Group B streptococcus infections on the rise despite prevention guidelines

1. The incidence of infant invasive group B streptococcus (GBS) infection in the Netherlands has increased 60% despite the introduction of prevention guidelines in 1999.

2. During the period after implementation of prevention guidelines, genetic investigations found an increase of clonal complex 17 among cases of early-onset GBS disease and a decrease of clonal complex 19 among cases of late-onset GBS disease. These changes could indicate a transformation in the pathogen itself related to antibiotic resistance.

Evidence Rating Level: 2 (Good)

Study Rundown: Group B streptococcus (GBS) is the most common cause of neonatal infections and can result in meningitis if allowed to progress. This study assessed the effect of prevention guidelines on the incidence of GBS infections in children under 3 months in the Netherlands over a 25-year period by analyzing nationwide surveillance data to compare 1,075 cases. This time period was divided into pre- and post-1999 guideline implementation periods. Onset of infection was classified as either within seven days after birth (early onset) or after seven days (late-onset) infection. Select genetic sequences were compared to assess for changes in virulence after guideline implementation.

Incidence in both onset stages of GBS infections increased during the study period, urging reassessment of current prevention guidelines and strategies. Genetic clonal complex 17 was significantly increased after the guideline implementation, possibly warranting further research on strain resistance. Though this study is the first of its kind, its estimates may have been inflated due to increased recognition of symptoms over time or a lower threshold for diagnostic tests. However, this possibility cannot account for the stable incidence of other infections measured in this study, such as E coli infection.

This study was funded by the National Institute of Public Health and the Environment, the European Union’s seventh framework programme, Netherlands Organization for Health Research and Development, Academic Medical Center, and the European Research Council.

Click to read the study in The Lancet Infectious Disease

Relevant Reading: Group B Streptococcus and Escherichia coli Infections in the Intensive Care Nursery in the Era of Intrapartum Antibiotic Prophylaxis

In-Depth [surveillance study]: This study evaluated the epidemiology of invasive neonatal group B streptococcus (GBS) and assessed the effect of the introduction of the prevention guidelines in the Netherlands on the incidence of neonatal disease. GBS as well as Escherichia coli (E Coli) infection data was collected from the Netherlands Reference Laboratory for Bacterial Meningitis and included all patients aged under 3 months with positive blood or cerebrospinal fluid culture between 1987 and 2011.

During the study period the incidence of invasive GBS infection increased from 0.20 to 0.32 per 1000 live births (p<0.0001). Incidence of early-onset GBS disease increased from 0.11 to 0.19 per 1000 live births (p<0.0001). Incidence of late-onset GBS disease increased from 0.03 to 0.13 per 1000 live births (p=0.004). Genetic clonal complex 17 and 19 were notable because their proportions changed in correlation to prevention guidelines implementation. The proportion of clonal complex 19 decreased among cases of late-onset GBS disease after implementation (12/63 [19%] post-implementation vs. 12/34 [35%] pre-implementation, p=0.02), whereas the proportion of clonal complex 17 increased among cases of early-onset GBS disease after implementation (21/63 [33%] vs. 2/34 [6%]; p=0.002).

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