Blame inappropriate implementation for failure of intrapartum antibiotic prophylaxis for group B Streptococcus

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In this issue of The Journal, Blaschke et al from Salt Lake City, Utah, provide the case that was bound to happen. With increasing resistance of group B Streptococcus (GBS) to erythromycin and clindamycin, and too-quick, too-easy reflex to substitute clindamycin for penicillin or ampicillin when mother has a history of penicillin “allergy,” the math was going to add up to transmission and disease due to a clindamycin-resistant GBS in a newborn. Blaschke et al provide the case—an “old fashioned” one—of severe early-onset disease in an otherwise healthy term infant, whose mother received IAP with clindamycin.

The guidelines for a screening strategy with intrapartum antibiotic prophylaxis (IAP) for GBS carriers, and its impact on prevention of early-onset GBS disease have occurred with surgical precision – evolving from excellent epidemiologic and prevention data, effectiveness trials, and an implementation arm with obstetricians, infectious diseases experts, and health experts on board.

With at least 10% of women expected to report penicillin “allergy,” and increasing resistance of GBS to erythromycin and clindamycin, the guidelines were revised in 2002 to include careful assessment of the mother's “allergy” history, use of cefazolin for women without risk for anaphylaxis, and need for susceptibility testing of individual isolates prior to decision to use clindamycin for IAP. The revised guidelines have been implemented poorly. This threat to the miracle of prevention of early-onset GBS must be addressed by educating physician-patient decision making and by optimizing systems for ordering in vitro susceptibility testing, reporting results, and affecting physician action when an individual's situation warrants the step beyond screening.