1. GBS in Saudi Arabia Nawaf Al-Dajani, 2008

2. Discolsure

3. History Introduction Milestone of the guidelines GBS carriage during pregnancy in KSA Current practice Future plans Conclusions

4. History 1930s, GBS ass’ mastitis in Cows. 1935, Lancefield isolated GBS from adult female patients. 1970’s GBS emerged as major pathogen in neonates

5. Postnatal Sepsis: Change in Etiology in North America 190019502000 GAS GBS E. coli GBS proph revised GBS proph

6. Introduction

7. GBS Maternal Colonization GBS Carriers Z10% - 30% of women higher in African Americans and nonsmokers Zclinical signs not predictive Zdynamic condition Risk factor for early-onset disease: GBS colonization at delivery Zprenatal cultures late in pregnancy can predict delivery status

8. Additional Risk Factors for Early-Onset GBS Disease Obstetric: prolonged rupture of membranes, preterm delivery, intrapartum fever GBS bacteriuria Previous infant with GBS disease Demographic (African American race, young age) Immunologic (low antibody to GBS capsular polysaccharide)

9. Mother to Infant Transmission GBS colonized mother Non-colonized newborn Colonized newborn Asymptomatic Early-onset sepsis, pneumonia, meningitis 50% 98%2%

10. GBS Disease in Infants Before Prevention Efforts A Schuchat. Clin Micro Rev 1998;11:497-513.

11. Early-Onset Neonatal GBS Disease Before Prevention Efforts A Schuchat. Clin Micro Rev 1998;11:497-513.

12. Milestone of the guidelines

13. Rate of Early- and Late-onset GBS Disease in the 1990s, U.S. Consensus guidelines 1st ACOG & AAP statements Group B Strep Association formed CDC draft guidelines published Schrag, New Engl J Med 2000 342: 15-20

14. Rates of Early-Onset GBS Disease by Prenatal Colonization & Risk Factors Col: prenatal vag/rect culture RF: risk factors (gest. 12 hr, fever > 37.5 C) Boyer & Gotoff, Antibiot Chemother 1985.

15. Change in incidence of early-onset GBS disease in hospitals w/ and w/out new policies Factor, Obstet Gynecol 2000;95:377-82

16. GBS partners meeting to re-evaluate the 1996 guidelines, November 1-2, 2001 Recommendation: Universal prenatal screening at 35-37 wks’ gestation Risk based strategy reserved for women with unknown GBS culture status at the time of labor MMWR, VOLUME 51 (RR-11), 2002 Schrag et al, NEJM 2002, 347:233-9

17. Screening !! Boyer et al, 1986 RCT of selective IPC, 12hrs, 83 (85) received Abx vs 77(79) NC vs EOD. NC 8/85 vs 40/79 p < 0.001 EOD 0/85 vs 4/79 p 0.052

18. Screening !! Matorras et el, 1991 RCT, 121 pt. 57 received ampicillin, 64 placebo. EOD 0/60 vs 3/65, p= 0.137. In Summary: Relative risk reduction 0.21, CI 0.04-1.17 No statistically significant.

19. Gilson et al, 2003, J Perinatol, Case control study 420 vs 470 0/420 vs 4/470, p 0.04

20. GBS carriage rate in KSA

21. Uduman et al, 1985, J Gynaecol Obstet. 1985 Feb ;23 (1):21- 4 260 pt in labour, 24 had +ve GBS, 9.2% 3 neonate screened +ve, 12.5% Aguis et al, 1987 3% colonised @ term Al-Suleiman et al, 1991. 1939 pt. screened in 3rd trimester. 17.2% were colonized with GBS El-Kersh et al, 2002, Saudi medical journal. 217 pt. screened 27.6 % colonised

22. Current Practice

23. Majority of regional hospital are not following the recommendation for screening. Few hospital have a policy for screening. Obstetricians vary among them self. Hospitals following screening approach doing various other approaches.

24. ZNorthwestern territories: Z3 hospitals, no screening, one trying!! ZWestern territories: Z8 hospitals, one screening, one ++. ZSouthwestern territories: Z2 hospitals, one have a policy. ZMiddle: ZOne +/-, one +, two ++

25. Why there is disparity and diversity? ZLack of adequate time!! ZLack of administrative support. ZLimited resources. ZUnbooked mothers. ZDifferent opinions.

27. What is the incidence of GBS ENOS ZAlMuneef et al, Z29601 live birth, 1990-1994 Z23 had GBS spsis Z0.8/ 1000 >>>> 0.64/1000

28. Others ZMany neonatologists feel it is a rare. ZDuring survey: ZA- no confirmed case per 7000 ZB- no confirmed case per > 5000 ZC- one case per 6000 (unbooked) ZD- no case last few yr, 1300/ yr ZE- one case in 34 wk, 5000

29. Why it is rare? Z Underdetection. Z Intrapartum antimicrobial exposure. Z Different serotypes. Z Different scale of colonization. Z False believe?

30. Future plan!! ZDepends on: ZIncidence of GBS EONS. ZPatients characteristics. Z? Colonization rate. ZAvailable resources.

31. Z Accurate incidence of EONS due to GBS is unknown in Saudi Arabia. Z Mohle-Boetani et al, JAMA,1993: Z Risk-based approach is not cost effective unless incidence is > 0.6/1000 Z Screening not cost effective unless it is 1.2/1000 Z Strickland et al, 1990, Z Colonization rate has to be > 10%

32. Z Allardice et al, 1982, 16 women NNT to prevent on EONS Z Garland et al, 1991, 2059 colonized women NNT to prevent one case of EONS.

33. Conclusions Z Screening approach is probably is better than risk based approach based on cohort study, level II evidence (fair). Z Probably is not cost effective if the neonatal infection is rare or uncommon. Z The incidence of EONS due to GBS is probably rare or low in Saudi Arabia.

34. Z Hospital with adequate resources may follow the guidelines for booked pt. Z Hospital with limited resources may follow the risk based approach. Z Self collection is an option for busy clinics. Z Rapid testing can be useful for unbooked mothers Z Vaccines