In July 2012, the Royal College of Obstetricians & Gynaecologists released their updated Greentop guideline on the prevention of early-onset group B Streptococcal disease (No 36) – click here.
Disappointingly, few changes have been made to the first edition (published in 2003), despite a lengthy consultation process to which GBSS and others contributed.
Unchanged remains the statement that routine bacteriological screening of all pregnant women for antenatal GBS carriage is not recommended (this is a Grade D recommendation, using Level 4 evidence – expert opinion). Given the wealth of evidence from other countries which screen and have seen their incidence fall dramatically (while the UK’s incidence is rising), which RCOG chooses to believe might be inappropriate to extrapolate to the UK, this is very disappointing.
There are some minor improvements to the updated guideline, particularly in giving more clarity (for example, the guidelines now use the term ‘offer’ rather than ‘consider’ giving antibiotics in labour for women found to carry GBS during the current pregnancy) and including guidance on vaginal cleansing which had not been there before.
On the other hand, the guideline recommends against antenatal testing for group B Strep carriage, continues to treats unknown GBS carriage status the same as negative GBS carriage status (which will be untrue for up to 30% of women), has removed a recommendation for prolonged rupture of membranes (a recognised risk factor for GBS infection in newborn babies) and fails to mention the difference between the tests for GBS carriage currently available in the UK.
As worrying are statements of facts which don’t bear scrutiny – for example, the statement “the incidence of EOGBS disease in the absence of systematic screening… is similar to that seen in the USA after universal screening and intra-partum antibiotic prophylaxis” is false. In 2011 in the USA, the incidence of EOGBS infection was 0.26 cases per 1,000 live births (ABCs Report: Group B Streptococcus, 2011http://www.cdc.gov/abcs/reports-findings/survreports/gbs11.html); in 2011 in England, Wales and Northern Ireland, the incidence voluntarily reported to the Health Protection Agency for early-onset GBS infection was 0.38 per 1,000 live births, 46% higher than the incidence in the US (HPA. Pyogenic and non-pyogenic streptococcal bacteraemia, England, Wales and Northern Ireland: 2011. Health Protection Report 2012; 6(46): Bacteraemiahttp://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1317136996075).
Whilst there are some improvements to the 2012 update, they are tweaks and clarifications rather than fundamental change in guidance. This is very disappointing. We at GBSS remain convinced that the best way to prevent more EOGBS infection is by informing all pregnant women about group B Strep and offering them a sensitive test late in pregnancy, with intravenous antibiotics offered in labour to women whose babies are at higher risk.
The evidence from countries which offer screening shows significant falls in EOGBS infection – the UK incidence since the introduction of the RCOG’s risk based prevention guideline in 2003 has risen. We had hoped that the RCOG would look at the evidence and realise that their risk-based strategy isn’t working and that it’s time to change. Sadly, they didn’t.
To read our more detailed comments, click here for a pdf
