Physicians who care for pregnant women and for infants have struggled for the past several years in weighing evidence regarding the usefulness of various strategies for preventing neonatal group B streptococcal infection. The difficulty in determining the value of these preventive measures reflects information overload and complex cost-benefit analysis, in addition to several other uncertainties faced daily during the course of providing perinatal care.
The issue of the prevention of group B streptococcal infection can be a very emotional one. It has attracted many medical players, as well as the Association of Trial Lawyers of America (ATLA), and has spawned a parents' organization called the Group B Strep Association (GBSA). The involvement of ATLA and GBSA serves to remind physicians that we deal with individual patients who either acquire the disease or do not—infants do not get 70 percent septic. Patients and lawyers do not generally care about who bears the aggregate screening costs involved in identifying or preventing a particular case of the disease at hand.
In an article in this issue, Keenan1 does a thorough job of addressing the evidence supporting screening for group B streptococcal disease and supporting the Centers for Disease Control and Prevention (CDC) consensus recommendations pertaining to perinatal group B streptococcal disease. The CDC recommends intrapartum antibiotic administration based either on intrapartum risk-factor assessment or on the results of screening after 34 weeks' gestation plus intrapartum risk-factor assessment.2 Yet, we know that these approaches cannot prevent all instances of group B streptococcal disease.
No matter what strategy we adopt, we must continue to deal with this nagging anxiety: What legal difficulties will we face if our strategy fails to prevent a case of group B streptococcal infection (as we know it eventually will)? This anxiety is not relieved by browsing the GBSA Web site (http://www.groupb-strep.org). The GBSA Web site contains references from medical and lay sources, a variety of educational links for laypersons and for health care professionals, a legal brief about informed consent related to group B streptococcal disease, and an appeal for legal information and assistance. The latter states: “Each malpractice suit we win gives a greater incentive to those physicians and facilities to begin the routine screening of GBS for their respective patients.”3
We clearly have our educational work cut out for us. The most important reason for this work is to help infants and their parents; a side benefit will be liability reduction. I believe that with a little foresight and organization, prevention of group B streptococcal disease can fit well into our other prenatal and intrapartum screening and treatment plans. I also believe that patients can understand this issue. The efforts we make to foster that understanding will be our best protection against a lawsuit when the inevitable group B streptococcal infection occurs.
First and foremost, we must not ignore the problem. Neonatal group B streptococcal infection is more prevalent than many of the other conditions we screen for in pregnancy, and the effects can be just as devastating. Based on the importance of group B streptococcal infection, there are two possible principles governing our obligation to inform and to care for patients: One is to adhere to the community standard and the other is to provide care that any reasonable patient would want.
Both of these principles can be addressed by two linked steps. First, each practice or care system can develop and document a standard (or reasonable choice of standards) that is supported by current literature or by authoritative clinical guidelines. The CDC consensus recommendations provide some latitude for this, as noted in this editorial and in the article by Keenan.1 Second, inform patients, document that the information has been provided and provide the opportunity for questions, additional information and choices, when choices are appropriate.
Most practices already have developed written patient information about prenatal and intrapartum tests and procedures. Adding a brief explanation of the local approach to group B streptococcal prevention based on CDC recommendations (screening, treatment based on risk factors, or both), reviewing that written information and documenting the interaction will suffice in most cases. The fact is that most patients look to their physicians to help them sort these issues out. For patients requesting more information, the CDC's two-page summary will be appropriate for many.4 It can be retrieved from the CDC Web site (http://www.cdc.gov). Furthermore, this model will serve well when the next screening test or procedure appears, as it most certainly will.
Another issue introduced in the analysis by Keenan warrants some thought and comment. He states: “In non-integrated medical care delivery systems like those of the United States, interorganizational agreements should be negotiated so that the costs of screening are not borne by entities . . . that do not realize the potential financial benefits of lower rates of (intrapartum chemoprophylaxis) and neonatal sepsis.”1 As bizarre as it may seem, there may be budget disputes over who should pay for increased ambulatory costs that benefit the hospital portion of the patient's care. Physicians must advocate for total patient care in these situations and fight against the shifting of such costs to an already stressed ambulatory system.
A consensus on neonatal group B streptococcal prevention has been many years in the making. Current recommendations offer latitude. It is now up to the physicians who provide perinatal care to make sure patients receive the hoped-for benefits. Good communication with patients is the best protection from lawsuits when screening and prevention fail.