Management of the infant whose mother has received group B streptococcal chemoprophylaxis
- Karen M Puopolo, MD, PhD
Karen M Puopolo, MD, PhD
- Associate Professor of Clinical Pediatrics
- University of Pennsylvania Perelman School of Medicine
- Carol J Baker, MD
Carol J Baker, MD
- Professor of Pediatrics, Molecular Virology and Microbiology
- Baylor College of Medicine
- Section Editors
- Morven S Edwards, MD
Morven S Edwards, MD
- Section Editor — Pediatric Infectious Diseases
- Professor of Pediatrics
- Baylor College of Medicine
- Leonard E Weisman, MD
Leonard E Weisman, MD
- Section Editor — Neonatology
- Professor of Pediatrics
- Baylor College of Medicine
Group B streptococcus (GBS or Streptococcus agalactiae) is an encapsulated gram-positive bacterium that colonizes the human gastrointestinal and genital tracts. GBS is the most frequent bacterial pathogen in neonates, and maternal colonization is the single most important risk factor for early-onset (younger than seven days of age) GBS infection [1,2]. Screening pregnant women for GBS colonization and administering intrapartum antibiotic prophylaxis (IAP) against GBS is the recommended approach to the prevention of early-onset infection in neonates [3,4]. However, this approach does not prevent all cases of early-onset GBS disease and does not prevent late-onset GBS disease (see "Neonatal group B streptococcal disease: Prevention", section on 'Missed cases'). Rapid detection and early initiation of appropriate antimicrobial therapy is necessary to minimize morbidity and mortality among the cases that continue to occur.
The evaluation and initial management of neonates at risk for early-onset GBS is reviewed here. Chemoprophylaxis of the mother, established GBS infection in infants and pregnant women, the microbiology and epidemiology of GBS, and the status of GBS vaccines are discussed separately. (See "Neonatal group B streptococcal disease: Prevention" and "Group B streptococcal infection in pregnant women" and "Group B streptococcal infection in neonates and young infants" and "Group B streptococcus: Virulence factors and pathogenic mechanisms" and "Vaccines for the prevention of group B streptococcal disease".)
SUMMARY OF MATERNAL IAP GUIDELINES
The Centers for Disease Control and Prevention (CDC) in collaboration with the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, the American Academy of Family Physicians, the American College of Nurse-Midwives, and the American Society for Microbiology issued new guidelines for the prevention of perinatal group B streptococcal (GBS) disease in 2010 [4,5]. Guidelines for maternal screening and administration of intrapartum antibiotic prophylaxis (IAP) are discussed separately (see "Neonatal group B streptococcal disease: Prevention"). Aspects of maternal IAP that affect newborn management are summarized below.
Indications for maternal IAP — The CDC guidelines recommend that all pregnant women be screened for GBS colonization with swabs of the lower (introitus) vagina and rectum at 35 to 37 weeks of gestation .
IAP should be administered to (table 1):
- Schuchat A. Group B streptococcus. Lancet 1999; 353:51.
- Schuchat A, Deaver-Robinson K, Plikaytis BD, et al. Multistate case-control study of maternal risk factors for neonatal group B streptococcal disease. The Active Surveillance Study Group. Pediatr Infect Dis J 1994; 13:623.
- Phares CR, Lynfield R, Farley MM, et al. Epidemiology of invasive group B streptococcal disease in the United States, 1999-2005. JAMA 2008; 299:2056.
- Verani JR, McGee L, Schrag SJ, Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention (CDC). Prevention of perinatal group B streptococcal disease--revised guidelines from CDC, 2010. MMWR Recomm Rep 2010; 59:1.
- Committee on Infectious Diseases, Committee on Fetus and Newborn, Baker CJ, et al. Policy statement—Recommendations for the prevention of perinatal group B streptococcal (GBS) disease. Pediatrics 2011; 128:611.
- Pulver LS, Hopfenbeck MM, Young PC, et al. Continued early onset group B streptococcal infections in the era of intrapartum prophylaxis. J Perinatol 2009; 29:20.
- Puopolo KM, Madoff LC, Eichenwald EC. Early-onset group B streptococcal disease in the era of maternal screening. Pediatrics 2005; 115:1240.
- Van Dyke MK, Phares CR, Lynfield R, et al. Evaluation of universal antenatal screening for group B streptococcus. N Engl J Med 2009; 360:2626.
- Stoll BJ, Hansen N, Fanaroff AA, et al. To tap or not to tap: high likelihood of meningitis without sepsis among very low birth weight infants. Pediatrics 2004; 113:1181.
- Ansong AK, Smith PB, Benjamin DK, et al. Group B streptococcal meningitis: cerebrospinal fluid parameters in the era of intrapartum antibiotic prophylaxis. Early Hum Dev 2009; 85:S5.
- Greenberg DN, Yoder BA. Changes in the differential white blood cell count in screening for group B streptococcal sepsis. Pediatr Infect Dis J 1990; 9:886.
- Christensen RD, Rothstein G, Hill HR, Hall RT. Fatal early onset group B streptococcal sepsis with normal leukocyte counts. Pediatr Infect Dis 1985; 4:242.
- Newman TB, Puopolo KM, Wi S, et al. Interpreting complete blood counts soon after birth in newborns at risk for sepsis. Pediatrics 2010; 126:903.
- Carbonell-Estrany X, Figueras-Aloy J, Salcedo-Abizanda S, et al. Probable early-onset group B streptococcal neonatal sepsis: a serious clinical condition related to intrauterine infection. Arch Dis Child Fetal Neonatal Ed 2008; 93:F85.
- Edwards MS, Nizet V, Baker CJ. Group B streptococcal infections. In: Infectious Diseases of the Fetus and Newborn Infant, 7th ed, Remington JS, Klein JO, Wilson CB, et al (Eds), Elsevier Saunders, Philadelphia 2010. p.419.
- Brady MT, Polin RA. Prevention and management of infants with suspected or proven neonatal sepsis. Pediatrics 2013; 132:166.
- Ottolini MC, Lundgren K, Mirkinson LJ, et al. Utility of complete blood count and blood culture screening to diagnose neonatal sepsis in the asymptomatic at risk newborn. Pediatr Infect Dis J 2003; 22:430.
- Hsu KK, Pelton SI, Shapiro DS. Detection of group B streptococcal bacteremia in simulated intrapartum antimicrobial prophylaxis. Diagn Microbiol Infect Dis 2003; 45:23.
- Escobar GJ, Li DK, Armstrong MA, et al. Neonatal sepsis workups in infants >/=2000 grams at birth: A population-based study. Pediatrics 2000; 106:256.
- Moore MR, Schrag SJ, Schuchat A. Effects of intrapartum antimicrobial prophylaxis for prevention of group-B-streptococcal disease on the incidence and ecology of early-onset neonatal sepsis. Lancet Infect Dis 2003; 3:201.
- Puopolo KM, Eichenwald EC. No change in the incidence of ampicillin-resistant, neonatal, early-onset sepsis over 18 years. Pediatrics 2010; 125:e1031.
- Escobar GJ, Puopolo KM, Wi S, et al. Stratification of risk of early-onset sepsis in newborns ≥ 34 weeks' gestation. Pediatrics 2014; 133:30.
- Schrag S, Gorwitz R, Fultz-Butts K, Schuchat A. Prevention of perinatal group B streptococcal disease. Revised guidelines from CDC. MMWR Recomm Rep 2002; 51:1.
- Bromberger P, Lawrence JM, Braun D, et al. The influence of intrapartum antibiotics on the clinical spectrum of early-onset group B streptococcal infection in term infants. Pediatrics 2000; 106:244.
- Pinto NM, Soskolne EI, Pearlman MD, Faix RG. Neonatal early-onset group B streptococcal disease in the era of intrapartum chemoprophylaxis: residual problems. J Perinatol 2003; 23:265.
- Hashavya S, Benenson S, Ergaz-Shaltiel Z, et al. The use of blood counts and blood cultures to screen neonates born to partially treated group B Streptococcus-carrier mothers for early-onset sepsis: is it justified? Pediatr Infect Dis J 2011; 30:840.
- Boyer KM, Gotoff SP. Prevention of early-onset neonatal group B streptococcal disease with selective intrapartum chemoprophylaxis. N Engl J Med 1986; 314:1665.
- SUMMARY OF MATERNAL IAP GUIDELINES
- Indications for maternal IAP
- Adequate IAP
- OVERVIEW OF MANAGEMENT
- Diagnostic evaluation
- - Full evaluation
- - Limited evaluation
- - Interpretation
- Empirical antibiotic therapy
- MANAGEMENT APPROACH
- Ill-appearing infant
- Well-appearing infants
- - Maternal chorioamnionitis
- - Mother received adequate IAP
- - Mother received no or inadequate IAP
- SOCIETY GUIDELINE LINKS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS