Chlorhexidine instead of Antibiotics in Treating
Group B Strep at Birth
Submitted by Gretchen
Humphries, who notes that this alternative
treatment in GBS+ labor is easily done at home.
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 vagial 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 chlorhexidinen. PMID: 11995801 [PubMed
- in process]
1: Int J Antimicrob Agents 1999 Aug;12(3):245-51
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.
Lancet. 1992 Sep 26;340(8822):791; discussion
791-2. Prevention of excess neonatal morbidity
associated with group B streptococci by vaginal
chlorhexidine disinfection during labour.
The Swedish Chlorhexidine Study Group.Burman
LG, Christensen P, Christensen K, Fryklund B,
Helgesson AM, Svenningsen NW, Tullus K. National
Bacteriological Laboratory, Stockholm, Sweden.
Streptococcus agalactiae transmitted to infants
from the vagina during birth is an important cause
of invasive neonatal infection. We have done a
prospective, randomised, double-blind, placebo-controlled,
multi-centre study of chlorhexidine prophylaxis
to prevent neonatal disease due to vaginal transmission
of S agalactiae.
On arrival in the delivery room, swabs were taken
for culture from the vaginas of 4483 women who
were expecting a full-term single birth. Vaginal
flushing was then done with either 60 ml chlorhexidine
diacetate (2 g/l) (2238 women) or saline placebo
(2245) and this procedure was repeated every 6
h until delivery.
The rate of admission of babies to special-care
neonatal units within 48 h of delivery was the
primary end point. For babies born to placebo-treated
women, maternal carriage of S agalactiae was associated
with a significant increase in the rate of admission
compared with non-colonised mothers (5.4 vs 2.4%;
RR 2.31, 95% CI 1.39-3.86; p = 0.002). Chlorhexidine
reduced the admission rate for infants born of
carrier mothers to 2.8% (RR 1.95, 95% CI 0.94-4.03),
and for infants born to all mothers to 2.0% (RR
1.48, 95% CI 1.01-2.16; p = 0.04). Maternal S
agalactiae colonisation is associated with excess
early neonatal morbidity, apparently related to
aspiration of the organism, that can be reduced
with chlorhexidine disinfection of the vagina
during labour.
1: Eur J Obstet Gynecol Reprod Biol 1989 Apr;31(1):47-51
Prevention of group B streptococci transmission
during delivery by vaginal application of chlorhexidine
gel.
Kollee LA, Speyer I, van Kuijck MA, Koopman R,
Dony JM, Bakker JH, Wintermans RG. Department
of Paediatrics, University Hospital, Nijmegen,
The Netherlands. In a prospective study in 227
parturients, carriership of group B streptococci
was established to be 25%. In carriers, transmission
of streptococci to the newborn occurred in 50%.
10 ml of a chlorhexidine gel containing hydroxypropylmethylcellulose
was introduced into the vagina during labor in
17 parturients, who were known to be carriers
of group B streptococci from the first trimester
of pregnancy. In none of the newborns from these
mothers colonization by group B streptococci did
occur. Vaginal application of chlorhexidine may
prevent transmission of group B streptococci,
and serve as an alternative to intrapartum prophylaxis
using antibiotics. A large multicenter randomized
controlled study should be performed to confirm
this hypothesis.
Eur J Obstet Gynecol Reprod Biol 1985 Apr;19(4):231-6
Chlorhexidine for prevention of neonatal colonization
with group B streptococci. III. Effect of vaginal
washing with chlorhexidine before rupture of the
membranes.
Christensen KK, Christensen P, Dykes AK, Kahlmeter
G.
A single vaginal washing with 2 g/l of chlorhexidine
was performed before rupture of the membranes
in 19 parturients who were urogenital carriers
of group B streptococci (GBS). Two (11%) of the
infants became colonized immediately after birth,
in contrast to 16 of 41 (39%) infants to controls
(P = 0.02). A significant reduction of GBS colonization
of the ear (P = 0.02) and umbilicus (P = 0.01)
was noted. Taken together, 2 of 57 (4%) cultures
obtained at birth were positive in the chlorhexidine
group, in contrast to 30 of 123 (24%) among the
controls (P less than 0.01). These findings raise
hope for the design of a simple washing procedure
which might prevent serious infections in the
early neonatal period with GBS but also with other
chlorhexidine-sensitive organisms.
|
