Author — Denise J. Jamieson, M.D.
CDC’s Division of Reproductive Health
As an obstetrician-gynecologist who practices at Grady, a large urban teaching hospital in Atlanta, I often have the opportunity to witness how guidance developed at CDC is translated into clinical practice. For example, in my role as a CDC medical officer, I participated in the CDC workgroup that helped develop the 2010 revised guidelines for the prevention of perinatal Group B Streptococcal (GBS) disease. Following the release of the new guidelines, I was able to see how the recommendations were interpreted and used in my role as a practicing obstetrician-gynecologist at Grady.
Shorty after the release of the revised GBS guidelines, Dr. Catherine Hudson, one of the Emory residents, presented the new recommendations on morning rounds while I was the attending physician on labor and delivery. To me, one of the many delightful (and humbling!) things about being at a teaching hospital is how much you can learn from the residents! Dr. Hudson was able to distill the essential points of the 32-page document concisely and accurately while integrating her own clinical perspective.
One of the issues that Dr. Hudson chose to highlight was how to manage GBS prophylaxis in a pregnant patient who reports a penicillin allergy, a common clinical situation in our patient population. If the patient reports a history of a penicillin allergy, it is critical to take a detailed history and find out what symptoms she had after receiving penicillin. If she reports a history of anaphylaxis, angioedema, respiratory distress, or urticaria, then antimicrobial susceptibility testing should be ordered at the time the third trimester vaginal-rectal swab is collected. If she is not at high risk for anaphylaxis (no history of anaphylaxis, angioedema, respiratory distress, or urticaria), then she should receive cefazolin if GBS prophylaxis is indicated. I realize that even in this circumstance of a patient who is at low risk of anaphylaxis to penicillin we are sometimes hesitant to give a cephalosporin to those with penicillin allergies, but beta-lactam-cephalosporin cross reactivity is relatively uncommon for such women, and cefazolin is more effective for GBS prevention than clindamycin or vancomycin. In addition, GBS resistance to clindamycin is increasing, so antimicrobial susceptibility testing is necessary if clindamycin is going to be used. If susceptibility testing has not been performed, then vancomycin is the preferred agent for penicillin-allergic women at high risk for anaphylaxis. It is sometimes challenging in our patient population because a relatively high proportion of patients do not receive regular prenatal care and therefore may present in labor without GBS screening. In these cases, it is critical to obtain a careful history, including any prior penicillin allergy, to give women the most effective prophylaxis agent and also to avoid the overuse of vancomycin.
What are some of the challenges you have found in translating the new CDC guidance “Prevention of Perinatal Group B Streptococcal Disease: Revised Guidelines from CDC, 2010” into your clinical practice?
Updated Guidelines for Prevention of Perinatal Group B Strep Disease, an expert commentary from CDC in partnership with Medscape