In the article by Alm B, et al, Neonatal Antibiotic Treatment Is a
Risk Factor for Early Wheezing, the study concludes that neonatal
antibiotics for greater than 24 to 48 hours is an independent risk factor
for wheezing in both term and preterm infants1. This is an important
study because asthma is on the rise in the United States and other
countries2. We wonder what is the percent of group B streptococcal (GBS)
colonized women in Western Sweden or Sweden? Is the Center for Disease
Control recommendation to prevent perinatal GBS disease followed in
Western Sweden or Sweden? If the Center for Disease Control protocol is
followed2, are any systematic efforts made to administer more than one
dose of intrapartum antibiotic greater than 4 hours prior to delivery of
the baby if the mother is GBS colonized4? How often are antibiotics given
to otherwise well appearing infants born to GBS colonized mothers and
greater than 35 weeks in Sweden or Western Sweden?
In the United States it is customary and almost universal to give
intrapartum antibiotics to GBS colonized women in an effort to decrease
GBS infection in babies3. In this protocol, an infant born of gestational
age greater than or equal to 35 weeks, whose mother receives intrapartum
antibiotic greater than 4 hours prior to delivery, receives routine care
(thus no neonatal antibiotics indicated) if appearing well. In contrast,
if the intrapartum antibiotic is given to mom less than 4 hours prior to
delivery, a blood culture and complete blood count (CBC) are drawn and a
I:T ratio is calculated [bands / (segs+bands+metamyelocytes)]. If the I:T
ratio is greater than 0.2 the baby receives antibiotics until the blood
culture is negative for 48 hours, even if the baby appears well.
Since 2006 Franciscan Skemp-Mayo Health System in LaCrosse began an
umbilical cord blood and infant blood I:T and blood culture program that
was modeled after the work published by Dr. Anne Hansen at Harvard and
after personal communication (electronic mail 2006) with Dr.
Costakos4,5,6. In addition, we mounted an educational campaign and
instituted clinical triggers to begin intrapartum antibiotics in
accordance with a Yale study7. The result was that compared to the first
5 months of the program in 2006 to the most recent 5 months of the program
in 2008, we increased by 25% the number of times mothers got antibiotics
greater than 4 hours prior to delivery. This decreased the number of well
appearing babies that received antibiotics because of a positive I:T ratio
as the only indication for antibiotics. Another benefit of our program
has been increased patient and staff satisfaction at Franciscan Skemp-Mayo
Health System in LaCrosse. Ideally, antenatal and intrapartum antibiotics
do not have the negative effect of being an independent risk factor for
wheezing in the baby but this needs to be studied8.
Finally, while maternal smoking in pregnancy was not an independent
risk factor in the multivariate analyses in the study by Alm B, et al, we
believe that physicians, nurses, and society must help to de-normalize the
behavior of tobacco smoking during preconception, pregnancy and
postpartum, as other studies have shown fetal and neonatal pulmonary
damage associated with maternal tobacco smoking.9,10.
Corresponding Author: Dennis T. Costakos, MD, Franciscan Skemp-Mayo
Health System, Department of Neonatology, LaCrosse, WI and Assistant
Professor of Pediatrics, Mayo Clinic College of Medicine, Rochester, MN;
Mary Therese Rinzel, MSN, RN, CCE, CNS, Department of Family Birthplace,
Franciscan Skemp-Mayo Health System, LaCrosse, WI; Jennifer Walden, RNC,
MS, NNP, Department of Neonatology, Franciscan Skemp-Mayo Health System,
LaCrosse, WI; Jose M. Yuvienco, MD, Department of Neonatology, Franciscan
Skemp-Mayo Health System, LaCrosse, WI; Dianne Kreibich, AAS, Department
of Neonatology, Franciscan Skemp-Mayo Health System, LaCrosse, WI.
References
1. Alm B, et al. Neonatal Antibiotic Treatment Is a Risk Factor for Early
Wheezing. Pediatrics 2008;121:697-702.
2. Moorman JE, et al. National surveillance for asthma—United States,
1980-2004. MMWR Surveill Summ 2007 Oct 19;56(8):1-54.
3. Schrag S, Gorwitz R, Fultz-Butts K, Schuchar A. Prevention of
perinatal group B streptococcal disease. Revised guidelines from CDC.
MMWR Recomm Rep 2002;51:1-22.
4. Hansen A, Forbes P, Buck R. Potential substitution of cord blood for
infant blood in neonatal sepsis evaluation. Biol Neonate 2005;88:12-18.
5. Herson VC, Block C, McLaughlin JC, Tetreault J, Eisenfeld LI, Krause
PJ. Placental blood sampling: an aid to the diagnosis of neonatal sepsis.
J Perinatal 1998;18(2):135-137.
6. Polin JI, Knox I, Baumgart S, Campman E, Mennuti MT, Polin RA. Use of
umbilical cord blood culture for detection of neonatal bacteremia. Obstet
Gynecol 1981;57(2):233-237.
7. Hamar BD, Illuzzi JL, Funai EF. Clinical Triggers to Initiate
Intrapartum Penicillin Therapy for Prevention of Group B Streptococcus
Infection. American J of Perinatology 2006;23(8):493-498.
8. Bizzarro MJ, Dembry LM, Saltimore RS, Gallagher PG. Changing Patterns
in Neonatal Escherichia coli Sepsis and Ampicillin Resistance in the Era
of Intrapartum Antibiotic Prophylaxis. Pediatrics 2008;121;689-696.
9. Fiore M. Wrench in the Killing Machine. In White Coat Wisdom by
Stephen J. Busalacchi. 167-169. Apollo’s Voice, LLC Publishing,
Middleton, WI.
10. Antonucci R, et al. Intrauterine smoke exposure: a new risk factor
for bronchopulmonary dysplasia? J Perinat Med. 32 (2004):272-277.
Conflict of Interest:
None declared
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