I have not read the article but am able to read some report about the rapid PCR test on GBS. One report with 97.5% negative predictive value is very promising. At least it is far better that the culture method in my opinion. The question is always comes down to publication bias and also applicability. A guideline should be applicable everywhere. At least bacterial culture is routine even to level I medical facility but I do not know whether PCR will be available all over EU? Also, was epidemiologist/biostatistician involved in the process? Good medical test also need to be cost effective. 

Depends on the regional Epidemiology, GBS related disease, in general is a problem in countries where Neonatal infecction for gram negative bacteries is controlated, After that is when the GBS appears as a cause of neonatal mortality,  In countries where this is achieved,  (reduction of the infection for gram negatives) usually have good sanitarial coberture of the pregnant women,  and therefore  the intrapartum screening would be used only if they don't have an adecuated pregnancy control,  like the inmmigrant population, thats more or less what we do where I work. 

This is a highly controversial and emotive area in clinical practice to say the least.  I offer you my best wishes and success in spearheading this extremely ambitious if not impossible task.  The current UK practice in this area is the complete opposite of the US practice in this area.  I enclose below the views of the UK Royal College of Obstetricians and Gynaecologists and the NICE institute in in a summerised form. 

Women with GBS found in their urine or a vaginal swab during the current pregnancy should be offered intrapartum antibiotic prophylaxis (IAP or intravenous antibiotics in labour as preventative medicine against early-onset GBS infection in the baby) - the first guideline had said “consider” rather than offer.  There is clarity about what should happen with a woman known to carry GBS experiences spontaneous rupture of membranes at term (immediate induction of labour plus IAP offered).  Women with a temperature of more than 38oC in labour should be offered intravenous broad-spectrum antibiotics in labour which include those which cover the GBS risk.

Oral antibiotics are not recommended in labour against GBS infection in the newborn baby.  There is no evidence that vaginal cleansing in labour will reduce the risk of GBS infection in the newborn baby.  Well infants without clinical signs of infection but with other risk factors for GBS infection should be observed closely for such signs over the first 24 hours of birth – previously no specific guidance was given, apart from a statement that most early onset GBS (EOGBS) infections present within the first 12 hours of life. EOGBS infections are usually classified as those which occur in the first 6 days of life. 

Treat unknown GBS carriage as no GBS carriage. In situations where one or more recognised risk factors for EOGBS infection are present (prematurity and prolonged rupture of membranes), the updated guideline treats unknown GBS status the same as negative GBS status. This will not always be true and so Mums may have multiple risk factors with no recommended action from RCOG. All too often though, waiting until labour starts to give intravenous antibiotics (as per the RCOG updated guideline) will be too late to prevent infection and preterm babies who develop GBS infection are at significantly higher risk of poor outcomes, particularly at the earlier gestations.  Recommend no IAP should be offered to mothers in preterm labour unless they are known to carry GBS. The risk of developing EOGBS infection for a preterm baby (less than 37 weeks of pregnancy) is estimated as being a 1:435 risk, very similar to the risk of a baby born to a mother carrying GBS in the current pregnancy (1:434).  It is illogical that IAP is not recommended although the risk is similar to that of a risk factor for which IAP should be offered (known carriage) plus up to 30% of these women will unknowingly be carrying GBS – therefore multiple risk factors will be present, multiplying the risk of EOGBS infection.  Make no recommendation for women with prolonged rupture of membranes at any gestation, although the risk of EOGBS infection if no antibiotics are given for women with rupture of membranes >18 hours at term is estimated as being 1:556. This is illogical – up to 30% of these women will unknowingly be carrying GBS so multiple risk factors are present, increasing the risk of EOGBS infection significantly.  Routine bacteriological screening of all pregnant women for antenatal GBS carriage is not recommended (Recommendation Grade D, evidence level 4: expert opinion).

Given the wealth of evidence from other countries which have introduced screening and seen their incidence fall (while the UK’s incidence is rising), this is extremely disappointing.  I trust that this summary is of some assistance to you.

Best regards

Dr Sayed S Bukhari MD FRCPath, Consultant in Infection

Thank you very much for your answers. To Ru-Jeng : exactly, this is  about cost effectiveness of the test. And yes, the idea was to introduce a pan-european guideline. There was no  time-frame suggested by the authors.

To me a guideline is different from recommendation. Recommendation is to suggest the best practice which maybe expensive but save life. A guideline should be applicable to everyone. Not unccomonly we know the best practice but if we put down as a guideline and all medical professionals need to follow it and guideline violation will be way too common.

In a studie of bacterial content in the breast milk of women with and without symptoms of mastitis (The role of bacteria in lactational mastitis and some considerations of the use of antibiotic treatment), I found that 10% of healthy breast milk donors had GBS in their breast milk. We must not lose sight of the fact that many bacteria become pathogenic only when biological circumstances suit proliferation and result in a dysbiosis. General screening and treatment might lead to overuse of antibiotics and increase our problems with resistant strains.

To follow guidelines is reasonable from the  legal responsibility point of view  . However it takes a time to upgrade a guideline and it is never ending story.   Linda, thanks a lot for your contribution. I didn't know, how many breast milk specimens are GBS positive. Breast milk is definitely one of the sources for late onset GBS disease, isn't it?

Dear Gabriella,

Congratulations with the fantastic work. I hope you can send it to me as I have to give a lecture about the topic soon.

I agree with the approach but think the bedside testing is not yet universilly accepted and availabla as long as there is not one FDA or EMEA approved device to use in general practice. Did you ask Begonia Martinez from Geneva for advise? She has a llong lasting and vast experience in ths field and published her work recently. 

Who did you invite in the pan-European committee from Belgium and the Netherlands (the latter still refuse to perform general screening...)?

I also have a question for Sayed. Thank you for the nice overview what happens in the UK. Did I ead you well that in unknwon GBS status it remains considered GBS negative EVEN IN THE PRESENCE OF RISK FACTORS???

warm regards to you all!

Dear Gilbert, thank you for your lovely contribution. I actually didn't attend the Consensus Congress, only have come across with published conclusions recently, when finishing my systematic review on GBS screening in pregnancy (btw. It's great.). I am completing statistical data at the moment and as soon as the article is accepted I'll send it to you.  I can agree, that GBS PCR is not routinely available in many European hospitals. My personal experience was, that a test which costs more than 10 Euro, is not interesting enough to be introduces immediately in an acute hospital . (I had similar experience with procalcitonin test). However, I feel the Congress conclusion as a very positive feature on the way towards paneuropean guidelines related to prevention and management of GBS disease in newborn babies, as well as GBS infections in pregnancy. I have background of working a decade in the Czech Republic, where universal GBS screening was introduced in the beginning of 21. century. Working now in Ireland where obstetricians follow UK guidelines (not recommending universal screening and promoting risk-based approach ) , it's a difference.

This sounds as a reasonable approach. However, I would be careful with straightforward paneuropean recommendation for implementation until you are sure that GBS is present everywhere.

Very true., Vadim. The only thing is, GBS invasive infection is not notifiable in all countries. Or, it has been notifiable for a very short time period. 

You can base your recommendation on the basis of smaller studies in relevant samples or audit of available data from if a few or single practice in the area do the testing. Anyway, I would use double conditional tense while discussing introduction of a prophylactic measures for areas without knowledge if the problem exists there and if it is going to work. Also, check the latest publication in Lancet ID edition. They have a report from Netherlands on their experience with GBS prophylaxis.

Thanks a lot for your advice - I definitely will.