188 Gynaecol Perinatol 2009;18(4):188–196 Klinika za ginekologiju i porodni{tvo Medicinskog fakulteta u Zagrebu, Op}a bolnica »Sv. Duh«, Zagreb PROFILAKSA BOLESTI NOVORO\EN^ADI UZROKOVANE β HEMOLITI^NIM STREPTOKOKOM IZ SKUPINE B PROPHYLAXIS OF NEONATAL DISEASE CAUSED BY GROUP B β HAEMOLYTIC STREPTOCOCCUS Milan Stanojevi}, Anita Pavi~i}-Bo{njak, Ratko Matijevi}, Berivoj Mi{kovi}, Dubravko Habek Pregled Klju~ne rije~i: beta hemoliti~ni streptokok iz skupine B, rana novoro|ena~ka sepsa, intrapartalna profilaksa, preporuke SA`ETAK. Beta hemoliti~ni streptokok iz skupine B (BHSB) mo`e izazvati vrlo te{ku bolest u fetusa, novoro|en~adi i dojen~adi. Aspiracija zara`ene plodove vode mo`e dovesti do smrti ploda, konatalne pnumonije ili sepse. Prolazak kroz zara`eni porodni kanal mo`e izazvati kolonizaciju, ranu bolest tijekom prvih 7 dana `ivota i kasnu bolest nakon prvoga tjedna pa sve do tre}ega mjeseca. Prevalencija bolesti bila je prije provo|enja intrapartalne profilakse od 2 do 15 na 1000 `ivoro|enih od ~ega je 80% otpadalo na ranu, a 20% na kasnu bolest novoro|en~eta. U trudno}i je od 6,5% do 36% `ena koje nemaju simptome bolesti kolonizirano BHSB-om. Od 2% do 4% trudnica ima bakteriuriju uzrokovanu BHSB. Primjenom intrapartalne profilakse smanjena je u~estalost bolesti u novoro|en~adi na 0,5 na 1000 `ivoro|enih u Sje- dinjenim Ameri~kim Dr`avama (SAD), a u Hrvatskoj je u~estalost rane BHSB bolesti smanjena na 10 na 1000 `ivro|enih. Smanjena je smrtnost oboljele novoro|en~adi od 50% na 4%. Prve preporuke o prevenciji neonatalne BHSB bolesti u SAD izdali su 1996. godine Ameri~ko dru{tvo optetri~ara i porodni~ara, Sredi{te za kontrolu bolesti, te 1997. Ameri~ka pedijatrijska akademija; preporuke su bile obnovljene i izmijenjene 2002. godine. Prema preporukama iz 1996. postoja- la su dva pristupa prevenciji: jedan koji se temeljio na tra`enju rizi~nih ~initelja i drugi koji se temeljio na probiru svih trudnica u kasnoj trudno}i. Prema preporukama iz 2002. preporu~uje se samo drugi pristup, jer je za vi{e od 50% u~in- kovitiji. U Hrvatskoj nema nacionalnih preporuka za prevenciju bolesti uzrokovane BHSB-om u novoro|en~adi. Prema ameri~kim preporukama, ukoliko je trudnica imala bakteriuriju u trudno}i uzrokovanu BHSB-om u bilo kojem broju, ako je izme|u 35 i 37 tjedana trudno}e imala pozitivne nalaze kulture vagine i rektuma na BHSB, ako je dijete u pret- hodnoj trudno}i imalo te{ku bolest uzrokovanu BHSB-om, te ako rezultati kulture izme|u 35 i 37 tjedana nisu poznati a u trudnice se radilo o trudno}i < 37 tjedana, plodova voda je curila ≥ 18 sati, te je trudnica u porodu imala temperaturu iznad 38,0°C, preporu~ena je intrapartalna profilaksa. Penicilin G je ostao lijek izbora za prevenciju i lije~enje bolesti uzrokovane BHSB-om u novoro|en~adi, alternativa je ampicilin. U slu~aju preosjetljivosti na penicilin, bez opasnosti od anafilaksije potrebno je primijeniti cefazolin, a u slu~aju opasnosti od anafilaksije klindamicin i eritromicin, ako je klica osjetljiva na ta dva antibiotika. U slu~aju rezistencije na klindamicin i eritromicin potrebno je dati vankomicin. Sve lijekove potrebno je primijeniti intravenozno. Review Key words: group B streptococcus, early onset neonatal disease, intrapartum prophylaxis, recommendations SUMMARY. Group B streptococcus (GBS) could cause severe fetal, neonatal and infant infection. Fetal aspiration of in- fected amniotic fluid can lead to stillbirth, conatal pneumonia, or sepsis. Infants can also become infected with GBS during passage through the birth canal, although the majority of infants who are exposed to the organism through this route become colonized on skin or mucous membranes but remain asymptomatic, while some of them develop early onset GBS neonatal disease during the first 7 days of life, while late GBS disease can develop after 7 days till three months of life. It is estimated that prevalence rate of GBS disease in neonatal period before introduction of intrapartal prophylaxis was 2 to 15 per 1000 live-births of which 80% were early and 20% late onset GBS disease. Approximately 6,5% to 36% of pregnant women are colonizated with GBS, most of them asymptomatic. It is estimated that bacteriuria caused by GBS complicate 2%–4% of pregnancies. Due to intrapartal prophylaxis prevalence rate of GBS decreased to 0,5 per 1000 live-births, while case fatality rate declined from 50% before era of intrapartal prophylaxis to 4% after in- troduction of intrapartal prophylaxis in United States of America (USA). In Croatia after introduction of intrapartal prophylaxis prevalence of early neonatal GBS disease declined from 15 to 10 per 1000 live-births. Recommendations for intrapartum prophylaxis to prevent perinatal GBS disease in USA were issued in 1996 by the American College of Obstetricians and Gynecologists and Center for Disease Control, and in 1997 by the American Academy of Pediatrics, which were updated in 2002. The guidelines from 1996 recommended the use of one of two prevention methods, a risk- based approach or a culture-based screening approach. According to updated recommendations, culture-based screening approach is only appropriate, because it is over 50% more effective. Recommendations for the prevention of GBS neo- natal disease do not exist in Croatia. According to the American recommendations, if there was bacteriuria in pregnancy, or vaginal and rectal cultures between 35 and 37 gestational weeks were GBS positive or infant from previous preg- nancy suffered severe early onset GBS disease, or if screening results were not known in pregnant women with <37 weeks of gestation with one of the following risk factors: rupture of membranes ≥18 hours, intrapartum temperature ≥38,0°C, in that case intrapartal prophylaxis is indicated. Penicillin G remains the agent of choice for intrapartum anti-