Yet Another GBS Treatment Question

[trimestersdoula]

Ok, so I have been hearing about antibiotic washes? (please correct me if I am wrong.) Anyways, if you can use an antibiotic wash, washing with colloidal silver should work too, right?

[nashvillemidwife]

It would depend on whether the bacteria was sensitive to that treatment. I have never heard of it being used. You should research it and find out as it would be interesting to know. There are different classes of antibiotics that work in different ways and each class of bacteria responds to them differently. You can't use just any antibiotics to treat any infection. There are certain specific antibiotics that are used to treat GBS and a gazillion others that aren't, just like how you don't take the same antibiotic for a bladder infection as you would for an ear infection.

Hibiclens (the treatment you're referring to) is an antiseptic, and diluted in various concentrations can be used to clean skin wounds, dental rinses, surgical scrub, even instrument sterilization. These are all used in different strengths, and the strength needed for eliminating GBS is very dilute. It is not selective to certain strains of bacteria but a general disinfectant.

[homewithtwinsmama]

There were several good trials of Chlorohexidine (Hibiclens is a brand name) that showed that it was as effective against GBS as antiobiotics and more effective on e coli (another potential infection for babies). I did two vaginal washes before my third was born and interestingly when my waters released I had zero labor for almost five days. I was really glad I had done the wash because my CPM does not have access to IV antibiotics. Baby and I were just fine after birth.

[momileigh]

We use 20 oz of water with 1/2 tsp bleach. This nightly wash (not the whole 20 oz, just a rinse-off) is done for 1 week prior to GBS testing, and then nightly until birth if the test is negative. We figure if the colonization can hold on through a week of chlorine washes, it might be a strong enough colonization to actually warrant IV antibiotics.

My guess is that colloidal silver may work, and it would be nice to do a study on it. If you have access to a number of women, you could have half of them wash w/ it for a week, the other half do nothing, do GBS swabs on all of them, and see if there was a difference in # of positives.

[mwherbs]

there is a topical silver wash that is used for burn patients that has been studied for effectiveness against certain types of bacteria as well as how much damage it can cause/and how far it will penetrate systemically-- hasn't been studied for birth but it may work- I would say look up the studies-- (silver sulphadiazine)

chlorhexidine has been studied not only for general surgical cleaning but in many other areas, including childbirth to and it's effectiveness to prevent GBS infection in the newborn- there are studies on how much goes into the newborn and studies on flora... so at the dilution and i mean great dilution mixing the way it comes- as a 4% down to .2%-- (the basic conversion of 4% to .2% 20 to 1; so for 1 teaspoon of 4% hibiclens you would add 20 teaspoons of water to dilute it to .2%)this has been shown to kill back GBS and E coli but will leave lactobacillus alone and not burn vaginal tissues- stronger concentrations will disrupt even lactobacillus and can burn tissues and damage eyesight!
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Hibiclens is chlorhexidine gluconate 4%, Isopropyl alcohol 4%,noionic surfactant, dye, fragrance, water.
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so it works as a phenol, as an alcohol and surfactant
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here is a web address that discusses how basic antibacterial/antiseptic soaps work- and it is different than antibiotics---

http://webs.wichita.edu/mschneegurt/...lecture18.html
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many plants have phenols/phenolitic compounds that would probably work as well but there are few to no studies -- so we don't know what is effective or not-- here is a short bit of info provided by David Hoffman on EOs and antiseptic properites --
http://www.healthy.net/scr/Article.asp?Id=1990
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and there is a difference between a topical agent and something that acts systemically- when you use a topical agent if there has already been an infection or an infection that is higher than where you wash then there is more chance of transmission of infection than with a systemic agent---although there is a fairly high rate of effectiveness with a topical agent used in labor there are some failures--
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additionally the long term treatment and changes to flora should be worked on via live culture foods , other dietary changes as well as direct application of live culture lactobacillus to the vagina-- lactobacillus changes the environment and GBS has a hard time living in the acid pH that lactobacillus and other healthy flora produce --

[nashvillemidwife]

I think chlorhexidine is a really great alternative to antibiotics. There is good evidence about it's efficacy, but the studies all used different parameters so it's difficult for me to decide what my protocols should be.

Originally Posted by mwherbs

chlorhexidine has been studied not only for general surgical cleaning but in many other areas, including childbirth to and it's effectiveness to prevent GBS infection in the newborn- there are studies on how much goes into the newborn and studies on flora...

This just has never made sense to me. The reason for treating with IV antibiotics during labor is to just go ahead and give the babies antibiotics prophylactically. The purpose of the vaginal culture is just to identify the babies most at risk and who "need" antibiotics, not because it's particularly important to try and decolonize the women with positive tests.

Oral antibiotics in labor aren't effective because it does not cross the placenta in sufficient quantities to load up the baby and unless she's in labor for days it doesn't have time to reliably clear up the colonization. Prenatal antibiotics can remove the bacteria from the vagina so the baby doesn't come in contact with it and hence not get infected. However, the oral ABs have to be started soon enough before labor starts to have done its work and will have to be continued until delivery to prevent re-colonization. This means that the mom has to remember to take her meds twice a day for up to 5+ weeks, and if she doesn't then they might not work AND increase the chance of developing a resistant strain. So it's a good strategy but may in practice may cause worse consequences of widespread antibiotics than the IVs in labor.

So we've got 2 separate schools of thought on preventing sick babies: make sure the mom doesn't have the bacteria so it's not an issue, or assume the baby might get sick so go ahead and load him up with antibiotics. I think getting rid of the bacteria is a good idea and will work to prevent sick babies, but the reality is that the IV in labor strategy prevents the most sick babies so it has won out.

So to get to the point of my post... Can a couple topical rinses of very dilute chlorhexidine during labor really cross the placenta in great enough quantities in such a short period of time to really have a prophylactic effect on the baby? I'm not even sure how that's possible, given that it's an antiseptic and not an antibiotic. I mean, when you rinse your mouth out with hydrogen peroxide, can it clear up a vaginal infection?

There are 2 ways a baby gets early onset GBS disease: by coming in contact with the bacteria while sliding out the vagina, or by becoming infected in the womb before labor even starts (which is why pre-term labor and symptoms of maternal infection are risk factors). Trying to remove the bacteria from the vagina on the day of the birth isn't going to matter a hill of beans to a baby who is already infected. However, starting antibiotic treatment in the womb is going to give him a fighting chance. This is probably the reason the the IV in labor is the strategy that prevents the most sick babies.

The sickest babies are the ones who are infected before birth, and it just doesn't seem to me that the chlorhexidine rinses during labor can prevent those. I know the research doesn't support that assumption, but that's what common sense tells me and I truly expect that evidence will shake out in the end.

The clinical trials of the rinses has only been for antepartum treatment (please correct me if I'm wrong). If it were used prenatally as soon as you knew the woman carried the bacteria you could wipe it out before it gets a chance to infect the baby. This is what I recommend, though unfortunately I have no basis for recommending how often to repeat the rinse to prevent recolonization before birth.

GBS is a fascinating topic.

Are my posts too long for anyone to actually make it to the end?

[mwherbs]

using the rinse is just that a topical treatment my comments on how much a baby gets was in reference to just how much it has been studied
it is used on babies in several ways- they also use it as a baby wash in hospitals and as a cord treatment -- the cord treatment(undiluted) is now a world wide recommendation in low resource areas- maybe the vaginal rinse is as well- in any case because in the past there was a soap/cleaner that had some neuro-toxic potential routinely used so now there is a process of study that looks to see if it enters the blood stream and how much- to be sure it isn't causing illness or damage-- and that is why I mentioned that it has been looked at to see if it gets into a baby's blood stream to rule out toxicisity not to achieve a systemic blood level because it doesn't do that --

-but as an alternative to routine IV antibiotics it has some merit and has been studied---
I agree that the exceptions are pre-existing amniotic infections and infections where the rinse does not reach including urinary tract colonization--- over all colony counts are what are important- so even if someone is using IV antibiotics it would probably be a good idea to do repeated rinses to reduce colony numbers -- since the studies do show that many women do not even get abx timely enough
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the reason that GBS (Streptococcus agalactiae) it is not being looked at and treated as if it is an infection in moms is because it doesn't cause many/any symptoms and so prevalent that it is thought to be "normal" flora notice that it isn't called "healthy" flora- because it is not healthy, the body does react to GBS in similar ways that it would respond to an infection and probably how this flora weed has survived by not triggering all the defenses- and the vaginal pH that it exists at 4.5 or higher is also the pH environment that BV likes to live in -- in the studies on preterm labor a pH of 4.5 is when to start trying to change flora to help prevent PTL you body wants to be more acidic--and with that in mind I define healthy flora differently than normal flora-
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I think that the vaccine is interesting and may be a good cover plan-- I don't know I think it doesn't address some of the deeper body ecology issues and in the wake of ridding one weed another or several others may spring into place if there isn't some sort of healthy flora cultivated --
knocking down colonies is one thing but replanting/colonizing with healthy flora is the long term back-up plan- the body's system for staying healthy-
in other countries there are some ways that healthy flora for the whole body is being promoted - like straws that are impregnated with live flora, and pads to do the same.
-- there is a product we have approved and is sold- they are wipes with an acidic pH but does not have any live colonies- so almost useless and certainly a "consumer" product because you have to keep buying them to stay healthy
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[nashvillemidwife]

I didn't mean to imply you were wrong in your comment about hibiclens reaching the baby. It's not a new question for me. A lot of midwives that I really respect insist that the evidence shows hibiclens is at least as effective as antibiotics regardless of the specific pathway, and that I'm wrong when I advise my clients that hibiclens is a good alternative but can't prevent the worst cases because they are caused by intrauterine infection. I could be wrong. I certainly believe in evidence-based practice and the clinical trials were actually good ones so I'm conflicted. Do I believe the research study sitting in front of me that doesn't make any sense logically? Even the midwives who tell me I'm wrong don't have an explanation as to why I'm wrong.

I've always been interested in GBS, but most of my ideas on colonization, treatment, and prevention arose out of my interest in BV. I totally agree with you that there's a connection there. I also think that we're misguided in thinking we can diagnose BV through symptoms and instead a large portion are asymptomatic or have atypical symptoms. I wonder how many women who run to Walgreens for Monistat to treat their yeast infection really have BV.

[mwherbs]

I was just trying to make what I said more clear and did not think you were being critical-- and since I did make a long post as well and thought oops- maybe I said it wrong--- I too feel very divided but for different reasons- I am not sure I understand the whole picture-- I feel like I still have a bunch of info that is not completely connected up--
I think that experimenting with alternative is just that experimenting-- and to prove that an alternative is going to actually work in practice takes a bigger group than we are likely to assemble to show effectiveness-- so I am more willing to stick closer to what has been studied and that seems to be lower impact-but the more invasive treatments -IV antibiotics do have a place--

the hibiclens rinse outcomes are as good as the older IV risk factor protocols but do not achieve the same level of effectiveness in the screen everyone and treat them in labor protocols.
an interesting orphan fact in the UK the same drop in GBS infections ocured at the same time that the risk factor protocols were instituted here even though they were not treating at that time-- so the beginning drop may have just represented a change in infection rates that did not relate to antibiotic use at all, not many years before that there was a global all time high in the numbers of cases--
other stuff in my head- that when we look at OVER ALL how many newborns get sick - that number has not decreased-- yes the number of babies that have early onset GBS is lower now but the numbers of babies that are admitted to the nursery and treated for symptoms or some other types of infections has stayed the same or increased -- so we know that no one infection has take the place of GBS but there are some slight increase in the usual suspects-

[nashvillemidwife]

the hibiclens rinse outcomes are as good as the older IV risk factor protocols but do not achieve the same level of effectiveness in the screen everyone and treat them in labor protocols.

Thank you, I was not aware of that. I will go back and look at those study parameters again.

I tell my clients that there are a lot strategies out there that are effective at preventing a sick baby, including the old risk factor approach; but that the screen everyone/IV antibiotics is the one that's going to prevent the highest number. That's just a fact. Doesn't necessarily mean it's the best when you look at all the other factors surrounding the issue, but it is what works most often.

yes the number of babies that have early onset GBS is lower now but the numbers of babies that are admitted to the nursery and treated for symptoms or some other types of infections has stayed the same or increased

That's another thing that people don't realize. Most babies who get GBS disease actually did have the antibiotics. That in no way means that the antibiotics aren't effective because think of how many babies didn't get sick. But despite our best efforts, some babies are going to get sick and may be even die.

I use a birth control analogy: condoms do a good job at preventing pregnancy, but effective as the pill. That doesn't mean you shouldn't use condoms, because of course they're much more likely to prevent pregnancy than not using anything. However, despite their best efforts sometimes even women on the pill end up pregnant.

[mwherbs]

Originally Posted by nashvillemidwife

That's another thing that people don't realize. Most babies who get GBS disease actually did have the antibiotics. That in no way means that the antibiotics aren't effective because think of how many babies didn't get sick. But despite our best efforts, some babies are going to get sick and may be even die.

I use a birth control analogy: condoms do a good job at preventing pregnancy, but effective as the pill. That doesn't mean you shouldn't use condoms, because of course they're much more likely to prevent pregnancy than not using anything. However, despite their best efforts sometimes even women on the pill end up pregnant.

Ok but off my point a bit-- what I was trying to say - and I guess I will try your analogy is that when populations use birth control pills there is a definate drop in pregnancies and births-- and that number changes the national statistics
Our infant morbidity (sickness) and mortality rates have not dropped --- so an effective treatment when we look at only one factor early onset infection with GBS has dramatically changed- but the morbidity and mortality rates of neonates for the nation are the same so treating GBS unlike effective birth control has only changed what a baby is sick with/from or that some babies actually avoid illness while others are made sick-- so somehow something is still wrong here-

[nashvillemidwife]

Yeah, following the analogy all the way through doesn't hold up, but I use it how to explain why IV in labor is the most effective strategy but that doesn't mean others aren't effective at all. Sorry, I didn't mean to get off the point.

I think it's also important on any topic to understand there are no guarantees. Women are told they have to have the test and they have to have the IV or their baby could get sick. Yeah, it probably will prevent a sick baby but it's not an either/or thing. It's an attempt to reduce the risk.

I completely agree that something is wrong. A great number of women are colonized; I think about half of those will have babies who are "colonized" (the bacteria is on them). Another smaller portion of those babies will get sick from it. Another smaller portion will get severely ill and/or die.

There's got to be another factor here that makes the tiny portion of sick sick babies different the other ~30% of all babies who are being born to colonized mothers. What are we missing?