What is the secondary treatment for Group B Streptococcus (GBS) in a laboring patient with a penicillin allergy?

From the Guidelines

For laboring patients with penicillin allergy who require secondary treatment for Group B Streptococcus (GBS), clindamycin 900 mg IV every 8 hours until delivery is the recommended regimen, as long as the GBS isolate is susceptible to clindamycin, as stated in the most recent guidelines 1. This recommendation is based on the latest evidence from the American Academy of Pediatrics, which emphasizes the importance of using clindamycin for penicillin-allergic women at high risk of anaphylaxis, provided the GBS isolate is susceptible to clindamycin 1. Some key points to consider when administering clindamycin include:

• Clindamycin susceptibility testing should be performed on prenatal GBS isolates from penicillin-allergic women at high risk for anaphylaxis, if laboratory facilities are adequate 1.
• If the GBS isolate is resistant to clindamycin or susceptibility is unknown, vancomycin is the preferred agent for GBS intrapartum prophylaxis for penicillin-allergic women at high risk for anaphylaxis 1.
• For patients with a mild penicillin allergy (no history of anaphylaxis, angioedema, respiratory distress, or urticaria), cefazolin 2 g IV initial dose, then 1 g IV every 8 hours until delivery may be used as it has minimal cross-reactivity with penicillin 1. It's essential to note that erythromycin is no longer recommended due to high rates of GBS resistance, as highlighted in the latest guidelines 1. These antibiotics play a crucial role in preventing vertical transmission of GBS to the newborn during delivery, thereby reducing the risk of early-onset neonatal GBS disease and its associated complications, such as sepsis, pneumonia, and meningitis.

From the FDA Drug Label

Clindamycin Injection, USP is indicated in the treatment of serious infections due to susceptible strains of streptococci Its use should be reserved for penicillin-allergic patients or other patients for whom, in the judgment of the physician, a penicillin is inappropriate.

The secondary treatment for Group B Streptococcus (GBS) in a laboring patient with a penicillin allergy is clindamycin.

• The dosage for serious infections due to aerobic gram-positive cocci is 600 mg to 1,200 mg per day in 2,3 or 4 equal doses 2.
• However, the FDA label does not explicitly state the treatment for GBS, it only mentions streptococci in general. Therefore, the use of clindamycin for GBS should be based on the judgment of the physician and the susceptibility of the bacteria.

From the Research

Secondary Treatment for Group B Streptococcus (GBS) in Laboring Patients with Penicillin Allergy

• The secondary treatment for GBS in laboring patients with a penicillin allergy depends on the severity of the allergy and the susceptibility of the GBS isolate 3, 4.
• For patients with a low risk of anaphylaxis, cefazolin is recommended as an alternative to penicillin 3.
• For patients at high risk of anaphylaxis, clindamycin and erythromycin are options, but their effectiveness may be limited due to increasing resistance rates 5.
• Vancomycin is recommended for patients allergic to penicillin and whose cultures indicate resistance to clindamycin and erythromycin, or when susceptibility is unknown 3, 6.
• Antibiotic susceptibility testing is crucial in guiding the choice of antibiotic for GBS prophylaxis in patients with penicillin allergy 4, 6.
• Studies have shown that cefazolin, vancomycin, and clindamycin are commonly used antibiotics for GBS prophylaxis in patients with penicillin allergy, with cefazolin being the most frequently used 6.