Antibiotics in Labor: Evidence? Alternatives?

“Most importantly, the scientific review found that the use of precautionary antibiotics did not reduce the number of infant deaths—neither from GBS (Group B Strep) infection nor from all causes—and the number of later, serious infections is increased by the use of antibiotics during labor.”

Excerpt from “Baby Poop.” Originally published at Pathways to Family Wellness Magazine.

Antibiotics Given to Laboring Mothers

Obstetricians are aware that when a bacterium known as group B strep (GBS) is colonizing a mother’s vagina during pregnancy, her baby is more likely to develop an early infection with this bacterium after birth. Around 20 to 30% of U.S. mothers are found to be colonized with GBS during late pregnancy screenings. Standard practice is to screen pregnant mothers for presence of this bacterium and provide antibiotics to colonized mothers during labor in attempt to prevent early GBS infections in their infants.

No Good Evidence for Treatment

A 2014 scientific review of available studies on such provision of antibiotics to mothers during labor finds reports of a reduction in infections in infants but states that this finding “may well be due to bias.” In other words, they found a high risk of bias in study reports, making their conclusions weak.

Antibiotic provision does not always prevent early GBS illness; one study reported that 38% of infected babies were born to mothers who had taken antibiotics during labor. Also, many babies who are infected are born to mothers who tested negative and who were therefore not treated.

I find it difficult to analyze the effects of preemptive antibiotics on GBS rates because some studies report rates of all colonized infants, some report the rates of seriously ill infants, and some studies report and compare the rates of infant deaths among those with early GBS infections, rather than the rate of infection.

No Defined Drop since Initiation of Antibiotic Protocols

Infant death rates in those with early GBS infections dropped dramatically before preventive antibiotics were first studied: from 55% in 1970; to 22% in1980, before clinical trials began; to 12% in 1990, just before standardized testing and treatment became recommended. From 1990 to today, there has been a continuation of the slow but steady decline to today’s 5% death rate for those infants who become infected with GBS.

U.S. early infant GBS disease rates prior to the establishment of precautionary antibiotic provisions are reported at 10 to 17 per 10,000 births. The CDC reports the current rate at 3 in 10,000, with some sources reporting slightly higher rates.

Another large review of available studies looked at the occurrence of premature births in relation to antibiotic usage. A predominance of undesirable vaginal bacteria is also associated with an increased rate of premature deliveries. This review found that antibiotic provision did decrease the appearance of vaginal bacterial over-colonization (vaginosis), but it did not reduce the rate of preterm births—the chief purpose of the antibiotic drug prescriptions in these cases.

Other Reasons for Drops in Infection Rates

A significant jump in the number of U.S. mothers who initially breastfed their newborns—from 52% in the year prior to the beginning of GBS preventive antibiotics to 60% only 6 years later, and to 70% not long after that—surely accounts for some of the reduction reported in early infant infections. Although cesarean births pose many health problems to infants, early GBS infection risks are lower. A 50% increase in C-section births (from 22 to 33%)—from before the preemptive antibiotic measures to the present—has likely also accounted for some of the drop in early GBS infection rates. Other factors may be involved as well.

The Real Antibiotic Results: More Serious Infections

Even if early serious GBS infections are being reduced by antibiotic practices, there has been an emergence of other types of early infections from bacteria not affected by the kinds of antibiotics used—including a surge of drug-resistant E. coli infections affecting preemies.

Most importantly, the scientific review found that the use of precautionary antibiotics did not reduce the number of infant deaths—neither from GBS infection nor from all causes—and the number of later, serious infections is increased by the use of antibiotics during labor. (Late-onset infections are defined as developing after one week of age.) Serious Candida (yeast) infections are among these, as a direct result of antibiotic exposure. Later bacterial infections are also increasingly occurring from antibiotic-resistant organisms. These are making the illnesses even more challenging to treat. Today, half of late-onset infections are with the very dangerous MRSA (antibiotic resistant strep). The conclusion of the above comprehensive review is that evidence is lacking to support preemptive antibiotic usage.

Industrialized Disease

Women in some other countries average far lower rates of GBS colonization than those in the leading industrialized nations. Rates are as low as 7% among nations measured, reflecting greater intestinal health in these nations. Prior antibiotic use, consumption of antibiotic-treated animals, low fiber diets, and pesticide consumption are among the factors destroying intestinal health in industrialized nations.

Natural Treatments for Mom

A 2012 study provided either probiotic yogurt or antibiotics to over 300 GBS colonized pregnant mothers and found equal resolution of vaginal bacterial infection with either treatment. Another study gave garlic tablets or antibiotic drugs to 120 non-pregnant women with bacterial vaginosis. A statistically similar level of bacterial resolution was found between the two treatment groups, while more side effects occurred in those treated with antibiotic drugs. Other women use freshly cut garlic cloves vaginally and find long-term relief of GBS vaginosis whereas antibiotic treatment is medically recognized to provide only temporary relief and to result in great imbalance of vaginal and intestinal flora.

Vaginal vitamin C tablets have also been shown to reduce bacterial vaginosis. Some mothers regularly apply probiotics or yogurt vaginally to help balance their florae. Of course, a wide spectrum of oral antimicrobial herbs and nutritional practices can help to improve mother’s floral balance before birth, as can oral probiotics. Such practices can certainly provide other large benefits for mother and baby. More studies are needed on alternatives to antibiotic treatments for the prevention of infant GBS infections.

A pregnant mother can use oral and vaginal treatments with probiotics and other immune-supporting antimicrobials, such as garlic and vitamin C, during her pregnancy. She can then be tested—or re-tested—for GBS to find out whether these flora-protecting measures are providing the results that doctors would like to see.

Improving Infant Health

Prematurely born infants are the most susceptible to serious infections of all kinds. Kangaroo care, in which a large amount of skin-to-skin contact is provided for an infant, along with frequent and near-exclusive breastfeeding, is shown to cut preemie infection risks in half. Studies also show significant reductions in newborn infection rates in term infants when exclusive human milk feeding is available. These measures help to optimize baby’s flora and help to protect against all kinds of potential infections, not just GBS. Donor milk is a proven valuable option when mother’s milk is not available.

The infant health effects from exposure to maternal antibiotics during labor have avoided scrutiny because the drugs are given to the mother, not directly to the infant. Because of the potential ramifications of such a study on infants, no one really wants to do it. In 2014, researchers did look into the effects on newborn floral development and found significant reductions in the numbers and variety of health-promoting bifidobacteria in babies from antibiotic-treated mothers. Moreover, they found deficiencies in the very species that actually help to fight against GBS.

Antibiotics create havoc in newborn intestines. They not only increase the risk of serious drug-resistant infections during baby’s first few weeks after birth but also create serious impacts on floral balance that influence many other short term and long-term health factors. In many cases, there are healthier options to antibiotic drugs that may bring few or no side effects and greater overall health to mother and child.

 

I also provide additional detailed discussion of the studies below:

In brief, my overall conclusion from available studies and reviews is that there is not nearly enough solid science published from which to make solid decisions about prophylactic antibiotic use in labor. This is certainly frustrating. In such a case, I tend to lean toward trying more-natural alternatives that are shown to be partly effective and safer to use, in hopes of avoiding downsides either of the feared infection or of negative side-effects of prophylactic treatment.

Shrag (2013) reports “The incidence of invasive early-onset GBS disease decreased by more than 80% from 1.8 cases/1000 live births in the early 1990s to 0.26 cases/1000 live births in 2010,” as the use of screenings and antibiotics increased. A consideration of the great increase in breastfeeding over these years (including earlier initiation and an end to unreported formula bottles in the nursery) was not made, nor was the unfortunate 45% increase in cesarean sections over these years—a procedure fraught with negative effects but which does reduce GBS transmission.

GBS emerged as the predominant source of newborn infections in the 70s. We know that exclusive breastfeeding reduces overall infection risks in infants, especially in the first weeks and months, and we know that the 70s found not only a low in breastfeeding overall (22% initiation in 1972), but a high likelihood of a breastfed infant receiving formula in the hospital nursery and a low likeliness of initiation within an hour.

Antibiotics, of necessity, became the new infant immune system, but they are certainly a double-edged sword. Although a few reports of late onset GBS in infants whose mothers also expressed GBS in their breastmilk are described in the literature, with the standard medical treatment of breastmilk as just some infectious bodily fluid, no studies are to be found specifically comparing overall GBS infections in infants to presence or absence of exclusive human milk feeding.

Although discussion focuses heavily on early onset infections, I’m most interested in overall mortality (early plus late), which I believe is the best measure of a treatment versus the side-effects of treatment. Generally, greater or lesser mortality also reflects the levels of serious infections and other complications. Long term disabilities are not being measured or reported in these studies but I believe that their comparable rates can generally be closely represented by comparing mortality rates. The Cochrane review found no difference in early mortality rates for antibiotic use versus no antibiotics (and remember, these are considered biased studies). They also found no reduction in the occurrence of late onset infections (for which we do not have mortality studies).

There are recent studies that suggest a greater number of late onset infections occur when intrapartum antibiotics have been used. We need to know whether these present more complications and deaths since antibiotic use may not represent a reduction in early deaths.

Dinsmoor (2005) reports a more than doubled risk of one kind of late onset infection: “mother-baby yeast infections.” This sounds rather benign compared to thoughts of death from GBS, however these words, also reflected in other studies, sound more serious to me: “Invasive candidiasis is a leading infectious cause of morbidity and mortality in premature infants.” (Kelly 2015)

In addition to these increases in fungal infections, Ashkenazi-Hoffnung (2011) found a much greater number of infants who developed late onset serious bacterial infections had received antibiotics in labor than those who did not have late onset infections. Glasgow (2005) found a doubled likeliness that those with serious late bacterial infections had received intrapartum antibiotics, along with a far greater likeliness of these being antibiotic-resistant infections. With more late infections, it appears possible that there are more overall deaths and complications associated with prophylactic antibiotics—possibly a number that is not apparent against a background of otherwise dropping infant mortality.

 

Endnotes

Aloisio, I., et al. Influence of intrapartum antibiotic prophylaxis against group B Streptococcus on the early newborn gut composition and evaluation of the anti-Streptococcus activity of Bifidobacterium strains. Appl Microbiol Biotechnol 98, no. 13 (Jul 2014): 6051–60.

Ashkenazi-Hoffnung, L., et al. The association of intrapartum antibiotic exposure with the incidence and antibiotic resistance of infantile late-onset serious bacterial infections. Clin Pediatr (Phila) 50, no. 9 (Sep 2011): 827–33.

Brocklehurst, P., et al. Antibiotics for treating bacterial vaginosis in pregnancy. Cochrane Database Syst Rev 1 (Jan 2013): CD000262.

Byington, C. L., et al. Serious bacterial infections in febrile infants younger than 90 days of age: The importance of ampicillin-resistant pathogens. Pediatrics 111, no. 5 Pt. 1 (May 2003): 964–8.

Cohain, J. S. Long-term symptomatic group B streptococcal vulvovaginitis: Eight cases resolved with freshly cut garlic. Eur J Obstet Gynecol Reprod Biol 146, no. 1 (Sep 2009): 110–1.

Conde-Agudelo, A., & Diaz-Rossello, J. L. Kangaroo mother care to reduce morbidity and mortality in low birthweight infants. Cochrane Database Syst Rev 4 (Apr 2014): CD002771.

Dermer, P., et al. A history of neonatal group B streptococcus with its related morbidity and mortality rates in the United States. J Pediatr Nurs 19, no. 5 (Oct 2004): 357–63.

Glasgow, T. S., et al. Association of intrapartum antibiotic exposure and late-onset serious bacterial infections in infants. Pediatrics 116, no. 3 (Sep 2005): 696–702. “Group B Strep Infection in Newborns,” Centers for Disease Control and Prevention, last modified November 18, 2010, accessed March 16, 2012, http://www.cdc.gov/groupbstrep/about/newborns-pregnant.html

Hantoushzadeh, S., et al. Comparative efficacy of probiotic yoghurt and clindamycin in treatment of bacterial vaginosis in pregnant women: A randomized clinical trial. J Matern Fetal Neonatal Med 25, no. 7 (Jul 2012): 1021–4.

Manzoni, P., et al. Prevention of nosocomial infections in neonatal intensive care units. Am J Perinatol 30, no. 2 (Feb 2013): 81–8.

Mohammadzadeh, F., et al. Comparing the therapeutic effects of garlic tablet and oral metronidazole on bacterial vaginosis: A randomized controlled clinical trial. Iran Red Crescent Med J. 16, no 7 (Jul 2014): e19118.

Ohlsson, A., & Shah, V. S. Intrapartum antibiotics for known maternal Group B streptococcal colonization. Cochrane Database Syst Rev 6 (Jun 2014): CD007467.

Petersen, E. E., et al. Efficacy of vitamin C vaginal tablets in the treatment of bacterial vaginosis: A randomised, double blind, placebo controlled clinical trial. Arzneimittelforschung 61, no. 4 (2011): 260–5.

Shane, A. L., & Stoll, B. J. Neonatal sepsis: Progress towards improved outcomes. J Infect 68, Suppl 1 (Jan 2014): S24–32. doi:10.1016/j.jinf.2013.09.011

Stoll, B. J., et al. Early onset neonatal sepsis: The burden of group B Streptococcal and E. coli disease continues. Pediatrics 127, no. 5 (May 2011): 817–26.

Toltzis, P. Colonization with antibiotic-resistant Gram-negative bacilli in the neonatal intensive care unit. Minerva Pediatr 55, no. 5 (Oct 2003): 385–93.

Wolf, J. H. Low breastfeeding rates and public health in the United States. Am J Public Health 93, no. 12 (Dec 2003): 2000–10.