3. What does the article suggest? What were the researchers’ conclusions or final remarks? What were the suggestions, if any, for future research on this topic?
Probiotic interventions to reduce antepartum Group B streptococcus colonization: A systematic review and meta-analysis Midwifery 105 (2022) 103208 Contents lists available at ScienceDirect Midwifery journal homepage: www.elsevier.com/locate/midw Probiotic interventions to reduce antepartum Group B streptococcus colonization: A systematic review and meta-analysis ✩ Lisa Hanson a , ∗, Leona VandeVusse b , Emily Malloy c , Mauricio Garnier-Villarreal d , Lauren Watson e , Alissa Fial f , Marie Forgie g , Katrina Nardini h , Nasia Safdar i a Klein Endowed Professor and Associate Director, Marquette University College of Nursing, Midwifery Program, Milwaukee, WI USA b Associate Professor Emerita, Marquette University College of Nursing Milwaukee, WI USA c PhD student, Marquette University College of Nursing; Nurse-Midwife, Midwifery and Wellness Center, Department of Obstetrics and Gynecology, Advocate Aurora Health Care, Milwaukee, WI, USA d Assistant Professor, Sociology department, Vrije Universiteit Amsterdam e Laboratory Manager, UW Madison School of Medicine and Infectious Disease, Madison, WI, USA f Research & Instruction Services, Associate Librarian, Raynor Memorial Libraries, Marquette University, Milwaukee, WI, USA g Physician, Department of Obstetrics and Gynecology, Advocate Aurora Women’s Health Care, Milwaukee, WI, USA h Associate Chief, Midwifery Division, University of New Mexico Health Sciences Center, Department of Obstetrics and Gynecology, Albuquerque, New Mexico, USA i Professor, Infectious Disease, UW Madison School of Medicine. Madison WI, USA a r t i c l e i n f o Article history: Received 29 April 2021 Revised 21 October 2021 Accepted 18 November 2021 Keywords: Probiotics Antenatal GBS in vitro, Systematic Review, Meta-analysis a b s t r a c t Objective: To systematically review and meta-analyse studies of the efficacy of probiotics to reduce ante- natal Group B Streptococcus (GBS) colonisation. Participants: Antenatal participants with known positive GBS colonisation or unknown GBS status. Intervention: Probiotic interventions containing species of Lactobacillus or Streptococcus . Design: Systematic review and meta-analysis. Measurements and findings: The systematic review included 10 studies. Five articles contained in vitro studies of probiotic interventions to determine antagonistic activity against GBS. Six clinical trials of pro- biotics to reduce antenatal GBS were systematically reviewed and meta-analysed. The meta-analysis re- vealed that the use of an antenatal probiotic decreased the probability of a positive GBS result by 44% ( OR = 0.56, 95% CI = 8.7%, 194.1%, p = 0.02) ( n = 709). However, only one clinical trial of 10 had a low risk of bias. Key conclusions: The probiotic interventions subjected to in vitro testing showed antagonistic activity against GBS through the mechanisms of acidification, immune modulation, and adhesion. The findings of the meta-analysis of the clinical trials revealed that probiotics are a moderately effective intervention to reduce antenatal GBS colonisation. More well-controlled trials with diverse participants and with better elucidation of variables influencing GBS colonisation rates are needed. Implications for practice: Probiotic interventions appear to be a safe and effective primary prevention strategy for antenatal GBS colonisation. Application of this low-risk intervention needs more study but may reduce the need for intrapartum antibiotic prophylaxis in countries or regions where antenatal GBS screening is used. Midwives can be instrumental in conducting and supporting larger well-controlled clinical trials. © 2021 Elsevier Ltd. All rights reserved. c N h 0 ✩ Midwifery Probiotic interventions to reduce antepartum Group B Streptococcus olonisation: A systematic review and meta-analysis –Manuscript Draft– Manuscript umber: YMIDW-D-21-00295 Article Type: Original Research ∗ Corresponding author. E-mail address:
[email protected] (L. Hanson). I S p m t ttps://doi.org/10.1016/j.midw.2021.103208 266-6138/© 2021 Elsevier Ltd. All rights reserved. ntroduction Streptococcus agalactiae , more commonly known as Group B treptococcus (GBS) is an encapsulated, beta-haemolytic, gram- ositive coccus, and a facultative anaerobe that is part of the com- ensal microbiome of humans. The gastrointestinal (GI) tract is he source for vaginal GBS colonisation in women (American Col- https://doi.org/10.1016/j.midw.2021.103208 http://www.ScienceDirect.com http://www.elsevier.com/locate/midw http://crossmark.crossref.org/dialog/?doi=10.1016/j.midw.2021.103208&domain=pdf mailto:
[email protected] https://doi.org/10.1016/j.midw.2021.103208 jraymond Highlight jraymond Highlight jraymond Highlight jraymond Highlight jraymond Highlight jraymond Highlight L. Hanson, L. VandeVusse, E. Malloy et al. Midwifery 105 (2022) 103208 l e ( o 2 W o i c a s b t t a C c w o g 2 H t p 1 B 2 m p 2 1 o t S w m w s c v r t t B 1 2 s t ( I g s p C c r c r g p m a g a ( s v r ( r p t a a s c w c f ( i s o S s s A H h M a s a N d t d s b m s d a g t i n t c e ( t s h R T i d v 2 a G ege of Obstetrics and Gynaecology, ACOG, 2019 ; Picard and Berg- ron, 2004 ). Prenatal GBS colonisation is generally asymptomatic Armistead et al., 2019 ; Marziali et al., 2019 ), and may be transient r persistent (ACOG, 2019 ; Armistead et al., 2019 ; Marziali et al., 019 ; Meyn et al., 2009 ; Picard and Bergeron, 2004 ). ( Brzychczy- łoch et al., 2014 ) conducted a descriptive study with a sample f 42 healthy adult pregnant women without signs of clinical gen- tourinary infection. Separate vaginal and rectal GBS swabs were ollected in each trimester. Fifteen participants were GBS positive t some point in pregnancy and 27 were GBS negative. The re- earchers found that vaginal GBS colonisation was relatively sta- le throughout pregnancy, averaging 7.42 × 10 4 CFU/ml in the first rimester and 1.74 × 10 4 CFU/ml in the third trimester, while rec- al colonisation changed substantially during pregnancy with an verage 2.8 × 10 4 CFU/ml in the first trimester and 4.37 × 10 5 FU/ml in the third trimester. Several risk factors have been asso- iated with GBS colonisation, including but not limited to: people ho are employed in healthcare, of African descent, overweight or bese, have low vitamin D levels, have poor vaginal hygiene, en- aging in oral sex, or have frequent sexual intercourse ( Akoh et al., 017 ; Capan-Melser et al., 2015 ; Foxman et al., 2007 ; Le Doare and eath, 2013 ; Stapleton et al., 2005 ). During normal vaginal birth, GBS can be vertically transmitted o the fetus. Approximately 50% of neonates born to GBS culture ositive women will become colonized with GBS but of these only –2% will develop Early Onset Group B Streptococcus Disease (EOG- SD) ( Chan et al., 2006 ; Illuzzi & Bracken, 2006 ; Virranniemi et al., 019 ). EOGBSD can result in significant neonatal morbidity and ortality ( Verani et al., 2010 ). Worldwide, GBS colonizes up to 65% of healthy nonpregnant eople and between 15-40% of pregnant people ( Russell et al., 017 ; Seale et al., 2017 ). The global estimate of antenatal GBS is 8% with a large range of regional prevalence; the lowest rates f colonisation (11–13%) are in Southern and Eastern Asia while he Caribbean has the highest rate (35%) ( Russell et al., 2017 ). eale et al. (2017) performed an extensive analysis of the world- ide burden of perinatal GBS. Of the 10 GBS serotypes, III is the ost virulent and accounts for 48% of the EOGBSD cases world- ide, while serotypes 1a and 1b are responsible for 30%, and seven erotypes (II, IV, V, VI, VII, VIII, and IX) account for the remaining ases. The United States (US) Centers for Disease Control and Pre- ention (CDC) 2010 guidelines recommended universal vaginal to ectal screening at 35-37 weeks gestation and intrapartum an- ibiotic prophylaxis (IAP) for those who test positive. Implemen- ation of these guidelines resulted in an 80% reduction in EOG- SD in the US, from 1.8 newborns per 1,0 0 0 live births in the 990s to 0.23 per 1,0 0 0 live births in 2015 ( Nanduri et al., 019 ; Verani et al., 2010 ). Residual GBS, including missed or tran- ient GBS and late onset neonatal GBS disease, remain persis- ent challenges despite the introduction of the CDC guidelines Berardi et al., 2013 ; Parente et al., 2017 ; Van Dyke et al., 2009 ). n 2019, ACOG American College of Obstetricians and Gynecolo- ists (ACOG) 2019 American Academy of Pediatrics (AAP) 2019 as- umed stewardship of GBS recommendations for all maternity care roviders and newborns respectively, replacing and updating the DC 2010 guidelines. Subsequently, the American Society for Mi- robiology (ASM) issued new recommendations for standard labo- atory practices related to GBS ( Filkins et al., 2020 ). An important hange in the recent ACOG guidelines is that of later vaginal to ectal antenatal GBS screening between 36 0/7 and 37 6/7 weeks estation to assure that the culture result is valid for a five-week eriod before anticipated birth (ACOG, 2019 ). Strategies used to prevent EOGBSD vary based on the recom- endations of guideline-setting organizations and by regional vari- tions in GBS prevalence. Three main EOGBSD prevention strate- 2 ies are used worldwide: (a) universal antenatal screening for GBS ccording to the ACOG guidelines, (b) the risk-based approach, or c) a combination of both ( Kolkman et al., 2013 ). Although con- idered a standard of care in the US, the CDC and ACOG/AAP uni- ersal screening approaches are both considered cost-effective in egions where the prevalence of newborn GBS infection is high > 1.2/1,0 0 0 births) ( Santhanam et al., 2017 ). In regions where the ate of newborn GBS infection is considered low, a risk-based ap- roach is often used to determine candidates for IAP administra- ion ( Santhanam et al., 2017 ). Risk