GBS disease, Perinatal
How to manage the newborn of a mother who receives intrapartum antibiotic prophylaxis (IAP)
Full diagnostic evaluation and empiric therapy:
Limited eval, observe at least 48 hours.
No evaluation, no therapy, observe at least 48 hours
A healthy appearing infant >38 weeks gestation whose mother received >= 4 hours of IAP, may be dc'ed home after 24 hours if other d/c criteria have been met and a person able to comply fully w/ instruction for hoem observation will be present. If any one of these conditions is not met, obs at least 48 hrs.
Full diagnostic eval: CBC/diff, blood cx, CXR if indicated, LP if signs of
sepsis)
Limited eval: CBC/diff, blood cx.
If mom did not get IAP despite an indication to get it, data are insufficient on which to recommend a single management strategy.
By Anne Schuchat, MD, Contemporary Pediatrics 9/03
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Before 1993, GBS caused about 7,600 cases of newborn invasive disease annually in the United States, with 6,100 early-onset infections evident in the first week of life.11 Such early-onset through vertical transmission during labor or after rupture of amniotic membranes. Risk of early-onset infection was higher among preterm deliveries, African- Americans, and deliveries complicated by amnionitis or prolonged rupture of the membranes. Late-onset infection, which develops from 1 week to 3 months of life, was less common and represented a mixture of vertical and horizontal transmission. A common factor for increased risk of infection is maternal colonization of the vagina or rectum with GBS.
Where we are now:
From 1998 through 2001, the incidence of early-onset GBS disease reached a plateau. Although prophylaxis prevented about 4,400 cases of early-onset infections each year, an estimated 1,720 babies developed early-onset GBS disease in 2001 and 70 to 90 infants died from the disease.14
To address the possibility of further disease prevention, the CDC collaborated on a study with investigators in eight states that have ongoing active surveillance for GBS disease. This multistate cohort study in a population of more than 600,000 births was designed to evaluate the relative effectiveness of the screening and risk-based strategy. It demonstrated that prenatal screening was over 50% more effective in reducing early-onset GBS disease than the risk-based strategy.6 The principal advantage of the screening-based approach is that it reaches women with no obstetric risk factors—and these women make up a large proportion of the population at risk of transmitting GBS infection to their newborns.
TABLE 1
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| Candidates for intrapartum antimicrobial prophylaxis are identified using a single strategy—prenatal screening |
| Intrapartum antimicrobial prophylaxis regimens are updated, using second-line agents for women with penicillin allergy |
| Detailed instructions are offered on specimen collection and handling |
| Instructions include how to manage planned cesarean deliveries |
| Instructions are provided on managing threatened preterm deliveries |
| The algorithm on neonatal management is updated |
| Adapted from MMWR Morb Mortal Wkly Rep 2002:51(No. RR-11)1 |
Recommendations:
Risk-based strategy
Unlike earlier guidelines, the new recommendations do not
present the risk-based approach as an acceptable alternative for disease
prevention (Table 1). Rather, the risk-based approach is reserved for two
specific situations:
These patients require intrapartum antimicrobial ppx if: threatened preterm delivery, membrane rupture >18 h, or intrapartum temp >100.4 or >38.
Indications for intrapartum antibiotic prophylaxis to prevent GBS disease:
Vaginal and rectal GBS screening cultures at 35 to 37 weeks gestation for ALL pregnant women (unless patient had GBS bacteriuria during the current pregnancy or previously had and infant with invasive GBS disease.
Intrapartum (after labor begins or membranes rupture) prophylaxis indicated:
Intrapartum prophylaxis not indicated:
TABLE 2
|
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| Regimen | Drug and dosage | |||
| Standard | Penicillin G, 5 million units IV initial dose, then 2.5 million units IV every 4 hours until delivery | |||
| Alternative | Ampicillin, 2 g IV initial dose, then 1 g IV every 4 hours until delivery | |||
| If patient is penicillin-allergic and is not at high risk of anaphylaxis | Cefazolin, 2 g IV initial dose, then 1 g IV every 8 hours until delivery | |||
| If patient is at high risk of anaphylaxis and GBS disease is susceptible to clindamycin and erythromycin (Note: GBS strains have become increasingly resistant to clinda and erythro) | Clindamycin, 900 mg IV every 8
hours until delivery or Erythromycin, 500 mg IV every 6 hours until delivery |
|||
| If patient is penicillin-allergic and GBS is resistant to clindamycin or erythromycin or susceptibility is unknown | Vancomycin, 1 g IV every 12 hours until delivery | |||
|
Adapted from MMWR Morb Mortal Wkly Rep 2002:51(No. RR-11)1 Note: See “Box 2” in source for additional details about regimens. |
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How to manage the newborn of a mother who receives intrapartum antibiotic prophylaxis (IAP)
If sepsis is suspected, always do full diagnostic eval and give empiric therapy.
Full diagnostic evaluation and empiric therapy:
Limited eval, observe at least 48 hours.
No evaluation, no therapy, observe at least 48 hours
A healthy appearing infant >38 weeks gestation whose mother received >= 4 hours of IAP, may be dc'ed home after 24 hours if other d/c criteria have been met and a person able to comply fully w/ instruction for hoem observation will be present. If any one of these conditions is not met, obs at least 48 hrs.
Full diagnostic eval: CBC/diff, blood cx, CXR if indicated, LP if signs of
sepsis)
Limited eval: CBC/diff, blood cx.
If mom did not get IAP despite an indication to get it, data are insufficient on which to recommend a single management strategy.
By Anne Schuchat, MD, Contemporary Pediatrics 9/03
The following recommendations are based on USC-LAC protocol as of 10/03, based on earlier 1996 ACOG recommendations:
If mom had risk factors (prev baby with invasive GBS, GBS UTI, PROM >18 h, clinical chorioamnionitis (mat fever, tachycardia, uterine tenderness)) OR if mom had (+) GBS screen at 35-37 weeks, she would get ABX (PCN, amp, erythro, clinda). For penicillin, giving 1 dose slightly decreased risk of GBS in baby. Giving >4 doses decreased risk by 95%.
All symptomatic babies get r/o sepsis.
Asymptomatic babies: