Comparison of Two Prevention Strategies
Comparison of Two Prevention Strategies
Background: Neonatal group B streptococcal disease is a serious infection, causing more than 2,000 cases of sepsis annually. The Centers for Disease Control and Prevention has recommended two alternative strategies to prevent infection, but few data directly compare the two in terms of intrapartum antibiotic administration, protocol feasibility, newborn laboratory evaluation, and costs.
Methods: We collected data on intrapartum antibiotic administration, protocol compliance, newborn laboratory evaluation, and maternal-newborn length of stay for 347 mother-infant pairs in a family practice residency maternity service. During the first study period, laboring women were managed under the screening strategy, and during the second study period, laboring women were managed under the risk factor strategy.
Results: Of those women who qualified for antibiotic prophylaxis, only 28% of women in the screening group and 47% of women in the risk factor group actually received the recommended two or more doses of intrapartum antibiotics. Ninety-one percent of women in the screening group had prenatal cultures done appropriately. Newborns in the screening group had an increased risk of having a complete blood count (OR = 1.35, 95% CI 1.01, 1.80). There was no difference between groups in maternal or newborn length of stay.
Conclusions: A minority of laboring women in either strategy received the recommended doses of intrapartum antibiotics. Feasibility of obtaining prenatal screening cultures is high. Although newborn laboratory testing increased with the screening strategy, overall costs and length of stay were comparable.
Neonatal group B streptococcal disease is a serious infection, with more than 2,000 cases reported in 1998 in the United States. A continuing dilemma in prevention and management is choosing of one of two acceptable protocols. A decision whether to administer intrapartum antibiotics must be made for every laboring patient. Consensus guidelines published by the Centers for Disease Control and Prevention (CDC), the American College of Obstetricians and Gynecologists (ACOG), and the American Academy of Pediatrics (AAP) in 1996 recommend two acceptable prevention strategies involving administration of intrapartum antibiotics. One strategy (screening) is based on prenatal screening cultures at 35 to 37 weeks' gestation, and the other strategy (risk factor) is based on intrapartum risk factors.
Although there is no direct evidence comparing the two strategies, the screening-based strategy is thought to be slightly more efficacious based on decision analyses using estimates from the literature. One recent study found no difference in efficacy. Because of the low prevalence of neonatal group B streptococcal disease, direct comparison studies of efficacy are not feasible, as they would require about 100,000 patients to show a difference in patient outcomes between the two groups.
When compared with the risk factor strategy, the screening strategy, although possibly more effective, is estimated to be more difficult to comply with, to expose more women and babies to antibiotics, to lead to an increased number of newborn laboratory evaluations, and to cost more. In the absence of published comparisons of the two strategies, providers are left with no definitive guidance and questions of whether the possible (but unproved) increased efficacy of the screening strategy is worth the increased exposure to antibiotics, inconvenience, and added laboratory testing.
The objective of our study was to compare the two strategies based on the rates of intrapartum-newborn antibiotic administration, protocol adherence, and amount of newborn laboratory testing in a family practice residency maternity service. A secondary analysis was performed to compare costs indirectly by determining length of stay for mothers and newborns and hospital charges for newborns.
The impetus for the study arose when we perceived that maternal intrapartum antibiotic usage and newborn laboratory evaluation increased after we adopted the screening strategy in July of 1996, compared with our previous use of the risk factor strategy. The CDC estimates that 28% of mothers would receive intrapartum antibiotics with the screening strategy and 18% would receive intrapartum antibiotics with the risk factor strategy. We hypothesized that compliance would be more difficult with the screening strategy, because screening must done in a restricted time frame and results must be available at the time of delivery. In addition, because more mothers would be receiving intrapartum antibiotics with screening, we postulated that newborn laboratory evaluations for sepsis and antibiotic administration would increase based on an algorithm included in the consensus statement for management of newborns if maternal intrapartum antibiotics were administered. This same algorithm might also lead to an increased length of stay for newborns based on a recommended minimal 48-hour stay if mothers received intrapartum antibiotics. This information could be useful for other practices in deciding which prevention strategy to implement for their maternity patients.
Background: Neonatal group B streptococcal disease is a serious infection, causing more than 2,000 cases of sepsis annually. The Centers for Disease Control and Prevention has recommended two alternative strategies to prevent infection, but few data directly compare the two in terms of intrapartum antibiotic administration, protocol feasibility, newborn laboratory evaluation, and costs.
Methods: We collected data on intrapartum antibiotic administration, protocol compliance, newborn laboratory evaluation, and maternal-newborn length of stay for 347 mother-infant pairs in a family practice residency maternity service. During the first study period, laboring women were managed under the screening strategy, and during the second study period, laboring women were managed under the risk factor strategy.
Results: Of those women who qualified for antibiotic prophylaxis, only 28% of women in the screening group and 47% of women in the risk factor group actually received the recommended two or more doses of intrapartum antibiotics. Ninety-one percent of women in the screening group had prenatal cultures done appropriately. Newborns in the screening group had an increased risk of having a complete blood count (OR = 1.35, 95% CI 1.01, 1.80). There was no difference between groups in maternal or newborn length of stay.
Conclusions: A minority of laboring women in either strategy received the recommended doses of intrapartum antibiotics. Feasibility of obtaining prenatal screening cultures is high. Although newborn laboratory testing increased with the screening strategy, overall costs and length of stay were comparable.
Neonatal group B streptococcal disease is a serious infection, with more than 2,000 cases reported in 1998 in the United States. A continuing dilemma in prevention and management is choosing of one of two acceptable protocols. A decision whether to administer intrapartum antibiotics must be made for every laboring patient. Consensus guidelines published by the Centers for Disease Control and Prevention (CDC), the American College of Obstetricians and Gynecologists (ACOG), and the American Academy of Pediatrics (AAP) in 1996 recommend two acceptable prevention strategies involving administration of intrapartum antibiotics. One strategy (screening) is based on prenatal screening cultures at 35 to 37 weeks' gestation, and the other strategy (risk factor) is based on intrapartum risk factors.
Although there is no direct evidence comparing the two strategies, the screening-based strategy is thought to be slightly more efficacious based on decision analyses using estimates from the literature. One recent study found no difference in efficacy. Because of the low prevalence of neonatal group B streptococcal disease, direct comparison studies of efficacy are not feasible, as they would require about 100,000 patients to show a difference in patient outcomes between the two groups.
When compared with the risk factor strategy, the screening strategy, although possibly more effective, is estimated to be more difficult to comply with, to expose more women and babies to antibiotics, to lead to an increased number of newborn laboratory evaluations, and to cost more. In the absence of published comparisons of the two strategies, providers are left with no definitive guidance and questions of whether the possible (but unproved) increased efficacy of the screening strategy is worth the increased exposure to antibiotics, inconvenience, and added laboratory testing.
The objective of our study was to compare the two strategies based on the rates of intrapartum-newborn antibiotic administration, protocol adherence, and amount of newborn laboratory testing in a family practice residency maternity service. A secondary analysis was performed to compare costs indirectly by determining length of stay for mothers and newborns and hospital charges for newborns.
The impetus for the study arose when we perceived that maternal intrapartum antibiotic usage and newborn laboratory evaluation increased after we adopted the screening strategy in July of 1996, compared with our previous use of the risk factor strategy. The CDC estimates that 28% of mothers would receive intrapartum antibiotics with the screening strategy and 18% would receive intrapartum antibiotics with the risk factor strategy. We hypothesized that compliance would be more difficult with the screening strategy, because screening must done in a restricted time frame and results must be available at the time of delivery. In addition, because more mothers would be receiving intrapartum antibiotics with screening, we postulated that newborn laboratory evaluations for sepsis and antibiotic administration would increase based on an algorithm included in the consensus statement for management of newborns if maternal intrapartum antibiotics were administered. This same algorithm might also lead to an increased length of stay for newborns based on a recommended minimal 48-hour stay if mothers received intrapartum antibiotics. This information could be useful for other practices in deciding which prevention strategy to implement for their maternity patients.
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