Rapid testing for group B streptococcus during labour: a test accuracy study with evaluation of acceptability and cost-effectiveness.
OBJECTIVE
To determine the accuracy, acceptability and cost-effectiveness of polymerase chain reaction (PCR) and optical immunoassay (OIA) rapid tests for maternal group B streptococcal (GBS) colonisation at labour.


METHODS
A test accuracy study was used to determine the accuracy of rapid tests for GBS colonisation of women in labour. Acceptability of testing to participants was evaluated through a questionnaire administered after delivery, and acceptability to staff through focus groups. A decision-analytic model was constructed to assess the cost-effectiveness of various screening strategies.


METHODS
Two large obstetric units in the UK.


METHODS
Women booked for delivery at the participating units other than those electing for a Caesarean delivery.


METHODS
Vaginal and rectal swabs were obtained at the onset of labour and the results of vaginal and rectal PCR and OIA (index) tests were compared with the reference standard of enriched culture of combined vaginal and rectal swabs.


METHODS
The accuracy of the index tests, the relative accuracies of tests on vaginal and rectal swabs and whether test accuracy varied according to the presence or absence of maternal risk factors.


RESULTS
PCR was significantly more accurate than OIA for the detection of maternal GBS colonisation. Combined vaginal or rectal swab index tests were more sensitive than either test considered individually [combined swab sensitivity for PCR 84% (95% CI 79-88%); vaginal swab 58% (52-64%); rectal swab 71% (66-76%)]. The highest sensitivity for PCR came at the cost of lower specificity [combined specificity 87% (95% CI 85-89%); vaginal swab 92% (90-94%); rectal swab 92% (90-93%)]. The sensitivity and specificity of rapid tests varied according to the presence or absence of maternal risk factors, but not consistently. PCR results were determinants of neonatal GBS colonisation, but maternal risk factors were not. Overall levels of acceptability for rapid testing amongst participants were high. Vaginal swabs were more acceptable than rectal swabs. South Asian women were least likely to have participated in the study and were less happy with the sampling procedure and with the prospect of rapid testing as part of routine care. Midwives were generally positive towards rapid testing but had concerns that it might lead to overtreatment and unnecessary interference in births. Modelling analysis revealed that the most cost-effective strategy was to provide routine intravenous antibiotic prophylaxis (IAP) to all women without screening. Removing this strategy, which is unlikely to be acceptable to most women and midwives, resulted in screening, based on a culture test at 35-37 weeks' gestation, with the provision of antibiotics to all women who screened positive being most cost-effective, assuming that all women in premature labour would receive IAP. The results were sensitive to very small increases in costs and changes in other assumptions. Screening using a rapid test was not cost-effective based on its current sensitivity, specificity and cost.


CONCLUSIONS
Neither rapid test was sufficiently accurate to recommend it for routine use in clinical practice. IAP directed by screening with enriched culture at 35-37 weeks' gestation is likely to be the most acceptable cost-effective strategy, although it is premature to suggest the implementation of this strategy at present.
University of Birmingham, Academic Department of Obstetrics and Gynaecology, Birmingham Women's Hospital, UK.
J
J
Daniels
J
J
Gray
H
H
Pattison
T
T
Roberts
E
E
Edwards
P
P
Milner
L
L
Spicer
E
E
King
R K
RK
Hills
R
R
Gray
L
L
Buckley
L
L
Magill
N
N
Elliman
B
B
Kaambwa
S
S
Bryan
R
R
Howard
P
P
Thompson
K S
KS
Khan
D000328:Adult; D000367:Age Factors; D019072:Antibiotic Prophylaxis; D001294:Attitude to Health; D001431:Bacteriological Techniques; D003362:Cost-Benefit Analysis; D005006:Ethnicity; D005260:Female; D006801:Humans; D007118:Immunoassay / Q000191:economics / Q000706:statistics & numerical data; D007231:Infant, Newborn; D007232:Infant, Newborn, Diseases / Q000382:microbiology; D007234:Infant, Premature; D008403:Mass Screening / Q000191:economics / Q000706:statistics & numerical data; D008880:Midwifery; D007744:Obstetric Labor Complications / Q000175:diagnosis*; D010298:Parity; D010352:Patient Dropouts; D016133:Polymerase Chain Reaction / Q000191:economics / Q000706:statistics & numerical data; D011237:Predictive Value of Tests; D011247:Pregnancy; D011248:Pregnancy Complications; D012007:Rectum / Q000382:microbiology; D012307:Risk Factors; D012680:Sensitivity and Specificity; D013290:Streptococcal Infections / Q000175:diagnosis*; D013292:Streptococcus agalactiae / Q000302:isolation & purification*; D014621:Vagina / Q000382:microbiology; D055815:Young Adult