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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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