrapartum antibiotics, these protocols mance bias
might not be able to protect infants from EOGBS disease Table S5. Risk of bias assessment: studies assessing intro-
to the same extent as general screening does. These findings duction of either of the two protocols compared with a
can be of help to future policy-making and individual period/area of ‘no policy’ (analysis 2)
pregnancy counselling.55 Table S6. Numbers needed to screen (NNS) as calculated
from the data in the included studies
Disclosure of interests Table S7. Secondary outcomes with weighted means
VB was a co-author of one of the included studies in this Table S8. Missed cases in the included studies &
analysis. Other authors declare no competing interests.
Completed disclosure of interests forms are available to
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