Featured Reading 2: Management of Infants at Risk for Group B Strep (GBS) Disease

Puopolo KM, Lynfield R, Cummings JJ. Management of Infants at Risk for Group B Streptococcal Disease. Pediatrics. 2019 Aug;144(2). doi: 10.1542/peds.2019-1881. Epub 2019 Jul 8. Review. PubMed PMID: 31285392.
https://pubmed.ncbi.nlm.nih.gov/31285392/ target=”_blank”

EARLY ONSET SEPSIS (EOS) RECOMMENDATIONS

1. AAP and ACOG agree on the following guidelines for the prevention of perinatal GBS disease newborns.
2. Administration of penicillin G, ampicillin, or cefazolin to the mother at least 4 hours before delivery can provide adequate intrapartum antibiotic prophylaxis (IAP) against neonatal early-onset GBS disease. Those mothers with high risk of anaphylaxis to beta-lactam antibiotics should use clindamycin or vancomycin before delivery to achieve some protection against early-onset GBS disease.
3. Risk assessment for early-onset GBS disease follows these guidelines:

• Infants born ≥ 35 weeks gestation should be assessed based on the neonatal early-onset sepsis calculator or with enhanced clinical observation (see below).
• Infants born < 35 weeks are at the highest risk for early-onset infection and should be managed based off NICU guidelines.

4. Do not routinely obtain CRP in predicting early onset infection in well-appearing infants. Early-onset GBS infection is diagnosed with blood culture and CSF culture
5. Late-onset GBS disease can occur with either a negative or positive GBS screen during pregnancy. Adequate IAP does not protect infants for late-onset GBS disease.
6. Penicillin G is the preferred antibiotic choice for either early or late-onset GBS in infants. Ampicillin is an acceptable alternative.

GROUP B STREPTOCOCCAL SEPSIS (GBS SEPSIS)

“Early onset” Group B streptococcal sepsis (GBS sepsis) refers to sepsis occurring within the first 6 days of life. It is usually due to GBS pneumonia. “Late onset” GBS sepsis refers to after 6 days and up to the first 90 days of life. Infections tend to be more focal. The most concerning would be meningitis. Also look for cellulitis and osteomyelitis. GBS is pretty much susceptible to anything, so TREAT WITH PENICILLIN G.
PEARL: Differential of sepsis-like picture in the newborn includes Congenital Adrenal Hyperplasia, Inborn Errors of Metabolism, and Heart Failure. If a WBC is given, look at the clinical picture. Look at the ratio of bands-to-neutrophils rather than the VERY UNRELIABLE WBC. A band:neutrophil ratio > 0.2 is suggestive of infection.

GBS SCREENING AND PROPHYLAXIS MADE EASY!

HERE ARE SOME KEY POINTS AND PEARLS ABOUT GBS SCREENING AND PROPHYLAXIS:

*  GROUP B BETA HEMOLYTIC STREPTOCOCCUS (GBS) SCREEN: Occurs at 35–37 weeks gestation.

*  PROPHYLAXIS: If indicated, give penicillin G at least 4 hours prior to delivery.

*  INTRAPARTUM GBS PROPHYLAXIS – TO GIVE OR NOT TO GIVE? To view latest guidelines from the CDC, visit www.pbrlinks.com/gbsprophylaxis. For PBR’s summary version, please read below:

Managing newborns:

• GROUP B BETA HEMOLYTIC STREPTOCOCCUS (GBS): AAP guidelines in 2019 say that a well-appearing infant, ≥ 35 weeks gestation, born to a mother who received adequatetreatment with intrapartum antibiotic prophylaxis (IAP) with penicillin G, ampicillin, or cefazolin at least 4 hours prior to delivery, does not need any diagnostic testing or empiric antibiotics and should be given routine newborn cares.
• On the other hand, an infant born to a mother with indications for intrapartum antibiotic prophylaxis (IAP) and did NOT receive adequatetreatment should be managed based off the categorical risk assessment, neonatal early-onset sepsis calculator, and enhanced observation guidelines (www.pbrlinks.com/gbsprophylaxis) which are summarized below:
• A well-appearing infant who is ≥ 35 weeks gestation should be monitored clinically with more frequent vital signs for 36-48 hours prior to discharge.
• An infant ≥ 35 weeks gestation, who is born to a mother with intrapartum temperature > 38 C or other signs of chorioamnionitis, should have a blood culture at birth, serial physical exams with more frequent vital sings for at least 48 hours and only start empiric antibiotics if signs of clinical illness develop.
• An infant ≥ 35 weeks gestation, who shows any sign of clinical illness should have a blood culture taken at birth and started on empiric antibiotics. Consider lumbar puncture and CSF culture (if stable) in those at highest risk for serious illness prior to starting empiric antibiotics.

NEONATAL EARLY-ONSET SEPSIS CALCULATOR (https://neonatalsepsiscalculator.kaiserpermanente.org/):

• This guideline applies to all infants born at ≥ 35 weeks.
• Three groups of infants require a blood culture and antibiotic treatment without delay:
  • Unwell appearing infants.
  • Infants whose sibling had early onset sepsis (EOS).
  • Infants whose mother currently has Group B Streptococcal (GBS) infection.
• Contact the on-call pediatric doctor for any queries or concerns about an infant.
• The early onset sepsis (EOS) risk score should be documented in the medical record.

INFORMATION REQUIRED FOR THE CALCULATION OF EARLY ONSET SEPSIS (EOS) SCORE

• Gestational age.
• Highest maternal antepartum temperature (between onset of labor to delivery). In case of precipitous delivery the first available temperature post-delivery may be used.
• Duration of rupture of membranes.
• GBS status.
• Maternal intrapartum antibiotics.
• Classification of maternal intravenous antibiotics:
  • GBS IAP: Penicillin, Ampicillin, Amoxicillin, Clindamycin, Erythromycin, Cefazolin, Vancomycin.
  • Broad-spectrum antibiotics: other Cephalosporins, Fluoroquinolone, Piperacillin/Tazobactam, Meropenem or any combination of antibiotics that includes an Aminoglycoside or Metronidazole.

DEFINITION OF EQUIVOCAL CLINICAL SIGNS (2 clinical parameters abnormal for > 2 hrs or 1 clinical parameter abnormal for 4 hrs)

• Heart rate > 160/min
• Respiratory rate > 60/min
• Temperature > 38.0°C or <36.4°C
• Respiratory distress (grunting,
• nasal flaring or costal recessions)

INTERPRETATION AND MANAGEMENT OF EARLY ONSET SEPSIS (EOS) SCORE

Management Plan for GREEN Group:

• Routine care.
• Early discharge possible.

Management Plan for YELLOW Group:

• Blood culture at birth and observation.
• No routine CBC with differential or CRP.
• Every 3-hour vital signs until blood culture results is available at 24 hrs.
• Infants with equivocal signs require observation in the NICU and possible NICU admission.

Management Plan for RED Group:

• Blood culture, CBC with differential, and CRP at birth.
• Treat with empiric antibiotics.
• Repeat CRP 8-12 hours after first CRP.
• NICU admission.