Group B streptococcal (GBS) sepsis is estimated to account for more than 80 percent of the infection-related morbidity and mortality in obstetric and neonatal services. The infection is estimated to cause more than 7,500 serious illnesses and approximately 300 infant deaths per year, with direct costs of more than $300 million per year in the United States. Over the past decade, various strategies to contain the infection and minimize its consequences have been developed. The 1996 guidelines published by the Centers for Disease Control and Prevention (CDC) have now been accepted by the major expert groups and introduced into clinical practice. In practice, concerns have been raised about compliance with the guidelines, and attention has turned to institutional policy and other strategies to ensure universal coverage.
Brozanski and colleagues assessed the impact of introducing the guidelines to an obstetric hospital staffed by university and community physicians. This hospital has 129 obstetric beds and manages 8,000 deliveries per year. Approximately one third of deliveries are managed by university faculty and two-thirds by physicians in private practice. The CDC guidelines were introduced in October 1995.
The authors used medical records to compare the prevalence of early-onset GBS sepsis in deliveries from 1992 through 1995 with those from 1995 through 1999. Cases of sepsis were defined by microbiologic evidence of infection. Data were also collected to assess compliance with the guidelines.
The mothers of the 31,133 live births in the earlier period were demographically and obstetrically similar to the mothers of the 28,733 live births after introduction of the guidelines. The rates of colonization with GBS in the two groups were 24.7 and 24.6 percent, respectively. Nevertheless, the prevalence of early-onset GBS sepsis fell from 1.16 to 0.14 per 1,000 live births after introduction of the guidelines. Overall, compliance with the guidelines was estimated to be 86 percent. In vaginal deliveries, 94 percent of eligible mothers received some prophylaxis, but only 70 percent received prophylaxis at least four hours before delivery. The most common reason for incomplete or absent prophylaxis was late presentation before delivery. Compliance was 53 percent for women who delivered by cesarean section. These deliveries are not included in the guidelines and the risk of GBS infection is believed to be low in scheduled or repeat deliveries at term. No cases of sepsis occurred in infants delivered by cesarean section.
The authors conclude that the guidelines can successfully be implemented and followed at a hospital staffed by university faculty and private practice physicians and that this initiative resulted in an 88 percent reduction in early-onset GBS sepsis.
editor's note: Although physicians are traditionally responsible for their personal standards of patient care, we all practice in some type of organizational framework (e.g., practice groups, hospital sections, medical societies). This study demonstrates the potential benefit of group action. Each physician applying the guidelines to an individual practice population is important. When the entire hospital staff acts together, individual physicians are more likely to practice to the higher standard, and the hospital systems facilitate and encourage the new “norms.”—a.d.w.