Group B streptococcal infection secondary prevention

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2]

Overview

Currently available Group B Streptococcal (GBS) infection prevention strategies will not prevent all cases of early-onset disease. Rapid detection of neonatal infections and initiation of appropriate treatment is needed to minimize morbidity and mortality among the cases that continue to occur. Any newborn with signs of sepsis should receive a full diagnostic evaluation and receive antibiotic therapy pending the results of the evaluation, regardless of the maternal colonization status. Well-appearing newborns whose mothers had suspected chorioamnionitis should undergo a limited evaluation and receive antibiotic therapy pending culture results. Well-appearing infants whose mothers had no chorioamnionitis and no indication for GBS prophylaxis should be managed according to routine clinical care. Well-appearing infants of any gestational age whose mother received adequate intrapartum GBS prophylaxis (≥4 hours of penicillin, ampicillin, or cefazolin before delivery) should be observed for ≥48 hours, and no routine diagnostic testing is recommended. For well-appearing infants born to mothers who had an indication for GBS prophylaxis but received no or inadequate prophylaxis, if the infant is well-appearing and ≥37 weeks and 0 days' gestational age and the duration of membrane rupture before delivery was <18 hours, then the infant should be observed for ≥48 hours, and no routine diagnostic testing is recommended. If the infant is well-appearing and either <37 weeks and 0 days' gestational age or the duration of membrane rupture before delivery was ≥18 hours, then the infant should undergo a limited evaluation and observation for ≥48 hours.

Secondary Prevention of Early-Onset GBS Among Infants

Secondary Prevention Algorithm

Shown below is an algorithm summarizing the indications for secondary prevention of early-onset GBS among infants.

Are there any signs of neonatal sepsis?

No

Yes

Is there maternal chorioamnionitis?§

Obtain a full diagnostic evaluation* AND Administer antibiotic therapy†

No

Yes

Is GBS prophylaxis indicated for the mother?

Obtain a limited diagnostic evaluation¶ AND Administer antibiotic therapy†

Yes

No

Did the mother receive intravenous penicillin, ampicillin, or cefazolin for ≥ 4 hours before delivery?

Perform routine clinical care††

No

Yes

Are the gestational age ≥ 37 weeks and the duration of membrane rupture < 18 hours?

Observe the infant for ≥ 48 hours††§§

No

Yes

Is the gestational age < 37 weeks or is the duration of membrane rupture < 18 hours?

Observe the infant for ≥ 48 hours††¶¶

Yes

Obtain a limited diagnostic evaluation¶ AND Observe the neonate for ≥ 48 hours††

* Full diagnostic evaluation includes a blood culture, a complete blood count (CBC) including white blood cell differential and platelet counts, chest radiograph (if respiratory abnormalities are present), and lumbar puncture (if patient is stable enough to tolerate procedure and sepsis is suspected).

† Antibiotic therapy should be directed toward the most common causes of neonatal sepsis, including intravenous ampicillin for GBS and coverage for other organisms (including Escherichia coli and other gram-negative pathogens) and should take into account local antibiotic resistance patterns.

§ Consultation with obstetric providers is important to determine the level of clinical suspicion for chorioamnionitis. Chorioamnionitis is diagnosed clinically and some of the signs are nonspecific.

¶ Limited evaluation includes blood culture (at birth) and CBC with differential and platelets (at birth and/or at 6--12 hours of life).

** See table 3 for indications for intrapartum GBS prophylaxis.

†† If signs of sepsis develop, a full diagnostic evaluation should be conducted and antibiotic therapy initiated.

§§ If ≥37 weeks' gestation, observation may occur at home after 24 hours if other discharge criteria have been met, access to medical care is readily available, and a person who is able to comply fully with instructions for home observation will be present. If any of these conditions is not met, the infant should be observed in the hospital for at least 48 hours and until discharge criteria are achieved.

¶¶ Some experts recommend a CBC with differential and platelets at age 6--12 hours.

Infants with Signs of Sepsis

Any newborn with signs of sepsis should receive a full diagnostic evaluation and receive antibiotic therapy pending the results of the evaluation, regardless of maternal colonization status. Therapy for the infant should include antimicrobial agents active against GBS (including intravenous ampicillin) as well as other organisms that might cause neonatal sepsis, such as E. coli (class A, level of evidence II).

Although maternal GBS colonization might increase clinical suspicion for early-onset GBS disease in an infant, in the era of universal screening, >60% of early-onset GBS cases have occurred among infants born to women who had a negative prenatal GBS culture screen. False-negative cases are not unexpected because culture at 35--37 weeks' gestation will fail to detect some women with intrapartum GBS colonization. As effective prevention strategies are increasingly implemented, a growing proportion of the remaining relatively low burden of disease will reflect inherent limitations in the strategies. Signs of sepsis in any newborn can be an indication of early-onset GBS disease, regardless of maternal colonization status.

Infants Born to Women with Chorioamnionitis

Well-appearing newborns whose mothers had suspected chorioamnionitis should undergo a limited evaluation and receive antibiotic therapy pending culture results (class A, level of evidence II). The evaluation should include a blood culture and a CBC including white blood cell differential and platelet count; no chest radiograph or lumbar puncture is needed. Consultation with obstetric providers to assess whether chorioamnionitis was suspected is important to determine neonatal management (class C, level of evidence III).

Chorioamnionitis is an important risk factor for early-onset GBS disease in women with GBS colonization and can reflect an intrauterine onset of infection in the neonate . Intrapartum fever, one sign of chorioamnionitis in parturient women, has been associated with failure of intrapartum antibiotics to prevent GBS disease in the newborn. Intrapartum treatment of chorioamnionitis can prevent neonatal sepsis. The diagnosis of chorioamnionitis usually is made clinically on the basis of signs and symptoms such as fever (which might be low-grade), uterine tenderness, fetal tachycardia, maternal tachycardia, and foul-smelling or purulent amniotic fluid. In an effort to avert neonatal infections, maternal fever alone in labor may be used as a sign of chorioamnionitis and hence indication for antibiotic treatment, particularly among women with a significant risk factor for chorioamnionitis (e.g., prolonged labor or prolonged rupture of membranes).

Well-Appearing Infants Exposed to Inadequate Intrapartum Antibiotics

Well-appearing infants whose mothers had no chorioamnionitis and no indication for GBS prophylaxis should be managed according to routine clinical care (class C, level of evidence III).

Well-appearing infants of any gestational age whose mother received adequate intrapartum GBS prophylaxis (≥4 hours of penicillin, ampicillin, or cefazolin before delivery) should be observed for ≥48 hours, and no routine diagnostic testing is recommended (class B, level of evidence III). Such infants can be discharged home as early as 24 hours after delivery, assuming that other discharge criteria have been met, ready access to medical care exists, and that a person able to comply fully with instructions for home observation will be present (class C, level of evidence III).

For well-appearing infants born to mothers who had an indication for GBS prophylaxis but received no or inadequate prophylaxis, if the infant is well-appearing and ≥37 weeks and 0 days' gestational age and the duration of membrane rupture before delivery was <18 hours, then the infant should be observed for ≥48 hours, and no routine diagnostic testing is recommended (class B, level of evidence III). If the infant is well-appearing and either <37 weeks and 0 days' gestational age or the duration of membrane rupture before delivery was ≥18 hours, then the infant should undergo a limited evaluation and observation for ≥48 hours (class B, level of evidence III).

References

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