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Management of the infants at

increased risk for early onset

sepsis from group Bstreptococcal infection

Martin Skidmore

University of Toronto

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Group B Streptococcus (GBS)

Most GBS early onset sepsis (EOS) caused bytypes Ia, Ib, II, III & V Type III more commonly associated with late onset

sepsis/meningitis 20-30% of American women are colonised (may

be as high as 60%)

50% of infants born to colonised mothers

become, themselves, colonised 1-2% of colonised infants will develop invasive

GBS

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GBS bacteriuria at anytime during the pregnancy

Previous child with invasive GBS disease

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BACKGROUND

1996: consensus guidelines from The Centers

for Disease Control and Prevention

recommended intrapartum antibiotic prophylaxis

(IAP) to women at risk for delivering an infantwith EOS, GBS infection

2002: CDC conducted a large, retrospective

cohort study which demonstrated positive impact

and issued universal screening guidelines

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Impact

Incidence of EOS from GBS

1993: 1.7 cases/1000 live births 2003-5: 0.34 cases/1000 live births

a reduction of 80%

Incidence of EOS from non GBS

unchanged

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Recommendations

Screen ALL mothers with rectovaginal

cultures at 35-37 weeks for GBS

Treat those with positive cultures with

penicillin in labour

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Cost

As many as 22% of all mothers will

receive IAP to prevent disease in 0.2 % of

infants and prevent mortality in 0.01% of

infants

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Strategies (A)

Well-appearing infant of GBS positive

mother, who received IAP more than 4

hours prior to delivery

N/B requires no therapy

stay in hospital 24 hours

Insufficient evidence regarding efficacy ofalternative antibiotics treat as incomplete IAP

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Strategies (B)

Well-appearing infant of GBS positive mother, whoreceived IAP less than 4 hours prior to delivery (ornot at all)

Risk approximately 1% are asymptomatic

Is empiric treatment therefore justified? 95% who develop EOS will present with clinical signs

< 24 hours 4% between 24 and 48 hours 1% > 48 hours

Therefore: to detect each case of EOS 2000 infantswould require 48 hours hospitalization

Therefore: case for careful assessment and discharge

at 24 hours

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Use of the CBC

Positive predictive value is low in the newborn

One study: abnormal CBC: WBC 5.0 x109/L or lower

WBC 30 x109

/L or greater Immature/mature ratio > 0.2

1665 well appearing term infants at risk for EOS

PPV of 1.5% of abnormal CBC in identifying thedevelopment of clinical sepsis

None developed positive blood culture Ottolini et al; 2003

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Use of the CBC cont.

Various scoring systems for analyzing CBCs

best individual finding with highest PPV is a low

total WBC (5.0 x109/L) LR between 10 and 20

? justifies treatment even if well appearing

infants (only 22%-44% of infants with sepsis will have such alow WBC)

Fowlie, Schmidt; 1998

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Strategies (C)

Well appearing infant of a GBS-negative motherwith risk factors at delivery

eg. ROM 18 hours

Pyrexia 38C\premature labour at < 36 weeks GBS bacteriuria Previous child with invasive GBS disease

Present in 22% and only identified 50% who

eventually developed invasive GBS disease Schrag et al, 2002 Towers et al, 1999

Limited evaluation: CBC & 24 hours ofobservation

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Strategies (D)

Well appearing infant of mother with unknown

GBS status

Managed as per risk factors:

Absence of risk factors no intervention required

Risk factors present

IAP > 4 hours: routine care

IAP < 4 hours: limited evaluation

(applies to late preterm infant as GBS screening results

may not be available)

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Chorioamnionitis

pyrexia may occur with epidural and/or

dehydration

possible chorioamnionitis

fever only

definite chorioamnionitis

fever

left shift in mat CBC

lower uterine tenderness

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Chorioamnionitis

Chorioamnionitis but infant well at birth

OR for sepsis 0.26 (95% C1 0.11to 0.63)

Invasive infection < 2% Jackson et al, 2004

Therefore limited evaluation only?

requirement for resuscitation at birth otherwise, treat only if CBC is suggestive of

infection (ie low WBC)

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Recommendations

Any newborn with clinical signs suggestiveof sepsis should have an immediate fulldiagnosis evaluation followed by the

institution of empirical antibiotic therapy

If a mother who is GBS positive receives

IAP with a penicillin more than 4 h beforedelivery, no further evaluation orobservation for invasive GBS disease in awell-appearing infant

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Recommendations

If a GBS-positive woman receives IAP less than4 h before delivery (or receives no antibiotics ora nonpenicillin regimen), then a limiteddiagnostic evaluation is required, and the infantshould not be discharged before 24 h of age. Atthe time of discharge, the infant should beevaluated and the parents should be educatedregarding signs of sepsis in the newborn.

Discharge at 24h to 48h is conditional on theparents ability to immediately transport the babyto a health care facility if clinical signs of sepsisdevelop

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Recommendations

If the CBC reveals a total WBC count lessthan 5.0x109/L, full diagnostic evaluationand empirical antibiotic therapy should beconsidered

If a GBS-negative woman with risk factorsdelivers a baby who remains well, theinfant does not require evaluation for GBS

If a woman with unknown GBS status andwith risk factors at the time of deliveryreceives IAP more than 4h before delivery,the infant requires no specific intervention

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Recommendations

If a woman with unknown GBS status and withrisk factors at the time of delivery receives IAPless than 4h before delivery, limited diagnosticevaluation is required and the infant is notdischarged for 24 h of life

The well-appearing infant born at less than 36weeks gestation with an unknown maternal GBSstatus should have a limited diagnosticevaluation and is not a candidate for earlydischarge

The well appearing infant of a mother withpossible chorioamnionitis requires a limiteddiagnostic evaluation for sepsis

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