Alternate treatments to reduce strep

Midwifery Updates, Summer Conference 2002

Gail Hart©

TREATMENTS TO REDUCE STREP

Researchers have been looking into other ways to reduce the incidence of strep (it is not possible to eliminate it completely, but many methods can REDUCE the rate). One strategy chosen by US doctors -- and recommended by the CDC - is to give IV antibiotics to women in labor who test positive for strep and/or who have risk factors for strep infection. I'm presenting some other methods for your consideration and discussion.

Other strategies:

vaccines to be given to all women of child-bearing age
childhood vaccination with a booster in adulthood
oral antibiotics given in the last weeks of pregnancy
IM antibiotics given in the last weeks of pregnancy
IM antibiotics given to the woman in labor
IM antibiotics given to the baby at birth
Reducing the vaginal culture of strep by germicidal washings in late pregnancy
Reducing the culture by germicidal washing in labor,
instilling germicide in the vagina in labor
waterbirth: infection rates seem to be lower than air births
limiting vaginal exams in pregnancy and/or labor

TREATMENT IN PREGNANCY--ANTIBIOTICS:

A course of oral antibiotics before term is controversial. Strep presence changes; treatment can eradicate it for an uncertain time. After 3 weeks most women treated by oral antibiotics will test positive. Little is known about effectiveness or timing of medication (and there is little incentive for research).
Maternal IM penicillin or erythromycin at appx 35 weeks is currently under review (I found no current updates).

TREATMENT IN LABOR-- ANTIBIOTICS:

A departure from the common IV treatment, is IM administration to the mother in early labor. IV therapy reaches effective blood levels within 5 minutes. It may be reasonable to assume that IM administration in labor though slower than IV may still be rapid enough to achieve effectiveness before the baby is born.

The IM antibiotic regime under study is:

Benzyl penicillin (48) 600 mg IM every 8 hours, or
Erythromycin 100mg IM for women allergic to penicillin

It may also be reasonable to assume that oral antibiotics would show similar effectiveness if the length of labor is long enough to achieve effective blood levels 4 to 8 hours. I found no data addressing oral antibiotics given at the first signs of labor, (and most multip labors will be too short anyway). However, there is evidence of effectiveness of oral antibiotics from decades of use in the treatment of Prolonged Rupture of Membranes. Since PROM is the most common step risk-factor experienced by out of hospital practitioners, oral antibiotics might be a logical choice.

TREATING THE BABY--ANTIBIOTICS:

Treating every baby with IM penicillin within the first hour of birth appears to be as effective as any of the CDC recommendations. It is a simple and universal approach. Adding the treatment of women in labor with risk factors results in a remarkable reduction in strep in the hospitals participating in these studies currently reporting rates under 0.3 per thousand.

<quote> (before implementation) "early-onset GBS infection developed in 31 of 13,887 live births (2.2/1000), 13 preterm and 18 term cases. After implementation of the prophylaxis protocol (1995), 6 of 13,527 live births had early-onset GBS (0.4/1000) (P <.001). There were no preterm (P =.0004) and 6 term GBS cases (P =.02). The efficacy continued through 1999 (0.5/1000) without an increase in neonatal infections from other bacteria." : Am J Obstet Gynecol 2002 Apr;186(4):618-26 Prevention of neonatal group B streptococcal disease: A combined intrapartum and neonatal protocol. Wendel GD Jr, Leveno KJ, Sanchez PJ, Jackson GL, McIntire DD, Siegel JD. Departments of Obstetrics and Gynecology and Pediatrics, University of Texas
Southwestern Medical Center See also: : Acta Paediatr 1999 Aug;88(8):874-9 Role of postnatal penicillin prophylaxis in prevention of neonatal group B streptococcus infection. Patel DM, Rhodes PG, LeBlanc MH, Graves GR, Glick C, Morrison J ).

This now well-proven method might be easily adopted by an out-of-hospital practitioner in collaboration with a prescribing doctor.

HOLISTIC STRATEGIES © Gail Hart www.midwiferyeducation.org

Preserving "Natures" protection:

Avoid rupture of the bag of waters. Fetal/infant infection is strongly linked to ruptured membranes; the longer the time period from rupture until the birth, the greater the risk.

Refrain from "un-necessary" AROM
Encourage stronger membranes with adequate intake of vitamin C in pregnancy (shown to reduce risk of PPROM)

Preserve the mucus plug and the natural "antibiotic" of cervical mucus:

Cervical mucus is STRONGLY bactericidal and is particularly effective at destroying strep bacteria!

Am J Obstet Gynecol 2002 Jul;187(1):137-44

Antimicrobial factors in the cervical mucus plug.
Hein M, Valore EV, Helmig RB, Uldbjerg N, Ganz T.
Department of Obstetrics and Gynecology, Aarhus University Hospital, Denmark.

OBJECTIVE: The cervical mucus plug is positioned between the microbe-rich vagina and the normally sterile uterine cavity, which suggests a host defense function, but few relevant data are available. We analyzed the composition and antimicrobial activity of cervical mucus plugs. STUDY DESIGN: Cervical mucus plugs were collected from healthy women at delivery. Groups of plugs were randomly selected for electrolyte analysis, antimicrobial activity assays against group B Streptococcus, Escherichia coli, Candida albicans, and assays of known antimicrobial polypeptides. RESULTS: Both intact cervical mucus plugs and their aqueous extracts exhibited antimicrobial activity against aerobic microbes, in the order of potency: group B Streptococcus > E coli > C albicans. Semiquantitative Western blotting of extracts showed that secretory leukoprotease inhibitor, lysozyme, lactoferrin, and neutrophil defensins were present at concentrations that were sufficient for antimicrobial activity. CONCLUSION: The cervical mucus plug is not only a mechanical but also a chemical barrier to infection that ascends from the vagina.

1: Am J Obstet Gynecol 2001 Sep;185(3):586-92

An in vitro study of antibacterial properties of the cervical mucus plug in pregnancy.
Hein M, Helmig RB, Schonheyder HC, Ganz T, Uldbjerg N.
Department of Obstetrics and Gynaecology, Aarhus University Hospital, Denmark. merete.hein@dadlnet.dk

OBJECTIVE: To evaluate whether cervical mucus plugs are antibacterial in vitro. STUDY DESIGN: Cervical mucus plugs from 56 healthy women in labor were studied by 2 different antimicrobial assays: (1) analysis of the inhibition by the cervical mucus plug of several gram-positive and gram-negative bacteria by overlaying the cervical mucus plug onto an agar plate with imbedded bacteria, and (2) determination of the antibacterial property of the cervical mucus plug material by radial diffusion assay with group B Streptococcus and Escherichia coli. RESULTS: In the agar overlay assay, there was complete inhibition of clinical isolates of Staphylococcus saprophyticus, E coli, and Pseudomonas aeruginosa and patient-variable partial-to-complete inhibition of Enterococcus faecium, Staphylococcus aureus, Streptococcus pyogenes, and Streptococcus agalactiae. In the radial diffusion assay, cervical mucus plugs had activity toward group B Streptococcus equivalent to 0.075 microg/mL of gentamicin and toward E coli equivalent to 0.5 microg/mL of gentamicin. CONCLUSION: A low-molecular substance with antibacterial activity in the cervical mucus plug may protect the fetus against ascending infections.

THE MUCUS PLUG IS THERE FOR A REASON!

Cervical exams are not sterile! They invariably carry bacteria from the lower vagina into the upper vagina and cervix; touching the cervix to assess dilation in pregnancy displaces the "plug" of cervical mucus.

The plug acts as both a chemical and mechanical barrier to infection

Sweeping the membranes to induce labor or to "prevent postdates" -- disturbs the cervical mucus and may breach the mucus plug.

It may not be a coincidence that the rise in strep colonization and infection rates mirrors the modern practice of frequent cervical exams to "monitor for risk of preterm labor" and the common routine of weekly sweeping membranes near term.

It is possible that WE THE MIDWIVES AND DOCTORS have been partially responsible for the increase in strep!

To lower the risk of strep:

Avoid cervical exams in pregnancy.
Avoid cervical exams in labor.
Avoid cervical exams after ROM.

If strep is a natural flora of the recto-genital area., and not a systemic disease, then we theoretically "should" be able to prevent the baby from becoming contaminated as he passes through the birth canal. Simple washing routines have worked to lower the transmission of hepatitis, and HIV. In the pre-antibiotic days they were quite effective at reducing STDs. Would a germicidal wash or douche be effective against strep? The European answer is an unequivocal "Yes"!

"Germicidal washings display the same efficacy as ampicillin in preventing vertical transmission of group B streptococcus. Moreover, the rate of neonatal E. coli colonization was reduced by chlorhexidine

After nearly two decades the results of a large study were recently. The researchers conclude that several methods show promise; a vaginal germicidal douche in the last weeks of pregnancy; an application of germicidal gel in labor; or a "rinse" in labor. The germicide most tested was chlorhexidine (hexachlorophene), but povidone iodine is also being tested. (Natural practitioners might wonder about herbal preparations). Here are two abstracts for your files.

J Matern Fetal Med 2002 Feb;11(2):84-8
Chlorhexidine vaginal flushings versus systemic ampicillin in the prevention of vertical transmission of neonatal group B streptococcus, at term.
Facchinetti F, Piccinini F, Mordini B, Volpe A. )Department of Gynecology, Obstetrics and Pediatric Sciences, University of
Modena and Reggio Emilia, Modena, Italy.)

OBJECTIVE: To investigate the efficacy of intrapartum vaginal flushings with chlorhexidine compared with ampicillin in preventing group B streptococcus transmission to neonates.

METHODS: This was a randomized controlled study, including singleton pregnancies delivering vaginally. Rupture of membranes, when present, must not have occurred more than 6 h previously.. Women with any gestational complication, with a newborn previously affected by group B streptococcus sepsis or whose cervical dilatation was greater than 5 cm were excluded. A total of 244 group B streptococcus-colonized mothers at term (screened at 36-38 weeks) were randomized to receive either 140 ml chlorhexidine 0.2% by vaginal flushings every 6 h or ampicillin 2 g intravenously every 6 h until delivery. Neonatal swabs were taken at birth, at three different sites (nose, ear and gastric juice).

RESULTS: A total of 108 women were treated with ampicillin and 109 with chlorhexidine. Their ages and gestational weeks at delivery were similar in the two groups. Nulliparous women were equally distributed between the two groups (ampicillin, 87%; chlorhexidine, 89%). Clinical data such as birth weight (ampicillin, 3,365 +/- 390 g; chlorhexidine, 3,440 +/- 452 g), Apgar scores at 1 min (ampicillin, 8.4 +/- 0.9; chlorhexidine, 8.2 +/- 1.4) and at 5 min (ampicillin, 9.7 +/- 0.6; chlorhexidine, 9.6 +/- 1.1) were similar for the two groups, as was the rate of neonatal group B streptococcus colonization (chlorhexidine, 15.6%; ampicillin, 12%). Escherichia coli, on the other hand, was significantly more prevalent in the ampicillin (7.4%) than in the chlorhexidine group (1.8%, p < 0.05). Six neonates were transferred to the neonatal intensive care unit, including two cases of early-onset sepsis (one in each group).

CONCLUSIONS: In this carefully screened target population, intrapartum vaginal flushings with chlorhexidine in colonized mothers display the same efficacy as ampicillin in preventing vertical transmission of group B streptococcus. Moreover, the rate of neonatal E. coli colonization was reduced by chlorhexidine. PMID: 11995801

1: Int J Antimicrob Agents 1999 Aug;12(3):245-
Vaginal disinfection with chlorhexidine during childbirth.

Stray-Pedersen B, Bergan T, Hafstad A, Normann E, Grogaard J, Vangdal M.
Department of Gynecology and Obstetrics, Aker Hospital, University of Oslo,
Norway.

The purpose of this study was to determine whether chlorhexidine vaginal douching, applied by a squeeze bottle intra partum, reduced mother-to-child transmission of vaginal microorganisms including Streptococcus agalactiae (streptococcus serogroup B = GBS) and hence infectious morbidity in both mother and child. A prospective controlled study was conducted on pairs of mothers and their offspring. During the first 4 months (reference phase), the vaginal flora of women in labour was recorded and the newborns monitored. During the next 5 months (intervention phase), a trial of randomized, blinded placebo controlled douching with either 0.2% chlorhexidine or sterile saline was performed on 1130 women in vaginal labour. During childbirth, bacteria were isolated from 78% of the women. Vertical transmission of microbes occurred in 43% of the reference deliveries. In the double blind study, vaginal douching with chlorhexidine significantly reduced the vertical transmission rate from 35% (saline) to 18% (chlorhexidine), (P < 0.000 1, 95% confidence interval 0.12-0.22). The lower rate of bacteria isolated from the latter group was accompanied by a significantly reduced early infectious morbidity in the neonates (P < 0.05, 95% confidence interval 0.00-0.06). This finding was particularly pronounced in Str. agalactiae infections (P < 0.0 1). In the early postpartum period,
fever in the mothers was significantly lower in the patients offered vaginal disinfection, a reduction from 7.2% in those douched using saline compared with 3.3% in those disinfected using chlorhexidine (P < 0.05, 95% confidence interval 0.01-0.06). A parallel lower occurrence of urinary tract infections was also observed, 6.2% in the saline group as compared with 3.4% in the chlorhexidine group (P < 0.01, 95% confidence p interval 0.00-0.05). This prospective controlled trial demonstrated that vaginal douching with 0.2% chlorhexidine during labour can significantly reduce both maternal and early neonatal infectious morbidity. The squeeze bottle procedure was simple, quick, and well tolerated. The beneficial effect may be ascribed both to mechanical cleansing by liquid flow and to the disinfective action of chlorhexidine