2025 – PAGE 302 – INFECTIOUS DISEASES

PNEUMONIA

Overall, Streptococcus pneumoniae (pneumococcus) is the most common etiology of bacterial pneumonia in children.

PEARL: If asked what the most common etiology of pneumonia is in a patient with cystic fibrosis, pick Staphylococcus aureus or Pseudomonas aeruginosa, not pneumococcus.

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.

(DOUBLE TAKE) GBS SCREENING AND PROPHYLAXIS MADE EASY!

Here are some key points and PEARLS about GBS screening and prophylaxis.

• RECTOVAGINAL GROUP B BETA HEMOLYTIC STREPTOCOCCUS (GBS)SCREENING CULTURES: These are obtained at 36 to 37 6/7 weeks gestation.
• INTRAPARTUM ANTIBIOTIC PROPHYLAXIS (IAP): Intrapartum Antibiotic Prophylaxis (IAP) refers to antibiotics given to mom when she presents for delivery. If indicated, give IV penicillin, ampicillin or cefazolin at least 4 hours prior to delivery. The latest guidelines from the CDC may be viewed for some “light reading” by visiting www.pbrlinks.com/gbsprophylaxis.
• TO GIVE OR NOT TO GIVE INTRAPARTUM ANTIBIOTIC PROPHYLAXIS? IAP is indicated for any of the following scenarios:
  • Invasive GBS disease was present in a previous infant
  • Positive GBS was noted in the URINE at ANYTIME during THIS pregnancy (regardless of treatment and subsequent cultures)
  • Positive rectovaginal GBS screening culture noted 36 to 37 6/7 weeks in THIS pregnancy
  • Unknown GBS status PLUS any of these:
    • < 37 weeks gestation
    • ROM > 18 hours
    • Intrapartum fever of >4 F
    • Positive intrapartum NAAT testing
• IAP is considered “adequate” when penicillin, ampicillin or cefazolin is administered > 4 hours prior to delivery.
• IAP is NOT indicated for GBS positivity in previous pregnancies or for c-sections done with intact membranes.

Managing Newborns

After the delivery, pediatricians must decide if a baby will need diagnostic evaluation, antibiotics and how long the baby should be observed in the hospital. A full diagnostic evaluation includes CBC, blood culture, chest x-ray (if there are any abnormal respiratory signs) and lumbar puncture (if the procedure can be tolerated). Limited diagnostic evaluation includes a CBC and blood culture. If antibiotics are started, baby should be monitored for 48 hours. If there were never any signs of sepsis, stop antibiotics after 48 hours. For a neonate born to a mom for whom IAP was indicated (or the GBS status was not known), the information below should help you decide how to treat the baby:

• • FULL DIAGNOSTIC EVALUATION + ANTIBIOTIC THERAPY (FULL COURSE): If appropriate IAP was given, then do this anytime the baby HAS SIGNS SEPSIS. Baby will stay for the full course of antibiotics.
  • LIMITED DIAGNOSTIC EVALUATION + ANTIBIOTIC THERAPY: If appropriate IAP was given, then do this if mom had chorioamnionitis and the baby has NO SIGNS OF SEPSIS. Discharge at 48 hours if the baby appears well.
  • LIMITED DIAGNOSTIC EVALUATION + NO ANTIBIOTIC THERAPY: If the baby is doing well (NO signs of sepsis), but mom DID NOT receive adequate IAP, then do a limited workup if there was PROM (> 18 hours) OR if gestation was < 37 weeks. Discharge at 48 hours if the baby appears well.
  • OBSERVE FOR 48 HOURS (SCENARIO 1): If the gestation was > 37 weeks with ROM occurring < 18 hours prior to delivery, and if the baby is doing well (NO signs of sepsis), but mom DID NOT receive adequate IAP, then no diagnostic workup is needed, and you can simply observe for 48 hours.
  • OBSERVE FOR 48 HOURS (SCENARIO 2): Regardless of gestational age, if appropriate IAP was given and the baby is well (no signs of sepsis), you can simply observe for 48 hours.