Group B streptococcal infection in the newborn The emergence of group B streptococci as serious pathogens in the newborn presents an epidemiologic challenge to obstetricians, neonatologists, pediatricians and general practitioners. Although there are reports in the literature dating back to the 1 930s that suggest possible group B hemolytic streptococcal infections in the perinatal period, it was not until the 1 960s that these organisms emerged as serious pathogens for newborn infants.1 Infants with only colonization by the organism must be differentiated from those with manifest sepsis. Baker and Barrett2 found that in 25.4% of parturient women the organism was harboured in the genital tract, and that the rate of colonization in the infants was 26.2%. Finch, French and Phillips,3 in a retrospective survey in London, England, found the incidence of group B streptococcal sepsis to be 1 in 900 newborn infants,3 while Eickhoff and colleagues4 in the United States showed that the incidence may be as high as 1 in 500. The overall mortality for this condition in newborn infants has been reported to be 44% *. These organisms are now considered as the main cause of sepsis in the newborn. There are two patterns of illness caused by group B streptococci in the newborn. The early form, consisting of acute respiratory distress with apnea, shock, septicemia and meningitis, usually occurs within the first 24 hours after delivery. The mortality has been reported to be 55% .. The organism may be found in the blood, skin, nasopharynx and cerebrospinal fluid. Clinically and radiologically the condition resembles hyaline membrane disease and should be included in the differential diagnosis of respiratory distress occurring in the first hours after birth.5 The serotypes of group B streptococci most commonly found in this pattern of illness are identical to those isolated from the genital tract of the mother. This suggests that the infection is transmitted from the mother to the infant during delivery, and, indeed, in many cases
delivery has been complicated, particularly by premature labour or a long interval between rupture of the membranes and delivery. The infection can also occur antenatally: in a number of cases there have been no antecedent complications.1 Although earlier studies suggested that the implicated serotype was la,6 this has not always been substantiated.7 The second pattern of illness caused by group B streptococci is purulent meningitis appearing after the 10th day of life. The mortality is lower, about 23% ,. and the streptococci are usually type 3. It is conceivable that this form of infection is acquired by the infant in the nursery, from other colonized infants or their attendants or both; however, the route of infection is still uncertain.8 The more virulent form of group B streptococcal infection is associated with maternal colonization. The possibility of screening for and treating group B streptococcal infection of the mother in late pregnancy has been considered, but the data and results from various studies are inconclusive. In particular, early treatment of the mother with penicillin or ampicillin, to which the organism is usually sensitive, may not eradicate the organism from the maternal genital tract, and even if treatment is successful the rate of recurrence is extremely high. Indeed, some investigators found that there was no difference in rates of colonization between infants born to treated women and infants born to untreated women.2'9 Treatment of the mother alone may be inappropriate because the infection could spread venereally if the organism were harboured in the urethra of the woman's sexual partner. If group B streptococcal infection is suspected in the newborn infant, cultures should be done of skin specimens, throat swabs, and blood and cerebrospinal fluid samples. Treatment with penicillin and gentamicin should then be started. It has been suggested that, once the organism has been identified, the daily dose of
penicillin be doubled from the standard 100 000 U/kg for a minimum of 10 to 14 days.10 The effectiveness of penicillin in the treatment of the carrier state has been questioned. Since the infant with group B streptococcal colonization can become a potential reservoir for nosocomial infection, appropriate skin care should be considered. One bath in pHisoHex® may be appropriate.5 The pathogenetic and epidemiologic aspects of group B streptococcal infections are not completely understood. A bacteriologist should keep a close watch on infants born to women who are known carriers of the organism and those born after a complicated pregnancy and delivery. A preliminary study by Yow and colleagues" in Houston has indicated that if the carrier mother is treated with penicillin or ampicillin during labour the colonization or infection in the newborn infants may be lessened. They recommend that parturient women living in an area known to have a high incidence of group B streptococcal infection, women who are known to have harboured the organism in the past and women who have given birth to an affected infant should be screened at 34 to 36 weeks' gestation and treated with appropriate antibiotics during early and established labour. This may be the first appropriate approach to the prevention of group B streptococcal infection in the newborn. DAVID SCHIFF, MD, PH D, FRCP[c] Professor of pediatrics, obstetrics and gynecology Director of newborn nurseries University of Alberta Edmonton, Alta.
References 1. ANTHONY BF, OKADA DM: Emergence of group-R streptococci in infections of newborn infant. A nnu Rev Med 28: 355, 1977 2. BAKER CJ, BARRETr FF: Transmission of group B streptococci among parturient women and their neonates. J Pediatr 83: 919, 1973 3. FINCH RG, FRENCH GL, PHILLIPS I:
Group B streptococci in the female genital tract. Br Med J 1: 1245, 1976 4. EICKHOFF TC, KLEIN JO, DALY AK, et al: Neonatal sepsis and other infections due to group B beta-hemolytic
CMA JOURNAL/MAY 5, 1979/VOL. 120 1047
Gravol
Canada's Leading Antinauseant/Antiemetic Dimenhydrinate USP INDICATIONS For prophylaxis and treatment of various forms of motion sickness, M.ni.re's syndrome, vertigo due to other labyrinthine disorders, postoperative vomiting, druginduced nausea and vomiting associated with radiation therapy, and migraine. CONTRAINDICATIONS None reported at customary doses. PRECAUTIONS Some degree of drowsiness may be experienced by certain patients and dosage should be reduced if necessary. Patients on GRAVOL should be cautioned against operating automobiles or machinery requiring alertness because of the possiblility of drowsiness associated with its use. The effects of hypnotic, sedative and tranquilizing drugs may be synergistic if given concomitantly with GRAVOL During the administration of antiemetics the possibility of underlying organic manifestations or toxic effects of other drugs being masked should be kept in mind. ADVERSE REACTIONS Drowsiness is the most common. Dizziness may also occur. Symptoms of dry mouth, lassitude, excitement and nausea have been reported. DOSAGE AND ADMINISTRATION GRAVOL may be administered by oral, rectal or parenteral routes. Adults: The usual dose is 50-100 mg with dosage repeated every 4 hours as required. Maximum daily dose is 300 mg parenterally, 500 mg orally. Suppositories should be well inserted. ChIldren: 6-8 years: 15-25 mg, two or three times daily 8-12 years: 25-50 mg, two or three times daily Over 12 years: 50 mg, two or three times daily Fer pest-anestheticlpest-surgical nausea and vemitinq: 50 mg i/in or i/v, about 45 minutes before surgery 50mg i/in or Iv, immediately after surgery 50 mg i/in or i/v, every 4 hours for 3 doses Fer pest-radiatlen nausea and vemiting: 50mg i/in or i/v, 30 to 60 minutes pre-therapy 50mg i/in or Iv, 11/2 hours post-therapy 50 mg i/in or i/v, 3 hours post-therapy Pediatric suppesiteries: 1-2 1/2 years: properly insert 1/2 rectal suppository Over 21/2 years: insert 1 suppository Repeat one after 6 hours if required, or as prescribed by physician. For ease and comfort, moisten and smooth any edges on suppository before use. SUPPLY GRAVOL TABLETS Each tablet contains 50 mg dimenhydrinate GRAVOL LONG-ACTING CAPSULES Each capsule contains 75 mg dimenhydrinate For immediate release 25 mg dimenhydrinate For prolonged release 50 mg dimenhydrinate GRAVOL LIQUID Each 5 ml spoonful contains 15 mg dimenhydrinate GRAVOL ADULT SUPPOSITORIES Each suppository contains 100 mg dimenhydrinate GRAVOL PEDIATRIC SUPPOSITORIES Each suppository contains 50 mg dimenhydrinate Also available in i/in and i/v presentations Full information available on request
PMOntr4.a
streptococci. N Engi J Med 271:1221, 1964 5. ABLOW RC, DRISCOLL SG, EFFMANN EL, et al: A comparison of early-onset group B streptococcal neonatal infection and the respiratory-distress syndrome of the newborn. N Engi J Med 294: 65, 1976 6. FRANcIOsI RA, KNOTSMAN JD, ZIMMERMAN RA: Group B streptococcal neonatal and infant infections. J Pediatr 82: 707, 1973 7. BAKER CJ, BARRETr FF:
Group B
streptococcal infections in infants; the importance of the various strains.
JAMA 230: 1158, 1974
8. STEERE AC, ABER RC, WARFORD LR, Ct al: Possible nosocomial transmission of group B streptococci in a newborn nursery. J Pediatr 87: 784, 1975 9. HALL RT, BARNES W, KRISHNAN L, et al: Antibiotic treatment of parturient women colonized with group-B streptococci. Am J Obstet Gynecol 124: 630, 1976 10. MCCRACKEN GH, FELDMAN WE: J
Pediatr 89: 203, 1976 11. Yow MD, LEEDS LI, THOMPSON PK, et al: Prevention of intrapartum transmission of group B streptococcal infection by intravenous ampicillin. JAMA 241: 1247, 1979
One for the road? During World War 1117 682 Canadians died of battle injuries. Between 1972 and 1978 more than 36000 persons died on the roads of Canada; of all these people, 40% of the drivers and 50% of the adult pedestrians were impaired at the time of death.1 The cost of death and injury on our roads is about $2.5 billion (2% of the gross national product). Most drivers are unfamiliar with the drinking-and-driving laws and the associated steps that can be taken by law-enforcement officers. According to "Snow's Criminal Code of Canada" (section 234.1),2 a person can be stopped at any time by the police and be asked to undergo a breath test with a roadside screening device. If the results of the test indicate that the driver's blood alcohol concentration is less than 80 mg/dl, but still at a concentration that would constitute a hazard if driving was permitted, his or her driver's licence may be suspended for up to 24 hours. In many instances the driver is sent or taken home and the car and keys are retained by the police, to be collected the next day by the sober driver. If the results indicate a blood alcohol concentration higher than 80 mg/dl, the driver is taken to the police station for further breath analysis (section 236 of the criminal code2). Some people use the word impairment only in relation to alcohol; however, the law is not restrictive. Section 234 of the criminal code states: "Every one who, while his ability to drive a motor vehicle is impaired by alcohol or a drug, drives
1048 CMA JOURNAL/MAY 5, 1979/VOL. 120
a motor vehicle or has the care or control of a motor vehicle, whether it is in motion or not, is guilty of an indictable offence or an offence punishable on summary conviction." A driver can be charged with a criminal offence if he or she refuses a breath test, has a blood alcohol concentration higher than 80 mg/dl while driving, or is driving while impaired. When you invite friends and colleagues in for dinner or cocktails, are you ever concerned, when it is time for them to leave, about their ability to drive? Do you watch good old Charlie drive down the street and mentally wash your hands of any responsibility? How would you feel if shortly afterwards he hit and fatally injured your daughter, who was walking home from her babysitting job? Too many of us ignore the moral, if not the legal, responsibilities when we ply guests with alcohol and send them on their merry way. For persons who are concerned about their ability to drive after a merry evening, the Department of Transport provides a guide for determining the blood alcohol concentration in its publication entitled "Smashed".1 As is pointed out in "Smashed", drinking and driving go together like a hearse and carnage. JOHN S. BENNETF, MB, FRcS[c], FACOG
Director of professional affairs Canadian Medical Association
References 1. Smashed, road and motor vehicle traffic safety branch, Dept of Transport, Ottawa, 1978, p 3 2. HEATHER DRH (ed): Snow's Criminal Code of Canada, 7th ed, Carswell, Toronto, 1976
delivery has been complicated, particularly by premature labour or a long interval between rupture of the membranes and delivery. The infection can also occur antenatally: in a number of cases there have been no antecedent complications.1 Although earlier studies suggested that the implicated serotype was la,6 this has not always been substantiated.7 The second pattern of illness caused by group B streptococci is purulent meningitis appearing after the 10th day of life. The mortality is lower, about 23% ,. and the streptococci are usually type 3. It is conceivable that this form of infection is acquired by the infant in the nursery, from other colonized infants or their attendants or both; however, the route of infection is still uncertain.8 The more virulent form of group B streptococcal infection is associated with maternal colonization. The possibility of screening for and treating group B streptococcal infection of the mother in late pregnancy has been considered, but the data and results from various studies are inconclusive. In particular, early treatment of the mother with penicillin or ampicillin, to which the organism is usually sensitive, may not eradicate the organism from the maternal genital tract, and even if treatment is successful the rate of recurrence is extremely high. Indeed, some investigators found that there was no difference in rates of colonization between infants born to treated women and infants born to untreated women.2'9 Treatment of the mother alone may be inappropriate because the infection could spread venereally if the organism were harboured in the urethra of the woman's sexual partner. If group B streptococcal infection is suspected in the newborn infant, cultures should be done of skin specimens, throat swabs, and blood and cerebrospinal fluid samples. Treatment with penicillin and gentamicin should then be started. It has been suggested that, once the organism has been identified, the daily dose of
penicillin be doubled from the standard 100 000 U/kg for a minimum of 10 to 14 days.10 The effectiveness of penicillin in the treatment of the carrier state has been questioned. Since the infant with group B streptococcal colonization can become a potential reservoir for nosocomial infection, appropriate skin care should be considered. One bath in pHisoHex® may be appropriate.5 The pathogenetic and epidemiologic aspects of group B streptococcal infections are not completely understood. A bacteriologist should keep a close watch on infants born to women who are known carriers of the organism and those born after a complicated pregnancy and delivery. A preliminary study by Yow and colleagues" in Houston has indicated that if the carrier mother is treated with penicillin or ampicillin during labour the colonization or infection in the newborn infants may be lessened. They recommend that parturient women living in an area known to have a high incidence of group B streptococcal infection, women who are known to have harboured the organism in the past and women who have given birth to an affected infant should be screened at 34 to 36 weeks' gestation and treated with appropriate antibiotics during early and established labour. This may be the first appropriate approach to the prevention of group B streptococcal infection in the newborn. DAVID SCHIFF, MD, PH D, FRCP[c] Professor of pediatrics, obstetrics and gynecology Director of newborn nurseries University of Alberta Edmonton, Alta.
References 1. ANTHONY BF, OKADA DM: Emergence of group-R streptococci in infections of newborn infant. A nnu Rev Med 28: 355, 1977 2. BAKER CJ, BARRETr FF: Transmission of group B streptococci among parturient women and their neonates. J Pediatr 83: 919, 1973 3. FINCH RG, FRENCH GL, PHILLIPS I:
Group B streptococci in the female genital tract. Br Med J 1: 1245, 1976 4. EICKHOFF TC, KLEIN JO, DALY AK, et al: Neonatal sepsis and other infections due to group B beta-hemolytic
CMA JOURNAL/MAY 5, 1979/VOL. 120 1047
Gravol
Canada's Leading Antinauseant/Antiemetic Dimenhydrinate USP INDICATIONS For prophylaxis and treatment of various forms of motion sickness, M.ni.re's syndrome, vertigo due to other labyrinthine disorders, postoperative vomiting, druginduced nausea and vomiting associated with radiation therapy, and migraine. CONTRAINDICATIONS None reported at customary doses. PRECAUTIONS Some degree of drowsiness may be experienced by certain patients and dosage should be reduced if necessary. Patients on GRAVOL should be cautioned against operating automobiles or machinery requiring alertness because of the possiblility of drowsiness associated with its use. The effects of hypnotic, sedative and tranquilizing drugs may be synergistic if given concomitantly with GRAVOL During the administration of antiemetics the possibility of underlying organic manifestations or toxic effects of other drugs being masked should be kept in mind. ADVERSE REACTIONS Drowsiness is the most common. Dizziness may also occur. Symptoms of dry mouth, lassitude, excitement and nausea have been reported. DOSAGE AND ADMINISTRATION GRAVOL may be administered by oral, rectal or parenteral routes. Adults: The usual dose is 50-100 mg with dosage repeated every 4 hours as required. Maximum daily dose is 300 mg parenterally, 500 mg orally. Suppositories should be well inserted. ChIldren: 6-8 years: 15-25 mg, two or three times daily 8-12 years: 25-50 mg, two or three times daily Over 12 years: 50 mg, two or three times daily Fer pest-anestheticlpest-surgical nausea and vemitinq: 50 mg i/in or i/v, about 45 minutes before surgery 50mg i/in or Iv, immediately after surgery 50 mg i/in or i/v, every 4 hours for 3 doses Fer pest-radiatlen nausea and vemiting: 50mg i/in or i/v, 30 to 60 minutes pre-therapy 50mg i/in or Iv, 11/2 hours post-therapy 50 mg i/in or i/v, 3 hours post-therapy Pediatric suppesiteries: 1-2 1/2 years: properly insert 1/2 rectal suppository Over 21/2 years: insert 1 suppository Repeat one after 6 hours if required, or as prescribed by physician. For ease and comfort, moisten and smooth any edges on suppository before use. SUPPLY GRAVOL TABLETS Each tablet contains 50 mg dimenhydrinate GRAVOL LONG-ACTING CAPSULES Each capsule contains 75 mg dimenhydrinate For immediate release 25 mg dimenhydrinate For prolonged release 50 mg dimenhydrinate GRAVOL LIQUID Each 5 ml spoonful contains 15 mg dimenhydrinate GRAVOL ADULT SUPPOSITORIES Each suppository contains 100 mg dimenhydrinate GRAVOL PEDIATRIC SUPPOSITORIES Each suppository contains 50 mg dimenhydrinate Also available in i/in and i/v presentations Full information available on request
PMOntr4.a
streptococci. N Engi J Med 271:1221, 1964 5. ABLOW RC, DRISCOLL SG, EFFMANN EL, et al: A comparison of early-onset group B streptococcal neonatal infection and the respiratory-distress syndrome of the newborn. N Engi J Med 294: 65, 1976 6. FRANcIOsI RA, KNOTSMAN JD, ZIMMERMAN RA: Group B streptococcal neonatal and infant infections. J Pediatr 82: 707, 1973 7. BAKER CJ, BARRETr FF:
Group B
streptococcal infections in infants; the importance of the various strains.
JAMA 230: 1158, 1974
8. STEERE AC, ABER RC, WARFORD LR, Ct al: Possible nosocomial transmission of group B streptococci in a newborn nursery. J Pediatr 87: 784, 1975 9. HALL RT, BARNES W, KRISHNAN L, et al: Antibiotic treatment of parturient women colonized with group-B streptococci. Am J Obstet Gynecol 124: 630, 1976 10. MCCRACKEN GH, FELDMAN WE: J
Pediatr 89: 203, 1976 11. Yow MD, LEEDS LI, THOMPSON PK, et al: Prevention of intrapartum transmission of group B streptococcal infection by intravenous ampicillin. JAMA 241: 1247, 1979
One for the road? During World War 1117 682 Canadians died of battle injuries. Between 1972 and 1978 more than 36000 persons died on the roads of Canada; of all these people, 40% of the drivers and 50% of the adult pedestrians were impaired at the time of death.1 The cost of death and injury on our roads is about $2.5 billion (2% of the gross national product). Most drivers are unfamiliar with the drinking-and-driving laws and the associated steps that can be taken by law-enforcement officers. According to "Snow's Criminal Code of Canada" (section 234.1),2 a person can be stopped at any time by the police and be asked to undergo a breath test with a roadside screening device. If the results of the test indicate that the driver's blood alcohol concentration is less than 80 mg/dl, but still at a concentration that would constitute a hazard if driving was permitted, his or her driver's licence may be suspended for up to 24 hours. In many instances the driver is sent or taken home and the car and keys are retained by the police, to be collected the next day by the sober driver. If the results indicate a blood alcohol concentration higher than 80 mg/dl, the driver is taken to the police station for further breath analysis (section 236 of the criminal code2). Some people use the word impairment only in relation to alcohol; however, the law is not restrictive. Section 234 of the criminal code states: "Every one who, while his ability to drive a motor vehicle is impaired by alcohol or a drug, drives
1048 CMA JOURNAL/MAY 5, 1979/VOL. 120
a motor vehicle or has the care or control of a motor vehicle, whether it is in motion or not, is guilty of an indictable offence or an offence punishable on summary conviction." A driver can be charged with a criminal offence if he or she refuses a breath test, has a blood alcohol concentration higher than 80 mg/dl while driving, or is driving while impaired. When you invite friends and colleagues in for dinner or cocktails, are you ever concerned, when it is time for them to leave, about their ability to drive? Do you watch good old Charlie drive down the street and mentally wash your hands of any responsibility? How would you feel if shortly afterwards he hit and fatally injured your daughter, who was walking home from her babysitting job? Too many of us ignore the moral, if not the legal, responsibilities when we ply guests with alcohol and send them on their merry way. For persons who are concerned about their ability to drive after a merry evening, the Department of Transport provides a guide for determining the blood alcohol concentration in its publication entitled "Smashed".1 As is pointed out in "Smashed", drinking and driving go together like a hearse and carnage. JOHN S. BENNETF, MB, FRcS[c], FACOG
Director of professional affairs Canadian Medical Association
References 1. Smashed, road and motor vehicle traffic safety branch, Dept of Transport, Ottawa, 1978, p 3 2. HEATHER DRH (ed): Snow's Criminal Code of Canada, 7th ed, Carswell, Toronto, 1976
