Tuesday, January 01, 2008

Group B Strep information

Since GBS came up in the comment section of an earlier post, I thought I would dedicate a new post to the topic.
First, let's do the numbers:
Courtesy of Stephanie Soderblom--numbers come from this article and the CDC

* 15-40% of women are suspected to be colonized.
* 98-99% of babies born to colonized women will not become infected.
* Of those infected with early onset, 15% will die.
* Of those infected with late onset, 50% did not contract it from their mother but rather from other sources such as hospital personnel.

Taking "worse case scenario" (ie. assuming 40% of women are colonized, and 2% of those babies will become infected)--if we did not screen, did not give antibiotics, did nothing at all...
* .0225% (1 in 4444) babies would die of early onset GBS

Next, some articles:
* Mothering magazine has an article overviewing GBS and IV abx treatment.
* Prenatal screening for group B streptococcal infection: gaps in the evidence (editorial in the International Journal of Epidemiology)

Finally, I have included several research abstracts from an alternative treament for GBS colonized mothers: chlorhexidine vaginal washes. These have been found to be as effective as IV antibiotics at preventing GBS infections in babies. A vaginal wash is much easier to administer than antibiotics, less invasive, and carries fewer side effects.

Chlorhexidine vaginal flushings versus systemic ampicillin in the prevention of vertical transmission of neonatal group B streptococcus, at term.

Matern Fetal Neonatal Med 2002 Feb; 11(2):84-8. Facchinetti F, Piccinini F, Mordini S, Volpe A. Department of Gynecology, Obstetrics and Pediatric Sciences, University of Modena and Reggio Emilia, Italy.

OBJECTIVE: To investigate the efficacy of intrapartum vaginal flushings with chlorhexidine compared with ampicillin in preventing group B streptococcus transmission to neonates.
CONCLUSIONS: In this carefully screened target population, intrapartum vaginal flushings with chlorhexidine in colonized mothers display the same efficacy as ampicillin in preventing vertical transmission of group B streptococcus. Moreover, the rate of neonatal E. coli colonization was reduced by chlorhexidine.

Prevention of excess neonatal morbidity associated with group B streptococci by vaginal chlorhexidine disinfection during labor.
Lancet 1992 Jul 11;340(8811):65-9. Comment in: Lancet. 1992 Sep 26;340(8822):791; discussion 791-2. Lancet. 1992 Sep 26;340(8822):792..

Conclusion: Chlorhexidine reduced the admission rate for infants born of carrier mothers to 2.8% (RR 1.95, 95% Cl 0.94-4.03), and for infants born to all mothers to 2.0% (RR 1.48, 95% Cl 1.01-2.16; p n 0.04). Maternal S. agalactiae colonization is associated with excess early neonatal morbidity, apparently related to aspiration of the organism, that can be reduced with chlorhexidine disinfection of the vagina during labor.

Vaginal Flushing vs. IV Antibiotics
Facchinetti F, Piccinini F, Mordini B, Volpe A. “Chlorhexidine vaginal flushings versus systemic ampicillin in the prevention of vertical transmission of neonatal group B streptococcus, at term.” J Matern Fetal Med 2002 Feb;11(2):84-8.
Department of Gynecology, Obstetrics and Pediatric Sciences, University of Modena and Reggio Emilia, Modena, Italy.

OBJECTIVE: To investigate the efficacy of intrapartum vaginal flushings with chlorhexidine compared with ampicillin in preventing group B streptococcus transmission to neonates.
METHODS: This was a randomized controlled study, including singleton pregnancies delivering vaginally. Rupture of membranes, when present, must not have occurred more than 6 h previously.. Women with any gestational complication, with a newborn previously affected by group B streptococcus sepsis or whose cervical dilatation was greater than 5 cm were excluded. A total of 244 group B streptococcus-colonized mothers at term (screened at 36-38 weeks) were randomized to receive either 140 ml chlorhexidine 0.2% by vaginal flushings every 6 h or ampicillin 2 g intravenously every 6 h until delivery. Neonatal swabs were taken at birth, at three different sites (nose, ear and gastric juice).
RESULTS: A total of 108 women were treated with ampicillin and 109 with chlorhexidine. Their ages and gestational weeks at delivery were similar in the two groups. Nulliparous women were equally distributed between the two groups (ampicillin, 87%; chlorhexidine, 89%). Clinical data such as birth weight (ampicillin, 3,365 +/- 390 g; chlorhexidine, 3,440 +/- 452 g), Apgar scores at 1 min (ampicillin, 8.4 +/- 0.9; chlorhexidine, 8.2 +/- 1.4) and at 5 min (ampicillin, 9.7 +/- 0.6; chlorhexidine, 9.6 +/- 1.1) were similar for the two groups, as was the rate of neonatal group B streptococcus colonization (chlorhexidine, 15.6%; ampicillin, 12%). Escherichia coli, on the other hand, was significantly more prevalent in the ampicillin (7.4%) than in the chlorhexidine group (1.8%, p < 0.05). Six neonates were transferred to the neonatal intensive care unit, including two cases of early-onset sepsis (one in each group). CONCLUSIONS: In this carefully screened target population, intrapartum vaginal flushings with chlorhexidine in colonized mothers display the same efficacy as ampicillin in preventing vertical transmission of group B streptococcus. Moreover, the rate of neonatal E. coli colonization was reduced by chlorhexidine. Vaginal Disinfection with Chlorhexidine During Childbirth
Stray-Pedersen B, Bergan T, Hafstad A, Normann E, Grogaard J, Vangdal M. “Vaginal disinfection with chlorhexidine during childbirth.” Int J Antimicrob Agents 1999 Aug;12(3):245-51.
Department of Gynecology and Obstetrics, Aker Hospital, University of Oslo, Norway.

The purpose of this study was to determine whether chlorhexidine vaginal douching, applied by a squeeze bottle intra partum, reduced mother-to-child transmission of vaginal microorganisms including Streptococcus agalactiae (streptococcus serogroup B = GBS) and hence infectious morbidity in both mother and child. A prospective controlled study was conducted on pairs of mothers and their offspring. During the first 4 months (reference phase), the vaginal flora of women in labour was recorded and the newborns monitored. During the next 5 months (intervention phase), a trial of randomized, blinded placebo controlled douching with either 0.2% chlorhexidine or sterile saline was performed on 1130 women in vaginal labour. During childbirth, bacteria were isolated from 78% of the women. Vertical transmission of microbes occurred in 43% of the reference deliveries. In the double blind study, vaginal douching with chlorhexidine significantly reduced the vertical transmission rate from 35% (saline) to 18% (chlorhexidine), (P < 0.000 1, 95% confidence interval 0.12-0.22). The lower rate of bacteria isolated from the latter group was accompanied by a significantly reduced early infectious morbidity in the neonates (P < 0.05, 95% confidence interval 0.00-0.06). This finding was particularly pronounced in Str. agalactiae infections (P < 0.0 1). In the early postpartum period, fever in the mothers was significantly lower in the patients offered vaginal disinfection, a reduction from 7.2% in those douched using saline compared with 3.3% in those disinfected using chlorhexidine (P < 0.05, 95% confidence interval 0.01-0.06). A parallel lower occurrence of urinary tract infections was also observed, 6.2% in the saline group as compared with 3.4% in the chlorhexidine group (P < 0.01, 95% confidence p interval 0.00-0.05). This prospective controlled trial demonstrated that vaginal douching with 0.2% chlorhexidine during labour can significantly reduce both maternal and early neonatal infectious morbidity. The squeeze bottle procedure was simple, quick, and well tolerated. The beneficial effect may be ascribed both to mechanical cleansing by liquid flow and to the disinfective action of chlorhexidine. Vaginal Chlorhexidine during labor
Burman LG, Christensen P, Christensen K, Fryklund B, Helgesson AM, Svenningsen NW, Tullus K. “Prevention of excess neonatal morbidity associated with group B streptococci by vaginal chlorhexidine disinfection during labour. The Swedish Chlorhexidine Study Group.” Lancet 1992 Jul 11;340(8811):65-9. Comment in: Lancet. 1992 Sep 26;340(8822):791; discussion 791-2. Lancet. 1992 Sep 26;340(8822):792.
National Bacteriological Laboratory, Stockholm, Sweden.

Streptococcus agalactiae transmitted to infants from the vagina during birth is an important cause of invasive neonatal infection. We have done a prospective, randomised, double-blind, placebo-controlled, multi-centre study of chlorhexidine prophylaxis to prevent neonatal disease due to vaginal transmission of S agalactiae. On arrival in the delivery room, swabs were taken for culture from the vaginas of 4483 women who were expecting a full-term single birth. Vaginal flushing was then done with either 60 ml chlorhexidine diacetate (2 g/l) (2238 women) or saline placebo (2245) and this procedure was repeated every 6 h until delivery. The rate of admission of babies to special-care neonatal units within 48 h of delivery was the primary end point. For babies born to placebo-treated women, maternal carriage of S agalactiae was associated with a significant increase in the rate of admission compared with non-colonised mothers (5.4 vs 2.4%; RR 2.31, 95% CI 1.39-3.86; p = 0.002). Chlorhexidine reduced the admission rate for infants born of carrier mothers to 2.8% (RR 1.95, 95% CI 0.94-4.03), and for infants born to all mothers to 2.0% (RR 1.48, 95% CI 1.01-2.16; p = 0.04). Maternal S agalactiae colonisation is associated with excess early neonatal morbidity, apparently related to aspiration of the organism, that can be reduced with chlorhexidine disinfection of the vagina during labour.

Chlorhexidine Gel
Kollee LA, Speyer I, van Kuijck MA, Koopman R, Dony JM, Bakker JH, Wintermans RG. “Prevention of group B streptococci transmission during delivery by vaginal application of chlorhexidine gel.” Eur J Obstet Gynecol Reprod Biol 1989 Apr;31(1):47-51.
Department of Paediatrics, University Hospital, Nijmegen, The Netherlands.

In a prospective study in 227 parturients, carriership of group B streptococci was established to be 25%. In carriers, transmission of streptococci to the newborn occurred in 50%. 10 ml of a chlorhexidine gel containing hydroxypropylmethylcellulose was introduced into the vagina during labor in 17 parturients, who were known to be carriers of group B streptococci from the first trimester of pregnancy. In none of the newborns from these mothers colonization by group B streptococci did occur. Vaginal application of chlorhexidine may prevent transmission of group B streptococci, and serve as an alternative to intrapartum prophylaxis using antibiotics. A large multicenter randomized controlled study should be performed to confirm this hypothesis.

Chlorhexidine before rupture of membranes
Christensen KK, Christensen P, Dykes AK, Kahlmeter G. “Chlorhexidine for prevention of neonatal colonization with group B streptococci. III. Effect of vaginal washing with chlorhexidine before rupture of the membranes.” Eur J Obstet Gynecol Reprod Biol 1985 Apr;19(4):231-6.

A single vaginal washing with 2 g/l of chlorhexidine was performed before rupture of the membranes in 19 parturients who were urogenital carriers of group B streptococci (GBS). Two (11%) of the infants became colonized immediately after birth, in contrast to 16 of 41 (39%) infants to controls (P = 0.02). A significant reduction of GBS colonization of the ear (P = 0.02) and umbilicus (P = 0.01) was noted. Taken together, 2 of 57 (4%) cultures obtained at birth were positive in the chlorhexidine group, in contrast to 30 of 123 (24%) among the controls (P less than 0.01). These findings raise hope for the design of a simple washing procedure which might prevent serious infections in the early neonatal period with GBS but also with other chlorhexidine-sensitive organisms.

21 comments:

  1. Thanks for this - very interesting, I've never heard of it so will have to find out if its avaliable here.

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  2. link to site started by parents of babies with GBS. Most interesting part is how the advocacy of these parents helped the medical community establish practices that dramatically reduced the mortality and morbidity from Group B strep.


    http://www.groupbstrep.org/

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  3. History of GBS association and the changes that a determined group of parents made to save the lives of babies!






    1990
    - Incorporated as a non-profit 501©3 organization, June

    - National Medical Advisory Board formed, June

    - First National Medical Advisory Board meeting, October

    - First GBSA Educational pamphlet published

    - First coverage in national women’s magazine, Women’s Day, October

    - First major newspaper articles, Washington Post

    - First coverage on national television talk show, November

    1991
    - GBSA Board members invited to meet with National Institutes of Health (NIH) Vaccine Grant Officers, Bethesda, MD, June

    - GBS researchers awarded first five-year NIH grant for GBS vaccine research

    - First GBSA National Parents Meeting, October

    - Second GBSA National Medical Advisory Board meeting, October

    - GBSA’s first national press release

    - National television coverage on “Rescue 911”

    - Phone calls to the Centers for Disease Control and NIH increase due to parent concerns

    1992
    - First published document on GBS preventions from the American College of Obstetricians and Gynecologists (ACOG), July

    - First published documents on GBS prevention from the American Academy of Pediatrics (AAP), November

    - Second GBSA National Parents Meeting, October

    - Third Annual National Medical Advisory Board meeting, October

    - First State Medical Advisory Board formed in North Carolina, June

    - Canadian chapter of the Group B Strep Association formed, November

    - GBSA President speaks at National Conference on Neonatal Morbidity and Mortality

    1993
    - Screening pregnant women for GBS is found to be cost-effective, Centers for Disease Control

    - First annual meeting of the GBS vaccine researchers under the NIH grant

    1994
    - Legislation passes in California calling for a National consensus conference of experts on GBS

    - Third GBSA National Parents Meeting, October

    - Legislation proposed for GBS prevention in Florida

    - Continued media exposure in magazine, newspapers and television

    - Canadian health officials call for GBS prevention standards

    1995
    - CDC publishes call for comments on GBS Prevention protocol, MMWR January

    - GBSA members send 5,000 letters to CDC supporting a prevention strategy of routine screening for all pregnant women, January

    - First National Consensus Conference on GBS prevention held, CDC (Centers for Disease Control), ACOG (American College of Obstetricians and Gynecologists), AAP (American Academy of Pediatrics) and GBSA, March

    - GBSA members send letters to ACOG in support of routine screening of all pregnant women, June

    - GBSA featured on National Public Television series, “The Visionaries”

    1996
    - CDC, ACOG, and AAP publish the first consensus statement on GBS National Prevention Guidelines, June

    - GBSA publishes new patient education pamphlet based on new medical guidelines

    - Vaccine Officers prepare for first widespread clinical trials of GBS vaccine

    - GBSA expands National Medical Advisory Board to include researchers on adult GBS

    - GBSA has twelve State Medical Advisory Boards

    - GBSI (Group B Strep Initiative) Vaccine researchers enter last year of five year NIH (National Institutes of Health) grant

    - GBSA awarded $10,000 grant to work with CDC on GBS awareness among medical professionals working with at-risk African American women in inner city Atlanta

    1997
    - American Academy of Pediatrics publishes prevention guidelines, January

    - GBSA collaborates with CDC on Prevention guideline implementation, GPAC (Group B Strep Prevention Activities Committee)

    - GBSA awarded PARENTS Magazine “As They Grow” award for volunteer service in health education, presented by First Lady, Hilary Clinton, at Whitehouse ceremony, May

    - GBSA website opens, 10,000 hits a month

    - GBSA receives $8,000 grant from North American Vaccine Company to support educational activities and to promote vaccine development

    1998
    - GBSA presents prevention issues to National Vaccine Advisory Commission (NVAC), Washington, DC, June

    - GBSA exhibits at National Immunization Conference, Atlanta, July

    - GBSA co-presents along with Carol Baker, MD to Advisory Committee on Childhood Vaccines (ACCV), Washington, DC, September

    1999 – 2001


    GPAC (Group B Strep Prevention Activities Committee/CDC) continues surveillance and compliance with 1996 Prevention Guidelines

    2001


    - CDC Second National Consensus Meeting on Group B Strep Prevention



    2002


    - National Consensus Guidelines Recommending Routine Screening for all Pregnant Women



    2005


    - First Conference on Maternal Immunization sponsored by the American College of Obstetricians and Gynecologists





    Return to About GBSA.

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  4. This sounds very interesting.

    But I have never ever heard of someone being offered this in Ottawa within 4 hospitals. Do you know if anyone ever has this option made available to them in other cities?

    erin

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  5. I can't answer your question, Erin, but my guess is that this is a discussion the client would need to initiate with her midwife or doctor. They might or might not be familiar with this research. If a woman decides to test for GBS and is positive, this would be useful information so she could balance IV abx versus chlorhexidine vs not treating.

    Michel Odent mentioned the vaginal wash technique at a conference I attended a few years ago. He said it's very simple and the woman usually does it herself--usually it's just a squirt bottle thing.

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  6. Hmmm, very interesting! Another rare occurence that many hospitals overtreat, methinks.

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  7. Rixa, this is interesting information, but why would Chlorhexidine washes be preferable to IV antibiotics?

    The hospital where I work requires us to use a Chlorhexidine-based hand disinfectant before touching any patients, and it is a very irritating chemical. I cannot imagine choosing to put it into my vagina.

    How does the rate of allergic reaction to and other adverse effects of the washes compare to that of the antibiotic?

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  8. I can't answer your question about adverse effects of the wash vs IV abx. Which one would be preferable depends a lot upon your individual circumstance. Some things that I personally would want to avoid with IV abx versus a local antibiotic wash:
    - IV abx increase the likelihood of developing yeast infections. I would be very concerned about doing anything to trigger thrush in a new nursing relationship
    - pain of the IV or heplock site during labor
    - limited mobility while IV is in place
    - disruption of your normal fluid balance with introduction of IV fluids
    - vaginal wash is easy to administer (which from what Dr. Odent said is just a simple squirt & doesn't involve introducing it deep into the vagina)

    So I guess my point is: it's important to know there is more than one effective way of treating a woman with a positive GBS culture.

    Also worth noting: while IV abx can decrease colonization of GBS, it may also cause an increase of E coli colonization. However, the vaginal wash doesn't have that negative side effect.

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  9. Rixa, the editorial that you link here -- the authors note there was a decline in infections since before screening began. They attribute this to the reduction in the intensity of colonization: the lighter the colonization, the lower the risk of transmission. Reduction, they argue, is a result of improved access to health care for high risk groups and improved management of urinary tract or other infections during pregnancy.

    I think for those of us who advocate for holistic care and self-care, investigating the effectiveness of protocols to reduce or eliminate colonization would be the answer. Many midwives already have their own anecdotally based GBS remedies they swear by. I hope they're onto something. We need evidence-based information on diet, probiotics, herbs, etc. In late pregnancy, I was half prepared to fool around with tampons soaked in tea tree oil... but not quite, because I do believe in evidence-based care.

    Wouldn't it be nice if we could spare ourselves the anxiety and bypass the whole debate on prophylaxis by just preventing colonization in the first place, especially if that prevention consists of healthful practices to begin with?

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  10. "I think for those of us who advocate for holistic care and self-care, investigating the effectiveness of protocols to reduce or eliminate colonization would be the answer."

    Agreed. I have a handout from Barb Herrera that she gives her clients about reducing GBS colonization. I should email her and see if she'd let me repost it here...

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  11. Thank you for taking the time and posting this, Rixa!

    Early on in my pregnancy I was diagnosed with GBS, a test that I had not consented to, when I was swabbed to confirm a vaginal thrush infection. As both a hormonal pregnant woman along with my university education in the biological sciences (with a keen interest in microbiology) All I could see in my mind's eye were colonies of the strptococci and a morgue full of dead babies--needless to say--I FREAKED!!!

    I went on a mad hunt of treatments to prevent the transmission of GBS to my baby, and all of their side effects to both baby and I. With my history of reaction to antibiotics, and that I faint each and everytime I get an injection/blood draw/or IV cannula, the use of a chlorhexidine vaginal wash is my only viable solution. There are a few of the abstracts that you have quoted that I have in my medical notes, and the NHS community midwives know that the vaginal washes are my treatment.

    As far as an irritant that someone brought up; a few weeks back, thought that I had an amniotic leak and was having regular-ish contractions, so as per instructions, I did the wash every 4 hours. I have never douched, but found that the wash was fairly easy to do (in between contractions!) and did not experience any irritation of my vaginal mucosa, just that my vulva and vagina had that peculiar chlorhexidine odour. It was unfortunately a bout of false labour, so I am still waiting for my baby to be born. I have not had any adverse reactions since then either.

    Thanks again!

    ~Karin~
    expecting a homebirthed baby anyday now!

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  12. Karen, enjoy these last few days of pregnancy!! I am so glad you gave us feedback on the chlorhexidine. That comment made me wonder if it's some other ingredient in the hand sanitizer that's irritating -- I'm pretty sure I've used chlorhexidine antiseptic mouthwash after oral surgery, with no ill effects on my mucous membranes there.
    Wishing you the birth and baby of your dreams!!!

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  13. http://gentlebirth.org/archives/gbs.html has a LOT of information about alternatives to antibiotics for GBS colonization.

    Anectdotally, women with worse diets are more prone to GBS infection. When the diet straightens up (using the homeopathic/herbals supplements as well as eating as if trying to eliminate candida), I've seen GBS disappear and not return despite re-testing several times.

    This is certainly a controversial issue. In Europe, they test the *babies* and only treat those that are infected. This saves a LOT of women and babies from having systemic yeast postpartum (as almost every woman I've seen have post-antibiotics) and the challenges that come with that.

    IF women choose the antibiotics in labor, starting probiotics and eating a candida-free diet has really helped some women avoid or lessen the yeasties that are sure to try and infiltrate the body. Probiotics for mom *and* baby... for at least 30 days.

    Hope this helps!

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  14. Hi! I found your blog through the Homebirth Debate blog. Kind of funny that we both wrote about GBS within a day of each other and both got blasted on the Homebirth Debate Blog. Glad to know I am in good company! Nice blog!
    Kat

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  15. here's a question... babies get GBS sepsis, just from being born.

    soo how come our lovers don't get it from oral sex?

    silly question?

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  16. Adults are already colonized... actually, many already-born people are already colonized. A baby, however, hasn't become colonized and doesn't have the means to tolerate the GBS the way someone already on the earth does.

    Transmission from adult to adult (or adult to child/child to adult) in a variety of ways, including sexual contact. GBS transmission can be extremely serious, up to and including death.

    Having GBS in the gut is a LOT different than having systemic GBS, too. When a mom has systemic GBS, seen in her urine AND through vaginal/rectal cultures, the baby has a *much* greater chance of contracting GBS during the birth... even before the amniotic sac has broken or during a scheduled cesarean.

    Please read this website to learn more:

    http://tinyurl.com/29yg25

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  17. Hi,
    I know this doesn't apply to this specific post, but I saw on your library profile site that your profile name is "ummzari"... just curious, are you Muslim/do you speak Arabic? :) I am a Muslim and I love your blog, so when I saw your profile name as "ummzari", I was just curious!! :) :) :)

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  18. I am not Muslim, but I did live in Jerusalem for five months before I got married and studied a bit of both Arabic and Hebrew. Zari's name is Arabic for "Rose" (shortened form of Zariah) so I thought it would be nice to use a screen name reflecting that.

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  19. The tinyurl Barb supplied isn't working. Here's another link to it:

    http://tinyurl.com/5k2qnh

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  20. the CDC has just concluded a study (not yet published, I know one of the PI's) on the effectiveness of chlorahexadine prophalaxis and the outcomes were the same as the control group which is very disappointing.

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  21. I realize this is an old post but thought I'd add my two cents. The research showing that the vaginal wash is just as effective as antibiotics only proves it is helpful in reducing TRANSMISSION, not actual infection. The article claims that the wash reduces neonatal infection rates, but this is not supported by the evidence presented. Colonization and transmission are totally different than infection/sepsis. Studies with Chlorhexidine wipes did not show any promise in reducing GBS infection.

    http://www2.cochrane.org/reviews/en/ab004070.html
    http://www2.cochrane.org/reviews/en/ab003520.html
    http://www.ncbi.nlm.nih.gov/pubmed/20502294
    http://www.ncbi.nlm.nih.gov/pubmed/19846212

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