The 1997 AAP Guidelines for Prevention of Early-onset Group B Streptococcal Disease (1997)

Representatives from the American Academy of Pediatrics (AAP) participated in the develop ment of the 1996 consensus guidelines for the prevention of early-onset group B streptococcal (GBS) disease with the Centers for Disease Control and Prevention (CDC), the American College of Obstetrics and Gynecology (ACOG), and the American Academy of Family Physicians.1 In March 1997, these guidelines were formally endorsed and the AAP Committee on Infectious Diseases and the Committee on Fetus and Newborn provided additional recommendations for the management of infants born to mothers receiving intrapartum prophylaxis.2 Gotoff and Boyer3 in a recent commentary were apparently unaware of the change in AAP guidelines and they incorrectly referred to the 1992 policy as current policy. They also incorrectly indicated that the ACOG guidelines differed from those of the CDC and the AAP. The consensus between obstetric and pediatric physicians in the development of the CDC guidelines is an important accomplishment, one that has been associated with a reduction in the incidence of early-onset GBS disease in areas of active surveillance (Figure).4The new AAP guidelines detailed in the March issue ofPediatrics2 allow for two equally acceptable approaches for the prevention of early-onset GBS disease: 1) a screening strategy with culture of pregnant women at 35 to 37 weeks of gestation and administration of intrapartum penicillin G (or ampicillin) to all GBS-positive women whether or not they have a risk factor, or 2) a nonscreening approach with administration of intrapartum penicillin G (or ampicillin) to all women with a risk factor (previous delivery of an infant with GBS disease, GBS bacteriuria during the pregnancy, preterm labor <37 weeks of gestation, rupture of membranes ≥18 hours before delivery, or intrapartum fever). These new guidelines address four of the five “limitations” of the 1992 AAP guidelines outlined by Gotoff and Boyer3: women lacking prenatal care or delivering at hospitals with difficulties in data management could enter the nonscreening approach, the screening strategy improves the predictive value of GBS cultures by testing at 35 to 37 rather than at 26 to 28 weeks of gestation, and women without risk factors are treated in both approaches.Gotoff and Boyer propose an alternative approach that has important limitations, only some of which were acknowledged. First, their proposal would not prevent disease in term infants who are infected during labor and are symptomatic at or shortly after birth. Only maternal chemoprophylaxis is appropriate in this clinical setting where intramuscular penicillin at birth would only serve to obscure blood culture results and delay initiation of appropriate broad-spectrum antibiotics by the intravenous route.Second, their proposal requires transfer of responsibility for prophylaxis from the physician who ordered the maternal culture to the physician caring for the infant. Transfer of culture results obtained late in gestation to the hospital at delivery, a “data management” issue listed by Gotoff and Boyer, is difficult1; transferring the information and responsibility to the pediatric care provider would only increase this difficulty in many settings. Moreover, confusion could occur because in some instances the at-risk pregnant woman would be treated by the obstetrical care provider, but in others the woman would not be treated and intervention would be left to the pediatric care provider. Undoubtedly, situations would occur where neither the mother nor the infant would receive prophylaxis due to the assumption that the responsibility for prevention was on someone else's shoulders.The option of treating infants born to colonized women (or all infants) was discussed during the development of the CDC consensus guidelines and rejected after thorough consideration of the issues. Gotoff and Boyer propose that those newborns who are in the “latent period before bacteremia develops” should receive a single dose of intramuscular penicillin. This proposal has two limitations. First, a substantial portion of GBS early-onset disease occurs in neonates born to women without risk factors, some of whom are symptomatic at or shortly after birth, a scenario where only maternal prophylaxis could be expected to be effective.5 Second, the study by Siegel et al6 that was quoted did not adequately assess infant GBS mucosal colonization by omitting throat and umbilical cultures and by use of suboptimal methods for isolation of GBS. A single dose of penicillin does not eradicate GBS colonization at mucosal sites.7 Infants who acquire GBS through vertical transmission would still be at risk for development of late-onset GBS disease, while intrapartum prophylaxis is documented to interrupt vertical transmission.We hope that the Academy membership is not confused by the recent appraisal of the Academy policy published in 1992 by Gotoff and Boyer. As indicated in the 1996 CDC consensus guidelines, ongoing reassessment of any strategy is indicated after several years of full implementation but would be premature and inappropriate at this time.1 The 1997 AAP guidelines2 encourage the evaluation of additional strategies (such as proposed by Gotoff and Boyer), and comparison of outcomes with the recommended strategies.